Fatal hepatic hemorrhage after trauma.

Two hundred twenty-five cases of acute hepatic trauma were reviewed. Thirty-four patients died, 28 (82 per cent) as a direct result of exsanguination. The successful management of hemorrhage associated with severe liver injuries requires early diagnosis, prompt hemostasis and restoration of blood volume, close attention to coagulation factors, and the precise application of surgical techniques.

Failure of splenic implants to protect against fatal postsplenectomy infection.

Overwhelming postsplenectomy infection is not a phenomenon confined to children. In all age groups, splenic trauma that requires surgery should be managed by splenorrhaphy if possible. Autoimplantation of splenic fragments into omental pockets has been performed in the few patients we have seen who required splenectomy. A case has been presented in which these small implants failed to protect a 61 year old woman from the development of fatal pneumococcal sepsis. The patient had received a pneumococcal vaccination, and her implants had shown activity on radionuclide scanning. Concerns about critical splenic mass, blood supply to the implant, and hepatic function require further study before this technique can be considered efficacious.

Complications of tube thoracostomy for acute trauma.

Closed tube thoracostomy is a common and very useful procedure in therapy of acute thoracic injury. However, it is not without risk. With aggressive use of this procedure in the emergency department, the incidence of technical complications was 1 percent. Our review suggests that complications can be further diminished by the routine use of large thoracostomy tubes that are placed well up on the chest after confirmation of an open pleural space, by avoiding the use of a trocar for tube placement, and by the use of a high volume, low pressure suction system. Empyema was the most common complication associated with tube thoracostomy after trauma. It occurred in 2.4 percent of the patients. Its exact causes is not known, and the role of prophylactic antibiotics needs to be established.

Arterial embolism from a bullet: a case report.

Accounting for each wounding bullet represents an important part of the emergency room evaluation of gunshot victims. Physical examination must include a thorough search for exit wounds. Medical personnel must be aware of the possibility of intra-arterial passage of a wounding missile and routinely obtain appropriate roentgenagraphic studies so that patients with arterial bullet embolization will be identified preoperatively and can receive optimal surgical repair of their injuries.

Abdominal stab wounds: evaluation of sinography.

This paper reviews a 30-month experience with 172 patients suffering abdominal stab wounds treated at the Denver General Hospital, during a period when policy included liberal sinography and all penetrating injuries were explored. Laparotomy was performed in 87%. Of the 65 patients undergoing sinography, 62% indicated peritoneal penetration; of these, 30% had no visceral injury. An additional 10%, with minor intraperitoneal injuries, probably would not have required celiotomy. In 25 cases the stab penetrated the peritoneal cavity after first entering the chest. Peritoneal tap and peritoneal lavage were used in 10 patients. It is concluded that the cost/benefit ratio of sinography is so poor that it is rarely indicated. When doubt exists as to significant intraperitoneal pathology following an abdominal stab wound, close observation without sinography is recommended for determining indication for laparotomy.