Spontaneous splenic rupture complicating anticoagulant or thrombolytic therapy.

PURPOSE: To characterize the clinical course and outcomes of reported cases of splenic hemorrhage during thrombolytic or anticoagulant therapy. METHODS: The Medline, EMBASE (Excerpta Medica), BIOSIS, and SCISEARCH databases for English and foreign literature between 1966 and 1991 were searched. All reports of patients with documented splenic hemorrhage during anticoagulant therapy or thrombolytic therapy were reviewed. Foreign language manuscripts were translated into English. RESULTS: Seventeen cases of splenic hemorrhage associated with anticoagulant or thrombolytic therapy were found. In one case, there was minor antecedent trauma; in the remaining cases, hemorrhage was spontaneous. Mortality overall was 24% and was more likely in patients with splenic hemorrhage after thrombolytic therapy (50%) than in patients receiving long-term anticoagulants (9%). Splenectomy was performed in 12 of 13 survivors. CONCLUSIONS: Splenic hemorrhage associated with anticoagulant or thrombolytic therapy is a rare entity. It may be lethal, especially when associated with lytic therapy. Reversal of the anticoagulated or lytic state and emergent splenectomy are the treatment of choice. Splenic hemorrhage can mimic acute myocardial infarction and cardiogenic shock and must be considered when the condition of cardiac patients receiving lytic or anticoagulant drugs suddenly deteriorates.

Purposeful delay in the repair of a traumatic rupture of the aorta with coexistent liver injury.

Purposeful delay in the repair of traumatic aortic injury by appropriate medical management is indicated when the risk of immediate thoracotomy is high. A grade V liver injury implies parenchymal disruption of greater than 75% of a hepatic lobe. We report the successful management of a patient with a class IB proximal descending aortic transection and concomitant grade V liver injury that precluded aortic repair until its resolution.

The study of the relationship between lifestyle characteristic self-reported drinking patterns and trauma.

A total of 161 usable interviews were obtained with 297 consecutive admissions to a Level I trauma center for purposes of evaluating patient socioeconomic patterns related to trauma. The median age of the purposeful sample was 31. There were 67.1% males, 29.2% females, and 3.7% unidentified; 43.5% were MVAs, 8.1% motorcycles, 2.5% pedestrians, 10.6% falls, and 3.7% penetrating trauma. Of those patients found ETOH positive, 40.8% admitted to drinking and driving regularly, 12.5% admitted to being previously arrested for DUI, 45% admitted that alcohol caused their current trauma, 28.6% had been previously arrested for traffic violation. Three-fourths did not routinely wear seat belts. The average education level of trauma victims was 12.2 years; 94% are blue collar workers. In summary the average trauma victim was a young adult male who had completed high school, somewhat below average earnings, and had a strong history of regular alcohol use as part of his lifestyle.

Arterial thromboembolism and associated antithrombin III deficiency.

A patient with antithrombin III (ATT) deficiency after arterial embolism manifested an increasing requirement for heparin to adjust a partial thromboplastin time. This was corrected by dramatically increasing doses of heparin and by conversion to warfarin sodium. "Heparin-resistance" should direct the physician to examine antithrombin III levels, and ATT levels should be determined as a baseline before anticoagulation therapy.

Risk, cost, and benefit of transporting ICU patients for special studies.

