Ultrasound-guided tracheostomy--not for the many, but perhaps the few... or the one.

Percutaneous tracheostomy has become a routine procedure in most intensive care units, and point of care ultrasound is becoming used with greater frequency to augment diagnosis and therapy for critically ill patients. The case series from Rajajee and colleagues incorporates 'real-time' ultrasound in an effort to improve the safety of percutaneous tracheostomy. While their report does not prove that ultrasound should be used prior to or during all percutaneous tracheostomies, it does reinforce several important safety considerations concerning the anatomy of the neck, and in particular the potential to encounter bleeding complications during these procedures.

Access to trauma systems in Canada.

BACKGROUND: Trauma is a leading cause of morbidity, potential years of life lost and health care expenditure in Canada and around the world. Trauma systems have been established across North America to provide comprehensive injury care and to lead injury control efforts. We sought to describe the current status of trauma systems in Canada and Canadians' access to acute, multidisciplinary trauma care. METHODS: A national survey was used to identify the locations and capabilities of adult trauma centers across Canada and to identify the catchment populations they serve. Geographic information science methods were used to map the locations of Level I and Level II trauma centers and to define 1-hour road travel times around each trauma center. Data from the 2006 Canadian Census were used to estimate populations within and outside 1-hour access to definitive trauma care. RESULTS: In Canada, 32 Level I and Level II trauma centers provide definitive trauma care and coordinate the efforts of their surrounding trauma systems. Most Canadians (77.5%) reside within 1-hour road travel catchments of Level I or Level II centers. However, marked geographic disparities in access persist. Of the 22.5% of Canadians who live more than an hour away from a Level I or Level II trauma centers, all are in rural and remote regions. DISCUSSION: Access to high quality acute trauma care is well established across parts of Canada but a clear urban/rural divide persists. Regional efforts to improve short- and long-term outcomes after severe trauma should focus on the optimization of access to pre-hospital care and acute trauma care in rural communities using locally relevant strategies or novel care delivery options.

Extravasation of intravenous computed tomography scan contrast in blunt abdominal and pelvic trauma.

BACKGROUND: Intravenous contrast extravasation (CE) on computed tomography (CT) scan in blunt abdominal trauma is generally regarded as an indication for the need for invasive intervention (either angiography or laparotomy). More recently, improvements in CT scan technology have increased the sensitivity in detecting CE, and, thus, we postulate that not all patients with this finding require intervention. METHODS: This study is a retrospective review of all patients who underwent a CT scan for blunt abdominal trauma between January 1999 and September 2003. Patterns of injury, associated injuries, management, and outcomes were examined for patients with CE. RESULTS: Seventy of 1,435 patients (4.8%) demonstrated CE. Mean age was 44 years and mean Injury Severity Score was 39. The location of CE was intra-abdominal in 25, pelvis/retroperitoneum in 39, and both areas in 3 patients. Six patients received supportive treatment for nonsurvivable head injury and were excluded from further analysis. Overall, 30 (47%) patients underwent immediate intervention (angiography or laparotomy) and 34 (53%) were managed nonoperatively. Of those who had initial nonoperative management, overall seven (20.5%) underwent intervention, with the remainder being managed without intervention. The success for nonoperative management was greater for those with pelvic/retroperitoneal CE (4 of 7: 57%) than for intra-abdominal extravasation (23 of 27: 85%). CONCLUSION: Although evidence of CE may suggest significant vascular injury, our data suggest that not all patients require invasive intervention. Further studies are needed to better define criteria for nonoperative management in patients with CE identified on their initial CT scan.

Association between alcohol and mortality in patients with severe traumatic head injury.

