Closed degloving injuries: results following conservative surgery.

Closed degloving wounds are uncommon but important injuries because they may be overlooked in the multiply injured patient and, if not treated correctly, may give rise to significant morbidity. This prospective study reports the results of a conservative surgical management policy in 16 patients with closed degloving wounds treated during a 1-year period in a tertiary referral center. Motor vehicle accidents caused most of the injuries, 69 percent of which occurred on the lower limb. The extent of injury ranged from 2 to 12 percent (mean 4.9 percent) of the total body surface area. The diagnosis of closed degloving wound was missed at initial assessment in one-third of patients. A uniform management policy with drainage of the degloved area through a small incision followed by compression bandaging was applied. The volume of blood and necrotic fat evacuated ranged from 15 to 800 ml (mean 120 ml). One patient with necrotic skin initially had excision and primary wound closure performed. Delayed necrosis occurred in one patient in whom extensive degloving occurred and effective compression could not be applied. Ultimate flap viability using this technique was excellent, since only 1 of 16 patents required skin grafting.

The suction test for oesophageal placement of the endotracheal tube using an oesophageal detector device: caution is required with inexperienced operators.

A modified oesophageal detector device made from simple universally available components was tested in a cadaver model using relatively inexperienced nurse volunteers as operators. In all but two of 71 tests the correct location of an endotracheal tube was identified in under 10 s. The errors were the result of inadequate attention to seating the device in the endotracheal tube connector. The positive predictive value for oesophageal placement was 100%. It is recommended that the device be more widely used, especially in ambulances and emergency departments, but that personnel should be specifically trained in its use.

The use of midazolam in trauma resuscitation.

Experience with the use of midazolam in the resuscitation of severely injured patients is described. All 33 patients included in the study were given midazolam to allow endotracheal intubation and/or positive pressure ventilation in the resuscitation room, prior to transfer to the operating theatre or intensive care unit. Those with possible head injury were subjected to computed tomography of the head once stabilized. Adjuvant analgesia with an intravenous opiate was required in less than 40% of patients, and the amnesic properties of midazolam were found to be excellent. Cardiorespiratory side effects were not seen. Midazolam was found to be a safe and viable alternative to muscle relaxants, allowing endotracheal intubation and ventilation, in addition to other invasive procedures, to be carried out with minimal distress to the patient.

Patients who reattend after head injury: a high risk group.

OBJECTIVE: To assess risk factors for important neurosurgical effects in patients who reattend after head injury. DESIGN: Retrospective study. SUBJECTS: 606 patients who reattended a trauma unit after minor head injury. MAIN OUTCOME MEASURES: Intracranial abnormality detected on computed tomography or the need for neurosurgical intervention. RESULTS: Five patients died: two from unrelated causes and three from raised intracranial pressure. On multiple regression analysis the only significant predictor for both abnormality on computed tomography (14.4% of reattenders) and the need for operation (5% of reattenders) was vault fracture seen on the skull radiograph (P < 10(-6)); predictors for abnormal computed tomogram were a Glasgow coma scale score < 15 at either first or second attendance (P < 0.0001) and convulsion at second attendance (P < 0.05); predictive for operation only was penetrating injury of the skull (P < 10(-6)). On contingency table analysis these associations were confirmed. In addition significant associations with both abnormality on computed tomography and operation were focal neurological abnormality, weakness, or speech disturbance. Amnesia or loss of consciousness at the time of initial injury, personality change, and seizures were significantly associated only with abnormality on computed tomography. Headache, dizziness, nausea, and vomiting were common in reattenders but were found to have no independent significance. CONCLUSIONS: All patients who reattend after head injury should undergo computed tomography as at least 14% of scans can be expected to yield positive results. Where this facility is not available patients with predictors for operation should be urgently referred for neurosurgical opinion. Other patients can be readmitted and need referral only if symptoms persist despite symptomatic treatment or there is neurological deterioration while under observation. These patients are a high risk group and should be treated seriously.

Haemothorax--a source of error in emergency central vein cannulation.

Central venous cannulation is often performed in patients with penetrating wounds of the chest as an aid to diagnosis, and is sometimes also used as a volume infusion resuscitation line in an emergency. The traditional signs of successful central venous cannulation--free aspiration of blood from the exploring needle and inserted cannula, free infusion flow and backflow of blood when the set is lowered below the patient--may all give a false impression of correct placement if there is a significant haemothorax on the same side. Two cases are described where the cannula was sited in a pleural cavity which contained blood, leading to inadequate resuscitation of the patient. The authors recommend that, where possible, peripheral lines or saphenous cutdown be used for volume resuscitation and that central venous cannulation in the emergency situation be performed on the side of the uninjured hemithorax, especially if the operator is inexperienced.

Closed traumatic forequarter amputation without fracture. A case report.

Closed forequarter amputation (scapulothoracic dissociation) is a rare, easily missed, life-threatening injury. The diagnosis should be suspected in patients with a pulseless, flail limb, supraclavicular haematoma, lateral scapular displacement and clavicular disruption. Early surgery is essential to control haemorrhage and completion of the amputation with attention to closure of the resulting defect is often required. Prognosis for long-term functional recovery is poor, in spite of modern prosthetic aids.

Traumatic haemothorax--experience of a protocol for rapid turnover in 1,845 cases.