Prospective evaluation of 103 consecutive transports for diagnostic studies of 56 patients out of the Shock Trauma Unit over a 3-month period was done to document physiologic changes, the cost of each transport, and to assess whether the information gained was utilized to change patient management. Of the 56 patients, 36 (65%) were males and 20 (35%) were females with an age range of 14-82 years (mean, 48 years). The Apache II score ranged from 3-49 (mean, 19.4). There were seven types of diagnostic studies: CT of the head (28), CT of abdomen (35), CT of chest (four), angiography (nine), ventilation/perfusion scan (three), tomography (seven) and miscellaneous studies (15). The average trip time was 81 minutes, a range of 15-210, requiring an average of 3.3 personnel per trip. Ninety-four transported patients had ventilatory support, 26 had PA lines, and 26 transports required three or more IV infusion pumps. Sixty-eight per cent of all transports experienced serious physiologic changes of 5 minutes' duration defined as BP systolic or diastolic +/- 20 mm Hg (40%), pulse +/- 20 beats/minute (21%), ventilatory rate +/- 5/minute (20%), O2 saturation decrease by 5% or more (17%). There was a total of 113 serious changes requiring an increase in support of the patient during the transport. There were no significant differences when comparing diagnosis of patient or types of studies to the number of changes in the physiologic parameters, nor were there significant differences within a physiologic parameter when comparing patient types or diagnostic studies.(ABSTRACT TRUNCATED AT 250 WORDS)

Tension pneumopericardium in blunt chest trauma.

Tension pneumopericardium is a rare complication of blunt chest trauma. We present two case reports of tension pneumopericardium, with clinical, hemodynamic, and radiographic evidence supporting the diagnosis. Although tension pneumopericardium is uncommon in blunt chest trauma, it should be considered in patients with pneumopericardium and hemodynamic instability.

Assessing the true risk of abdominal solid organ injury in hospitalized rib fracture patients.

BACKGROUND: Despite the lack of evidence, traditional trauma teaching has suggested that low rib fractures increase the risk of abdominal solid organ injury (ASOI). This study was designed to assess if in fact this is true, and to try and define other factors that increased the risk of ASOI in rib fracture patients. METHODS: The charts of 476 hospitalized rib fracture trauma patients were reviewed. Data were collected for age; sex; Injury Severity Score (ISS); rib fracture location; and the presence or absence of injuries to the abdominal organs, head, neck, face, thorax, great vessel, heart, thoracolumbar spine, pelvis, and extremities. RESULTS: The probability of liver injury increased with the presence of any right-sided rib fracture, any low rib fracture, female gender, young age, and an elevated ISS. The probability of splenic injury increased with the presence of left-sided rib fractures only, any low rib fracture, young age, and an elevated ISS. CONCLUSION: In hospitalized trauma patients, low rib fractures, right-sided rib fractures, female gender, young age, and an elevated ISS increased the probability of liver injury; and low rib fractures, left-sided only rib fractures, young age, and an elevated ISS increased the probability of splenic injury. Associated pelvic fractures and long bone fractures did not increase the likelihood of ASOI in this cohort.

Injury from silage wagon accident complicated by mucormycosis.

Infection due to farm machinery injuries may be caused by microorganisms found in soil or decaying vegetable material. A case of injury due to entrapment of a young boy in a silage wagon is reported here. His injuries were complicated by infection with Aspergillus species, Absidia species, Rhizopus species (the latter two are members of the Mucorales order), and Pseudomonas maltophilia. Successful treatment of his infection followed aggressive surgical debridement of the anterior abdominal wall, amphotericin B, hyperbaric oxygen therapy, and surgical closure utilizing delayed placement of split-thickness skin grafts.

Blunt thoracic trauma. Analysis of 515 patients.

A retrospective analysis of 515 cases of blunt chest trauma is presented. The overall thoracic morbidity rate was 36% and mortality rate was 15.5%. Atelectasis was the most common complication. Severe chest trauma can be present in the absence of rib or other thoracic bony fractures. Emergency thoracotomies for resuscitation of the patient with blunt chest trauma with absent vital signs proved unsuccessful in 39 of 39 patients. A high index of suspicion for blunt chest injury occurring in blunt trauma, coupled with an aggressive diagnostic and therapeutic approach, remains the cornerstone of treatment to minimize the morbidity and mortality of such injuries.

Posttraumatic tension pneumopericardium: the "small heart" sign.