HYPOTHESIS: Admission blood alcohol concentration (BAC) is associated with in-hospital death in patients with severe brain injury from blunt head trauma. DESIGN: Retrospective cohort study. SETTING: Academic level I trauma center in Toronto, Ontario. PATIENTS: Using trauma registry data, between January 1, 1988, and December 31, 2003, we identified 1158 consecutive patients with severe brain injury from blunt head trauma. INTERVENTION: There was no active intervention. The primary exposure of interest was the BAC at admission, stratified into the following 3 levels: 0, no BAC; 0 to less than 230 mg/dL, low to moderate BAC; and 230 mg/dL or greater, high BAC. MAIN OUTCOME MEASURE: In-hospital death. RESULTS: In patients with severe brain injury, low to moderate BAC was associated with lower mortality than was no BAC (27.9% vs 36.3%; P = .008). High BAC was associated with higher mortality than was no BAC (44.7% vs 36.3%), although this was not statistically significant (P = .10). These associations were all statistically significant after adjusting for demographic data and injury factors using logistic regression analysis. The odds ratio for death was 0.76 (95% confidence interval, 0.52-0.98) for low to moderate BAC compared with no BAC. The odds ratio for death was 1.73 (95% confidence interval, 1.05-2.84) for high BAC compared with no BAC. CONCLUSIONS: Low to moderate BAC may be beneficial in patients with severe brain injury from blunt head trauma. In contrast, high BAC seems to have a deleterious effect on in-hospital death in these patients, which may be related to its detrimental hemodynamic and physiologic effects. Alcohol-based fluids may have a role in the management of patients with severe brain injury after they have been well resuscitated.

Emergent right hemicolectomies.

Emergent right hemicolectomies have historically been associated with surprisingly high morbidity and mortality rates. A retrospective review of emergent right hemicolectomies over a 7-year period was performed to assess current morbidity and mortality. Emergent right hemicolectomy was defined as a procedure performed for an acute abdomen with no formal preoperative cleansing of the colon. Demographic data, diagnostic evaluation, length of stay and outcomes were evaluated. Over the study period, 122 emergent right hemicolectomies were performed on both general surgery and trauma patients. The average patient was 52.9 +/- 18.5 years old, and the majority of patients (66.4%) were male. The indications for the procedures performed were bowel perforation (51), hemorrhage (25), cancer (16), benign obstruction (14), phlegmon (8), ischemia (6), or other (2). Resection with primary anastomosis was performed in 98 patients, 16 had an end ileostomy, and 8 underwent damage control procedures in which gastrointestinal continuity was not reestablished at the time of the original operation. Postoperative complications developed in 48 patients (39.3%). The majority of the complications (83.3%) were related to infection including intra-abdominal abscess (21 patients), sepsis (16), and wound infection (5). Other complications included anastomotic leak (5), wound dehiscence (3), stoma-related (3) and postoperative bowel obstruction (2). The patients who developed complications did not differ from those who had an uneventful postoperative course in terms of age, indication for procedure, or presence of intraabdominal abscess or gross contamination at the time of the original procedure. The overall mortality rate was 13 per cent. Patients who died were older than those who lived (63 +/- 19 vs 52 +/- 18; P = 0.03) and were significantly more likely to have evidence of shock on presentation (P = 0.0013). Emergent right hemicolectomies continue to be associated with high morbidity and mortality rates. The most common complications are related to infection. Age and manifestations of shock at the time of admission are strong predictors of mortality.

Are resuscitation and operation justified in injured patients with extreme base deficits (less than -20)?

BACKGROUND: This study assessed the outcome of injured patients in shock with an admission base deficit of -20 or less (approximate pH <7.0) at a level 1 trauma center. METHODS: A retrospective review was made of the trauma registry, supplemented by chart review, of all trauma patients admitted with a base deficit -20 or less from 1995 to 2002. Data collected included mechanism of injury, base deficit, Injury Severity Score(ISS), operative procedures, and outcome. Data are presented as mean +/- SD. RESULTS: Over the study period, 110 trauma patients (88% male; 31 +/- 13 years; 34% blunt trauma; ISS 26 +/- 15) were admitted with base deficit of -20 or less. Overall survival was 38%, with the majority of deaths occurring within hours of admission. CONCLUSIONS: An admission base deficit of -20 or less is associated with high mortality in patients with gunshot wounds (64%) or blunt trauma (70%). The majority of patients who die will do so within hours of admission. Beyond 24 hours, the survival rates of 73% for patients with blunt trauma, 79% for those with gunshot wounds, and 90% for those with stab wounds justify continuing resuscitation and reoperations.