Incomplete or prolonged drainage of the pleural cavity for haemothorax may lead to the development of empyema, with long-term morbidity. Using a protocol based on vigorous physiotherapy and early withdrawal of the thoracostomy tube (average drainage time 27.1 hours), hospital stay in 1,845 patients with traumatic haemothorax was 48 hours or less in 81.8% of patients. In all, 152 haemothorax patients (8.1%) required either early or late thoracotomy, 46 of which were for associated cardiac injury. Prophylactic antibiotics were not given routinely. Severe complications occurred in 40 patients (2.2%); 15 developed empyema (0.8%) and 25 died (1.4%), mainly from ongoing haemorrhage. The early identification of patients needing operative or other intervention minimises the hospital stay and complications associated with residual blood in the pleural cavity. This study shows that the short-period drainage protocol used gives very acceptable results in the treatment of traumatic haemothorax.

Conservative management of abdominal injuries: audit of criteria for discharge.

This prospective study was conducted to audit the discharge criteria of patients admitted for the conservative management of abdominal trauma. A total of 184 patients who were admitted to Groote Schuur Hospital (GSH) with penetrating or blunt abdominal injuries and who were conservatively managed according to the GSH protocol were assessed. The study concluded that patients with abdominal trauma who do not require emergency laparotomy can be safely discharged after a period of conservative management provided they are pain-free, hungry and passing flatus.

Traumatic rhabdomyolysis from severe beating--experience of volume diuresis in 200 patients.

Fluid loading with balanced salt solution (BSS) was carried out in 200 patients with extensive soft tissue injuries from severe beatings. Urinary volume and dipstick specific gravity testing were used to monitor renal function with administration of furosemide for persistent oliguria. Acute intrinsic renal failure (AIRF) occurred in 21 patients (10.5%) and five patients died (2.5%); two of hyperkalemia, two of sepsis and one of multiple organ failure. Significantly increased rates of AIRF and death were associated with injury-admission intervals of more than 12 hours, severe metabolic acidosis, low initial hemoglobin, heavy pigmenturia, and high serum creatine kinase (CK) levels. An increased serum creatinine/BUN ratio was noted in four of the five patients who died. An average of 7.5 L fluids was needed in non-AIRF patients to achieve adequate diuresis with a mean positive fluid balance of 4.7 L. No patient without pigmenturia developed AIRF. Balanced salt solution volume diuresis supplemented with furosemide as necessary appears to be safe and effective in preventing AIRF in soft tissue injuries sustained in beatings.

Low initial hemoglobin levels in trauma patients: an important indicator of ongoing hemorrhage.

The initial hemoglobin (Hb) levels and vital signs of 1,000 patients treated with intravenous infusion in the admission area of Groote Schuur Hospital Trauma Unit were recorded. The mean Hb level of 860 patients with mild or no signs of shock was 12.7 g/dL. Lower mean Hb levels were noted in 91 moderately shocked patients (11.8 g/dL, p less than 0.0001) and 49 severely shocked patients (9.9 g/dL, p less than 0.00001). In 140 patients with systolic blood pressure (SBP) under 80 mm Hg on admission, mortality was increased in those with a Hb level under 8 g/dL (p less than 0.001), and a reduced mean Hb level was observed in 11 who died of hypovolemia (6.8 g/dL) compared with 6 dying of nonhypovolemic causes (11.7 g/dL), 10 dying of multiple causes (10.2 g/dL), or 113 survivors (11.7 g/dL, p less than 0.000001). In 31 patients with initial Hb levels of less than 8 g/dL, the overall mortality was 48.4%, compared with 2.6% in 969 patients whose initial Hb level was 8 g/dL or more (p less than 0.00001). Hypovolemia was judged to be the major factor in causing death in 13 (86.7%) of the 15 patients with a Hb level under 8 g/dL who died. A low Hb level observed soon after injury is usually an indicator of serious ongoing hemorrhage and has important implications for management and prognosis. Measurement of the Hb level may prove useful in prehospital assessment of the level of trauma care required and also in injury severity scoring as a predictor of mortality.

Tension pneumopericardium following stab wounds to the chest: report of two cases.

Two cases of tension pneumopericardium following stab wounds to the chest are reported. The first presented with delayed onset respiratory distress and a precordial systolic murmur, and was treated by thoracotomy. The second presented with acute cardiac tamponade and was treated by needle aspiration. The clinical and radiological features of tension pneumopericardium and its treatment are reviewed.

Involuntary defaecation in acutely injured patients: a useful clinical sign.

The phenomenon of involuntary defaecation following acute, severe injuries has never been documented before, but has been noted by those who work in major trauma units. The exact cause of the phenomenon is unknown. We prospectively noted 14 patients who involuntarily defaecated in a 3-month period and analysed their clinical findings retrospectively. Involuntary defaecation occurred only in patients with severe penetrating or blunt injuries. In those with precordial stabs, involuntary defaecation was particularly predictive of cardiac injury, and in all injuries was associated with higher surgical intervention and mortality rates. The occurrence of involuntary defaecation in injured patients is a useful sign that nearly always indicates the need for urgent intervention.

Esophageal obstruction by phytobezoar. Rare complication of gastric bezoar.

We describe a patient in whom a gastric phytobezoar was regurgitated into the esophagus during an episode of vomiting, giving rise to sudden dysphagia. The bezoar remained impacted for 3 days during which time a sever ulcerative esophagitis due to pressure necrosis and secondary infection developed. Healing has been accompanied by esophageal stricture formation which still necessitates esophageal dilatation at intervals.