Radiographic measurements of the cardiothoracic ratio in four adult victims of blunt thoracic trauma with pneumopericardium demonstrated a sudden, substantial decrease in the size of the cardiac silhouette, which was accompanied by pathophysiologic effects of cardiac tamponade. The sudden decrease in cardiac size could not be attributed to a decrease in intravascular volume or to changes in positive airway pressure. Following surgical relief of tension pneumopericardium, the cardiac size was restored to baseline dimensions and the hemodynamic effects of tamponade resolved. In the presence of pneumopericardium, the "small heart" sign may alert one to the presence of tension pneumopericardium and impending cardiac tamponade.

Psychological consequences of blunt head trauma and relation to other indices of severity of injury.

To investigate the relationship between APACHE II, Injury Severity Score (ISS), Glasgow Coma Score (GCS), and behavioral outcome, a group of 39 patients who had been admitted on an emergency basis with a traumatic head injury were selected from the Neuropsychology Registry for study. Except for subtle personality and cognitive changes, all of the patients were making good neurological recoveries. The Halstead-Reitan Neuropsychological Test Battery, which has been shown to be accurate in identifying brain-damaged patients, was used as the measure of outcome. The age of the patients ranged from 16 to 49 years (mean, 25.6; SD, 9.3). The patients' educational levels ranged from elementary school to college (mean, 11.6 years of education; SD, 1.5). Halstead Impairment Indexes (HII) ranged from 0.0 to 1.0 (mean, 0.6; SD, 0.26). APACHE II scores were calculated using the worst values, obtained during the first 24 hours. These scores ranged from 5 to 35 (mean, 16; SD, 7). APACHE II was found to not significantly correlate with HII (r = 0.21, P greater than .05). ISS was calculated for each patient and ranged from 5 to 70 (mean, 27; SD, 13). ISS was found to significantly correlate with HII (r = 0.38, P less than .01). GCS ranged from 3 to 15 (mean, 9.3; SD, 3.4). Of all the correlations, GCS was the most strongly correlated with outcome as measured by the HII (r = -0.44, P less than .01). Our data emphasize that head-injured patients have subtle cognitive dysfunction even when apparently recovering well and demonstrate the need for formal psychological evaluation in all patients with injury significant enough to warrant hospitalization.

Blunt chest trauma in the elderly.

Significant differences were identified between a group of elderly patients (65 years and older) and a nonelderly group both with blunt thoracic trauma. There was a lower incidence of elderly patients presenting in shock; however, cardiopulmonary arrest at arrival was more frequent in this group. Although the types of complications were similar in both populations, the morbidity and mortality rates were higher in the elderly. A high index of suspicion must be generated for an elderly patient who has sustained blunt chest trauma. An aggressive diagnostic and therapeutic approach may lead to a decrease in the high morbidity and mortality rates in the elderly.

Maternal predictors of fetal demise in trauma during pregnancy.

Trauma complicates 6 to 7 per cent of all pregnancies, but fetal demise secondary to maternal trauma occurs much less frequently. This study was done to analyze the incidence of fetal demise as a function of 21 maternal characteristics determined within the first 24 hours after trauma. Nine instances of fetal demise were identified from 73 pregnant patients with trauma admitted to four Level I trauma centers from a combined data base of 30,000 patients. Maternal factors examined by logistic regression were Injury Severity Score (ISS), Trauma Score (TS), Abbreviated Injury Scale (AIS), fluid requirements in the initial 24 hours, systolic blood pressure (SBP), heart rate (HR), hemoglobin, hematocrit and arterial blood gas analysis. Fetal demise was found to be associated with increasing ISS, increasing face and abdominal AIS, increasing fluid requirements, maternal acidosis and maternal hypoxia. Standard maternal laboratory and physiologic parameters, such as hemoglobin and hematocrit, oxygen and hemoglobin saturation, partial pressure of carbon dioxide, SBP and HR were not predictive. The TS was also found to be nonpredictive.