A two institution experience with 226 endoscopically placed jejunal feeding tubes in critically ill surgical patients.

BACKGROUND: Early jejunal feeding after surgery or trauma reduces infectious complications. Although not ideal gastric and postpyloric feedings are often used, however, because of difficulty in placing feeding tubes distal to the ligament of Treitz (LOT). Our hypothesis was that feeding tube placement distal to the LOT can be accomplished using a bedside transendoscopic technique. METHODS: Transendoscopic jejunal (TEJ) tube placement and TEJ tubes inserted simultaneously through percutaneous gastrostomy (PEG) tubes (PEG/TEJ) were attempted to be placed distal to the LOT. RESULTS: In all, 226 feeding tubes (185 TEJ, 41 PEG/TEJ) were placed in 179 trauma and 47 nontrauma patients over 3 years (August 20, 1998 to July 15, 2001). Tube location was jejunal in 93.8% of trauma patients, 76.6% of nontrauma patients, and 90.3% of all patients. (Confidence intervals were 89.3% to 96.5%, 62.8% to 86.4%, and 85.7% to 93.5%). Days of total parenteral nutrition were reduced 71.3% in trauma patients, 22.8% in nontrauma patients, and 45% overall at one institution. CONCLUSIONS: Bedside TEJ and PEG/TEJ placement is safe and successful in placing feeding tubes distal to the LOT in more than 90% of critically ill surgical patients.

Assessment of initial base deficit as a predictor of outcome: mechanism of injury does make a difference.

Initial base deficit in injured patients has been shown to predict the adequacy of resuscitation and outcome. The usefulness of base deficit as a predictor of outcome, however, may be dependent on the mechanism of injury. We conducted a retrospective review of the trauma registry, supplemented by chart review, of all trauma patients treated at a Level I trauma center from January 1995 through July 2001. Data collected included mechanism of injury, base deficit, Injury Severity Score, and outcome. From 1995 through 2001 a total of 3275 patients (23% of trauma admissions) at a mean age of 34 +/- 15 years had a base deficit recorded at the time of admission. The patients were 78 per cent male, and the mechanism of injury was blunt trauma in 58.2 per cent. Mortality increased with successive increases in base deficit but was markedly lower for a given base deficit in those patients having sustained stab wounds and/or severe lacerations as compared with those with gunshot wounds or blunt trauma. The value of the base deficit as a predictor of outcome depends upon the mechanism of injury and appears most useful for patients sustaining gunshot wounds or blunt trauma. Future studies in patients with penetrating trauma using base deficit as a predictor of outcome should separate patients with gunshot wounds from those with stab wounds or lacerations.

Perioperative vasopressors are associated with an increased risk of gastrointestinal anastomotic leakage.

BACKGROUND: The purpose of this study was to investigate the effect of vasopressors on gastrointestinal (GI) anastomotic leaks. Vasopressors are commonly used in surgical patients admitted to the intensive care unit (ICU) and their effects on GI anastomotic integrity are unknown. PATIENTS AND METHODS: Surgical patients admitted to the ICU in our tertiary university hospital following the creation of a GI anastomosis were studied by a retrospective chart analysis for anastomotic leaks and complications RESULTS: A total of 223 patients with 259 GI anastomoses, mostly for cancer, were admitted to the ICU immediately after surgery. Twenty-two patients developed anastomotic leaks (9.9%). The two groups (leak versus no-leak) had similar demographics, surgery type and indication, type of anastomosis, co-morbidities, cancer, steroid use, blood transfusion, drains, and epidural catheters. Vasopressor use was associated with increased anastomotic leakage (p = 0.02, OR 3.25). Multiple vasopressors and prolonged exposure caused even higher leaking rates. This effect was independent of the medical status and operative morbidity (APACHE II, POSSUM). Blood pressure preceding vasopressor use was similar in both groups. Vasopressors might have been occasionally used to treat hypovolemia. Patients with leaks had higher reoperation rates (41% versus 1%, p < 0.0001) and mortality (21% versus 4%, p = 0.002). CONCLUSIONS: Vasopressors appear to increase anastomotic leaks threefold, independent of clinical/surgical status or hypotension. Evidence-based guidelines are warranted for the optimal use of vasopressors in postoperative patients admitted to the ICU.

