Guided percutaneous drainage for posttraumatic empyema thoracis.

BACKGROUND: Guided percutaneous drainage (GPD) is used in the management of posttraumatic empyema thoracis; however, its equivalence to decortication has not been evaluated. METHODS: We retrospectively reviewed the records of 12 patients who underwent GPD and nine who were treated with decortication. RESULTS: No primarily GPD-managed empyemas necessitated a subsequent thoracotomy. The size and number of fibrinopurulent loculations treated by each technique were equivalent. Sterile purulent collections were found in 55.6% of decortication-treated patients and in 33% of patients who underwent GPD. Intrapleural analgesia was administered to 71.4% of decortication-treated patients and 28.6% of GPD-treated patients. Five patients undergoing decortication required intensive care unit monitoring after operation (average, 2.8 days), compared with no GPD-treated patients. The catheter was left in place at discharge in 41.6% of GPD-treated patients and was removed on an outpatient basis. CONCLUSIONS: The efficacy of GPD in handling loculated pleural space infections equals that of decortication. An intensive care unit stay is avoided. The ability to discharge patients with external drainage catheters and the decreased requirement of pain control should reduce the number of inpatient hospital days. GPD is an effective first-line approach for posttraumatic empyema thoracis.

Positron emission tomography in diagnosis of occult adenocarcinoma of the breast.

Occult adenocarcinoma with clinically apparent axillary lymphadenopathy represents a challenging surgical problem. Mammography is frequently unable to identify a primary breast carcinoma, and extramammary sources are common and equally difficult to identify. This may leave the clinician and patient with a conundrum of whether to proceed with "blind" mastectomy. A 35-year-old white female presented with axillary adenopathy and a normal breast physical exam. Mammography was unable to demonstrate a specific tumor. Excisional biopsy of the axillary lymph node demonstrated metastatic adenocarcinoma. Positron emission tomography showed increased uptake in the breast and the axilla, consistent with breast carcinoma and axillary metastases. The patient underwent modified radical mastectomy and pathologic review of the specimen proved infiltrating ductal carcinoma in the breast with metastatic nodes. Positron emission tomography may be helpful in localizing occult carcinoma of the breast that presents with metastatic lymph nodes and in excluding other potential primaries.

Evaluation of acute mental status change in the nonhead injured trauma patient.

Acute mental status change in the first 24 hours after trauma is uncommon in nonhead injured patients who initially present with a normal sensorium. Although arterial hypoxemia is the classic etiology for such a mental status change, three less common etiologies should always be considered: cerebral fat embolism, blunt carotid artery injury, and vertebrobasilar artery thrombosis. Prompt diagnosis and appropriate treatment can significantly improve patient morbidity and mortality. Three nonhead injured trauma patients are described illustrating cerebral fat embolism, blunt carotid artery injury, and vertebrobasilar artery thrombosis as causes of acute mental status change. Each patient initially presented with a clear sensorium, but subsequently developed neurological deficits within 24 hours after admission. All had a normal admission CT scan of the head. MRI or conventional arteriography was diagnostic in each case. Any patient who is initially lucid and subsequently develops a neurological deficit, or a patient whose neurological status does not correlate with brain CT findings should undergo immediate evaluation for possible cerebral fat embolism or cervical vessel injury. An algorithm for management of nonhead injured trauma patients with acute mental status deterioration is presented.

Percutaneous endoscopic gastrostomy in patients with an open abdomen.

Percutaneous endoscopic gastrostomy is a commonly performed procedure for enteral access. In the past decade surgeons have used the open abdomen technique with increased frequency for the treatment of intra-abdominal compartment syndrome. Because these patients often have associated malnutrition long-term enteral access is complicated by the massive ventral hernia. We reviewed the records of two patients with an open abdomen who needed long-term enteral access. Both patients had a large midabdominal soft tissue defect, which posed a concern about the technique for gastrostomy creation. Both patients underwent percutaneous endoscopic gastrostomy. In each case the entrance site was located on a portion of intact abdominal wall lateral to the open abdomen tissue defect. No intraoperative or postoperative complications were noted. We conclude that percutaneous endoscopic gastrostomy can be safely performed in patients with an open abdomen. Adherence to standard principles of performing percutaneous endoscopic gastrostomy allows for enteral access in these patients.

An unusual case of corneal perforation secondary to Pseudomonas keratitis complicating a patient's surgical/trauma intensive care unit stay.

We report a case of corneal perforation secondary to bacterial keratitis caused by Pseudomonas aeruginosa in a trauma patient in our intensive care unit. A 43-year-old man was involved in a motorcycle crash and suffered multiple injuries necessitating a prolonged intensive care unit (ICU) stay. Subsequently P. aeruginosa was cultured from his sputum, blood, and open abdomen. He developed a bacterial keratitis in his right eye, which also grew P. aeruginosa. This infection rapidly progressed to corneal perforation requiring a Gunderson conjunctival flap and lateral tarsorrhaphy in addition to aggressive antibiotic treatment. At the time of discharge from the hospital the patient had the return of vision to light only in his right eye. Corneal perforation is an unusual event in the ICU. Prevention or early detection of bacterial keratitis with aggressive antibiotic treatment is needed to prevent such complications. Pseudomonas is one of the more virulent organisms that can infect the cornea and early identification is paramount for a good outcome. Management of this complicated case is discussed and the limited amount of literature on nosocomial bacterial keratitis in the ICU is reviewed.

The natural history of extremity venous repair performed for trauma.

Surgical repair of extremity venous injuries remains controversial. Literature supports both ligation and repair when analyzed for functional recovery. However, few studies review the natural history of venous repair for trauma. Twenty patients were prospectively enrolled in a protocol of immediate repair of major extremity veins. Simple venorraphy and complex reconstructions were performed at the discretion of the operative team. Patients were studied by contrast venogram on postoperative day 3 and 6 weeks after surgery. Patients with occluded repairs at 3 days received a 5-day course of intravenous anticoagulation and were discharged. Overall, patency at 3 days was 55 per cent and increased to 88 per cent at 6 weeks (P < 0.02). Lateral venorraphy and direct reapproximation had higher patency rates than complex repairs at 6 weeks (92% versus 50%; P < 0.05). All veins that were patent at 3 days remained patent (correlation coefficient 1.0). Repair of traumatized extremity veins carries minimal morbidity and has a high rate of early and eventual patency. Long-term anticoagulation in the face of early thrombosis is unnecessary.

Ingested endotracheal tube in an adult following intubation attempt for head injury.

General surgeons are often consulted for assistance in the management of ingested foreign bodies. Deglutition of an endotracheal tube is an unusual complication of airway management. In these cases, the artificial airway is "lost" when it becomes lodged deep into the esophagus. Endoscopic extraction has been described as therapeutic. We report a case in which prehospital endotracheal intubation attempt for the management of closed head injury resulted in a swallowed endotracheal tube. The tube remained undetected until radiographs were performed for a second unrelated traumatic event 2 years later. Endoscopic extraction was unsuccessful, due to rigidity of the tube. Surgical extraction via gastrotomy was uneventful. Surgeons involved in trauma and other emergency settings should be aware of this complication and options in management.

Urgent lobectomy and pneumonectomy.

A small number of trauma patients with penetrating thoracic trauma will require formal pulmonary resections to repair severe injuries or control massive haemorrhage. Although previous reports on this subject have addressed the management of these injuries in battle conditions, civilian experience with this type of chest injury is limited. In a 3-year period, 259 patients underwent urgent thoracotomies for penetrating thoracic trauma. We retrospectively reviewed 43 patients who underwent lobectomies or pneumonectomies to control bleeding (93%) or bronchial injuries (7%). Handguns were the aetiologic agent in 41 patients (95%). The most common complication, pneumonia, was seen in 21 patients (87%). Fifteen patients (62%) developed respiratory failure. The complications of wound infection, post-operative haemorrhage and empyema were seen in equal frequency in four patients (16%). Two patients (8%) developed bronchopleural fistulas. Nine pneumonectomies and 34 lobectomies were performed with mortality rates of 66% and 38%, respectively (overall mortality, 44%). Ten (53%) deaths occurred in the operating room, late deaths (2-15 days) were secondary to sepsis and multiple organ dysfunction syndrome (MODS). Currently, the management of patients with devastating thoracic injuries to the thoracic cavity is divided into two stages. First, initial resuscitation with rapid surgery to control major bleeding, cardiac tamponade, tracheal disruptions and potentially lethal air embolism is indicated. Once the life-threatening conditions have been resolved, definitive surgical procedures are performed to repair injuries to any of the thoracic structures.

Utility and cost-savings of diagnostic laparoscopy in low-probability gunshot wounds of the abdomen.

Gunshot wounds of the abdomen are associated with a 90% or greater incidence of intra-abdominal injury, prompting many trauma centers to routinely explore these patients via laparotomy. Increasingly, diagnostic laparoscopy has been used to evaluated the abdomen to exclude peritoneal violation by the missile. Retrospective analysis of the experience at a Level I Trauma Center with 20 isolated abdominal gunshot wound patients who did not have obvious indications for laparotomy such as peritonitis or shock is detailed. Outcome and cost analysis were compared in patients who had diagnostic laparoscopy or laparotomy. Patients who underwent diagnostic laparoscopy instead of laparotomy had a 42% reduction in operative time, a 33% reduction in hospital charges, and a reduction in hospital length of stay from an average of 3.5 days to less than one day. The only operative complication noted was in a patient who underwent laparotomy. Diagnostic laparoscopy may be used in select patients to exclude significant intra-abdominal injuries following gunshot wounds of the abdomen with reduction in health care costs and morbidity.

Trauma on the Internet: early experience with a World Wide Web server dedicated to trauma and critical care.