Preventable deaths from hemorrhage at a level I Canadian trauma center.

BACKGROUND: Studies of trauma deaths have had a tremendous impact on the quality of contemporary trauma care. We studied causes of trauma death at a Level I Canadian trauma center, and tabulated preventable deaths from hemorrhage using explicit criteria. METHODS: Trauma registry data were used to identify all trauma deaths at our institution from January 1, 1999 to December 31, 2003. Demographics, mechanism, and time or location of death were recorded. Registry data analysis and selective chart or autopsy review were then performed to assign causes of death. RESULTS: A total of 558 consecutive trauma deaths were reviewed. Mean age was 48.7 (46.7-50.6), and mean Injury Severity Score was 38.8 (37.6-40.0); 29% were females. Blunt trauma represented 87% of all cases; penetrating injuries were only 13%. Central nervous system (CNS) injuries were the most frequent cause of death (60%), followed by hemorrhage (15%), and then combination CNS and hemorrhagic injuries (11%). Multiple organ failure caused 5% of deaths and 9% of deaths were from other causes. Of hemorrhagic deaths, 48% (n = 41) were from blunt injury, and 52% (n = 45) were from a penetrating mechanism. Of these hemorrhagic deaths, 16% were judged to be preventable because of significant delays in identifying the major source of hemorrhage. Hemorrhage from blunt pelvic injury was the major cause of exsanguination in 12 of 14 of these preventable deaths. CONCLUSIONS: Blunt injury is the major mechanism leading to trauma deaths. Massive bleeding from blunt pelvic injury is the major cause of preventable hemorrhagic deaths in our study.

Radiation exposure from diagnostic imaging in severely injured trauma patients.

BACKGROUND: Trauma patients often require multiple imaging tests, including computed tomography (CT) scans. CT scanning, however, is associated with high-radiation doses. The purpose of this study was to measure the radiation doses trauma patients receive from diagnostic imaging. METHODS: A prospective cohort study was conducted from June 1, 2004 to March 31, 2005 at a Level I trauma center in Toronto, Canada. All trauma patients who arrived directly from the scene of injury and who survived to discharge were included. Three dosimeters were placed on each patient (neck, chest, and groin) before radiologic examination. Dosimeters were removed before discharge. Surface doses in millisieverts (mSv) at the neck, chest, and groin were measured. Total effective dose, thyroid, breast, and red bone marrow organ doses were then calculated. RESULTS: Trauma patients received a mean effective dose of 22.7 mSv. The standard "linear no threshold" (LNT) model used to extrapolate from effects observed at higher dose levels suggests that this would result in approximately 190 additional cancer deaths in a population of 100,000 individuals so exposed. In addition, the thyroid received a mean dose of 58.5 mSv. Therefore, 4.4 additional fatal thyroid cancers would be expected per 100,000 persons. In all, 22% of all patients had a thyroid dose of over 100 mSv (mean, 156.3 mSv), meaning 11.7 additional fatal thyroid cancers per 100,000 persons would result in this subgroup. CONCLUSION: Trauma patients are exposed to significant radiation doses from diagnostic imaging, resulting in a small but measurable excess cancer risk. This small individual risk may become a greater public health issue as more CT examinations are performed. Unnecessary CT scans should be avoided.

Traumatic abdominal wall hernia: epidemiology and clinical implications.

BACKGROUND: Traumatic abdominal wall hernias (TAWHs) are uncommon, and it remains controversial whether such patients require urgent laparotomy. As such, this study was undertaken to assess the clinical sequelae of operative versus nonoperative management of TAWH, and whether certain patient or injury characteristics are predictive of the need for early surgery. METHODS: Retrospective review of all patients presenting acutely with a TAWH at a Regional Trauma Center from January 2000 to December 2004. RESULTS: Thirty-four patients were identified (age 39 +/- 12 years; Injury Severity Score 31 +/- 13). The most frequent mechanism of injury was motor vehicle collision (MVC; 24 cases), followed by motorcycle collision (6) and falls (4). The diagnosis of a TAWH was made primarily by computed tomography scan. Overall, 19 patients underwent urgent laparotomy or laparoscopy (56%) and 15 patients required bowel resection (44%). TAWH secondary to a MVC more frequently required urgent laparotomy and bowel resection than other mechanisms (p < 0.05). All three patients with clinically apparent anterior TAWH had intra-abdominal injuries and required urgent laparotomy. Only eight patients (24%) had their TAWH repaired acutely. At follow-up, two patients managed nonoperatively had symptomatic hernias, and three patients that had had an early repair had developed recurrent hernias. CONCLUSIONS: First, the mechanism of injury should be considered when deciding if a patient with a TAWH needs an urgent laparotomy. Clinically apparent anterior TAWHs appear to have a high rate of associated injuries requiring urgent laparotomy. Finally, occult TAWHs diagnosed only by computed tomography may not require urgent laparotomy or hernia repair.

Do trauma patients with a Glasgow Coma Scale score of 3 and bilateral fixed and dilated pupils have any chance of survival?

BACKGROUND: Low Glasgow Coma Scale score (GCS) and pupillary status predict poor outcomes in head injury (HI) patients. We compared the mortality of GCS 3 patients having bilateral fixed and dilated pupils (BFDP) with GCS 3 patients having reactive pupils (RP). We then determined if trauma system or patient factors were responsible for the difference in mortality. METHODS: We reviewed all adult, blunt HI patients with GCS=3, admitted to our institution from January 1, 2001 to December 31, 2003. Demographics, injury data, prehospital times, procedures, and outcomes were recorded. RESULTS: During this period, 245 patients were admitted with GCS of 3, and met inclusion criteria. In all, 173 patients were analyzed, after excluding 23 patients who were dead-on-arrival, and 45 others, who were intoxicated with alcohol, or received paralytic agents in the trauma room. All BFDP patients died, whereas 42.0% of reactive pupil (RP) patients died (p < 0.0001). With regards to patient factors, BFDP patients were more likely to be unstable, have extra-axial bleeding, and evidence of midline shift and/or herniation. Trauma system factors, however, may also have had an impact on outcome. Despite having more extra-axial bleeding, BFDP patients were less likely to have a neurosurgical operation than RP patients. CONCLUSION: Patients with GCS of 3 and BFDP have a dismal prognosis. These patients have suffered devastating brain injuries and tend to be hemodynamically unstable. Clinicians, however, are less likely to aggressively treat BFDP patients than RP patients. Further prospective studies are required to determine which patients with GCS of 3 and BFDP are likely to benefit from aggressive treatment.

Diagnosis and outcome of blunt caval injuries in the modern trauma center.

BACKGROUND: Blunt vena caval injury (BCI) is uncommon with only a few published reports in the literature. Recently, with high resolution computed tomography (CT) scan imaging signs of caval injury are sometimes found in hemodynamically stable patients. The purpose of this study was to assess the current course of patients with BCI. METHODS: Retrospective review of all patients with BCI treated at a Regional Trauma Center from April 1999 to May 2005. Data collected included demographics, mechanism of injury, associated injuries, diagnostic investigations, surgical findings, and outcomes. RESULTS: During the 6-year study period, 10 patients presented with BCI (age 42 +/- 19 years; 70% mortality; Injury Severity Score 39 +/- 15). The spectrum of vena cava injury ranged from an intimal flap to extensive destruction. Six of the seven deaths were secondary to exsanguination and one secondary to severe brain injury. Four patients presented with refractory shock and were taken emergently to surgery (all died). Six patients responded to fluid resuscitation and underwent CT imaging (three out of six survived). Although active venous contrast extravasation was not seen in any patient, all six had indirect signs on CT suggestive of BCI. Overall, the diagnosis of BCI was confirmed at surgery in nine patients. The remaining patient had an intimal flap and contained pericaval hematoma confirmed by ultrasound, and was successfully managed nonoperatively. CONCLUSIONS: The spectrum of BCI ranges from intimal flaps to extensive destruction. CT imaging may not diagnose or may underestimate the severity of BCI. Stable patients with intimal flaps and contained hematoma may be successfully managed nonoperatively.

Risk and benefit of intravenous contrast in trauma patients with an elevated serum creatinine.

OBJECTIVE: Assess if the benefits outweigh the risks of intravenous (iv) contrast in trauma patients who present with an elevated serum creatinine (Cr). BACKGROUND: Radiologic investigations with iv contrast are often used in trauma patients to rapidly assess for life threatening injuries. However, contrast nephropathy (CNP) is associated with increased morbidity and mortality. This poses a dilemma for the physician who must weigh the risks and benefits of proceeding with iv contrast versus the risks of missed injuries/delayed diagnosis. METHODS: A 2 year (2002-2003) retrospective chart review of all trauma patients presenting with an elevated Cr(> or =1.3 mg/dL or > or =115 micromol/L). Results are mean +/- sd (p < 0.05 significant). RESULTS: Ninety-five patients (age 51 +/- 23 years; ISS 31.7 +/- 15.6; hospital stay 29 +/- 32 days; mortality 9%) presented with a Cr > or = 1.3 mg/dL (31 with Cr > or =1.7; 3 dialysis dependent). Fifty-six (59%) were given iv contrast (C+), of which only 2 (3%) had a transient rise of 25% in Cr within 48 hours versus 6 (16%) patients not exposed to contrast (C-). No C+ patient developed CNP requiring longterm dialysis. Of the 56 undergoing C+ tests, 16 had injuries requiring urgent intervention identified; 16 had injuries that were managed nonoperatively, and 24 had serious injuries ruled out. Of the 39 C- patients, 9 had indeterminate CT's; 2 had missed injuries; and 2 had no intraabdominal injuries found at celiotomy. CONCLUSION: This study suggests the benefits may outweight the risks for proceeding prn with iv contrast in trauma patients with an elevated creatinine. A larger study is needed to confirm these findings.

Secondary extremity compartment syndrome.

BACKGROUND: Abdominal compartment syndrome has been reported to occur after fluid resuscitation in injured patients, even in the absence of intra-abdominal injuries. This report describes a set of patients who developed the secondary extremity compartment syndrome (SECS) in uninjured extremities after resuscitation for other injuries. METHODS: This study was a retrospective chart review of all trauma patients developing SECS at a Level I trauma center. Data are mean +/- SD. RESULTS: From 1996 to 2001, 10 patients (8 men, age 31 +/- 13 years, Injury Severity Score of 29 +/- 17, and 3 with penetrating trauma) from a series of 11,996 trauma admissions developed SECS after resuscitation for other injuries. The mean number of extremities developing the SECS per patient was 3.1. This included compartment syndromes in 10 upper extremities and in 12 lower extremities that did not have any apparent injuries (i.e., contusions, fractures, or vascular injuries). After evaluation by the trauma team, abdominal silos were needed in 7 of the 10 patients also, and the mortality in patients with the SECS was 70%. CONCLUSION: SECS is a rare complication of the postresuscitation systemic inflammatory response syndrome, is associated with significant morbidity, and may be a marker for mortality. SECS should be ruled out by measurement of compartment pressures in uninjured and injured extremities in patients with severe diffuse edema after resuscitation for injury.

Blunt vascular trauma in the extremity: diagnosis, management, and outcome.

BACKGROUND: Blunt vascular trauma in an extremity is an uncommon diagnosis. Considering the complexity of these injuries, it is worthwhile to determine how select factors affect the outcome of the limb and the patient. The objectives of this study were to review the diagnosis, management, and outcomes of patients who sustained blunt vascular injuries in the extremities and relate factors in their treatment to the outcome of the injured extremity. METHODS: A retrospective review of data on adult and pediatric patients who had a diagnosis of blunt vascular injury in an extremity and underwent some attempt at restoration of vascular flow was conducted. RESULTS: From January 1995 to December 2002, 62 patients (80.3% male; mean age, 33.2 +/- 15.8 years) sustained blunt trauma (mean Injury Severity Score, 14.6 +/- 8.4), with 93 vascular injuries in 65 extremities (16 upper and 49 lower). Hard signs of vascular injury occurred in 41 (66%) patients. An associated fracture and/or dislocation was present in 59 patients (95%). Preoperative arteriograms were obtained in 20 patients (17 occlusions, 2 embolizations, and 1 untreated). Vessel injuries were as follows: 16 upper (brachial artery, 50%) and 63 lower (tibial/peroneal/popliteal, 84%), with ligation being the most common treatment in the latter. Intravascular shunts were used to restore blood flow in 18 vessels (13 arteries and 5 veins) in 13 patients. Delays in diagnosis or treatment occurred in six patients, mostly because of errors in management/judgment. Delayed or late fasciotomies were performed in six patients, and five developed rhabdomyolysis. Six patients died. The age (p = 0.0006), Injury Severity Score (p = 0.0007), and Mangled Extremity Severity Score (p = 0.0009) were significantly different for the survivors compared with the nonsurvivors. CONCLUSION: Blunt vascular injuries in the lower extremities occur most commonly in the anteroposterior tibial arteries; injured arteries in the proximal upper and lower extremity require resection with interposition grafting, whereas those in the forearm or calf are usually ligated; the amputation rate in 65 injured extremities with blunt vascular trauma was 18.%, which is at least three times that for those who sustain penetrating injury; and delays in diagnosis and treatment are uncommon in these patients with multiple injuries.

Injurious ventilation induces widespread pulmonary epithelial expression of tumor necrosis factor-alpha and interleukin-6 messenger RNA.

OBJECTIVE: We examined the hypothesis that injurious strategies of mechanical ventilation alter the expression and distribution within the lung of tumor necrosis factor-alpha and interleukin-6 that are both duration and ventilation strategy dependent. SUBJECTS: Male Sprague Dawley rats. INTERVENTIONS: Lungs from rats were preserved immediately after death or were randomized to ex vivo ventilation with either a) noninjurious ventilation; b) high end-inspiratory lung volume with positive end-expiratory pressure (PEEP); c) high end-inspiratory lung volume without PEEP; or d) intermediate lung distension without PEEP, for periods ranging from 30 mins to 3 hrs. MEASUREMENT AND MAIN RESULTS: Changes in cytokines were assessed by in situ hybridization, immunocytochemistry, simultaneous in situ hybridization and immunocytochemistry, Northern analysis, and enzyme-linked immunosorbent assay. Whereas minimal expression of tumor necrosis factor-alpha and interleukin-6 mRNA was found in lungs subjected to noninjurious ventilation, the three injurious strategies resulted in a diffuse increase in expression of tumor necrosis factor-alpha and interleukin-6. The principal cells involved were the bronchial, bronchiolar, and alveolar epithelium. The changes in tumor necrosis factor-alpha mRNA and protein expression were dependent on both duration of ventilation and the ventilation strategy used. CONCLUSIONS: The vast pulmonary epithelium is a major contributor to ventilation-induced changes in cytokine production and may play an important role in the pathogenesis of lung injury and systemic sequelae in ventilated subjects.

Traumatic rupture of the urinary bladder: is the suprapubic tube necessary?

BACKGROUND: Although surgical principles are well accepted for the treatment of an intraperitoneal or extraperitoneal rupture of the urinary bladder, the type and number of drainage catheters needed to obtain a satisfactory outcome with minimal patient morbidity have yet to be determined. METHODS: This was a retrospective review of data on injured patients with the diagnosis of an intraperitoneal or extraperitoneal rupture of the urinary bladder from penetrating or blunt trauma. RESULTS: Of the 51 patients identified, 28 were treated with suprapubic and transurethral catheters, whereas 23 received a transurethral catheter only. Complications and catheter duration times were similar regardless of type of bladder injury or drainage catheter used (p > 0.5). CONCLUSION: These data suggest that there are similar outcomes and complication rates for patients treated with suprapubic and transurethral catheters versus transurethral catheter only. Transurethral catheters alone seem effective in draining all types of bladder injuries.