UNLABELLED: The Internet is the newest and one of the most powerful communications media today. This study evaluates the utility of dissemination of educational information and exchange of ideas related to trauma at a single site on the Internet. A World Wide Web server on a desktop computer provided a library of downloadable medical software, trauma prevention information, and patient case studies. RESULTS: Most server accesses came from connections at other educational institutions (29.6%). Connections by foreign clients accounted for 17.9% of use. Over a 6-month period, the usage increased from an average of 80 files transmitted per day to 600 per day (750% increase). CONCLUSIONS: A trauma and surgical critical care related data server has shown a progressive increase in use in its initial period. Further development by other trauma care providers will be of value in educating the health care community and lay public.

Nutritional support of the gut: how and why.

Trauma, sepsis, and other conditions of stress are characterized by a hypermetabolic state, in which markedly increased substrate availability is required to meet energy demands for tissue repair and host defenses. Inability to meet these increased metabolic demands results in accelerated visceral protein depletion, impaired immune function, and impaired wound healing. In addition, alteration of the gut flora, impaired host immune defenses, or direct gut mucosal injury may result in gut barrier failure. All of the above derangements, acting in concert, may ultimately lead to sepsis or multiple organ failure. Since enteral nutrition improves resistance to experimentally induced infections, blunts the hypermetabolic response to injury, and maintains intestinal structure and function better than parenteral nutrition, there are many reasons to favor a policy of early enteral feeding in critically ill patients. We demonstrated the safety and efficacy of immediate enteral feeding in patients with major thermal injury, and have found this practice to be applicable to a wide variety of other critically ill patients. These patients had not been felt to be candidates for enteral nutrition due to unfounded fears related to the presence of ileus or fresh gastrointestinal anastomosis.

Management of BB shot wounds to the heart.

OBJECTIVE: The aim of this study was to review our experience with BB shot injuries to the heart. DESIGN: This is a retrospective chart review. MATERIALS AND METHODS: Three patients were found to have BB injuries to the heart. All patients were stable upon presentation. Echocardiography localized the BB pellets to the muscular septum. MEASUREMENTS AND MAIN RESULTS: All patients were treated with nonoperative therapy. There was not mortality. One patient developed an interventricular conduction delay that resolved before discharge. CONCLUSIONS: Nonoperative management of stable patients who present with BB wounds to the heart is safe and effective if the BB is intramuscular. An echocardiogram should be used to localize the pellets and evaluate the pericardium.

Compartment syndrome in the critically injured following massive resuscitation: case reports.

Compartment syndrome of the extremities is usually associated with locally mediated events such as ischemia or injury. Three cases are presented of patients who did not sustain direct extremity trauma, but who developed compartment syndrome following massive fluid resuscitation. Global ischemia/reperfusion may be responsible for the observed morbidity. Patients undergoing large volume resuscitation should be closely monitored for this entity.

Value of creatine phosphokinase isoenzyme determinations in the diagnosis of myocardial contusion.

Myocardial contusion is an injury often missed in the patient with severe multisystem trauma. Fifty patients with physical findings or mechanisms of injury that were suggestive of possible nonpenetrating injury to the heart were studied with serial creatine phosphokinase isoenzyme (CPK/MB), continuous arrhythmia monitoring, and ECGs for at least 72 hours. Two-dimensional echocardiograms were obtained on all patients within 48 hours of admission. Seventy-two percent (36 of 50) had detectable CPK/MB. Ten patients had echocardiograms suggestive of cardiac contusion. Of these ten, three had no detectable CPK/MB and six had CPK/MB of less than 5%. CPK/MB had a sensitivity of 70% and a specificity of 27.5%. We conclude that in the patient with multisystem injury, CPK/MB determinations are not reliable. The decision to evaluate the patient with echocardiography should be made on the basis of physical findings and, more importantly, on mechanism of injury.

Preload assessment in patients with an open abdomen.

BACKGROUND: Intra-abdominal hypertension and abdominal compartment syndrome cause significant morbidity and mortality in surgical and trauma patients. Maintenance of intravascular preload and use of open abdomen techniques are essential. The accuracy of pulmonary artery occlusion pressure (PAOP) and central venous pressure (CVP) in patients with intra-abdominal hypertension has been questioned. METHODS: Twenty surgical and trauma patients with intra-abdominal hypertension requiring open abdominal decompression were monitored using volumetric thermodilution pulmonary artery catheters. Hemodynamic, oxygenation, inspiratory, and intravesicular pressure measurements were collected prospectively. PAOP, CVP, and right ventricular end-diastolic volume index (RVEDVI) were compared as estimates of preload status. RESULTS: Multiple regression analysis demonstrated that cardiac index correlated significantly better with RVEDVI (r = 0.69) than with PAOP (r = -0.27) or CVP (r = -0.28) during resuscitation after open abdominal decompression (p < 0.0001). CONCLUSION: RVEDVI is superior to PAOP and CVP as an estimate of preload status in patients with an open abdomen.

The role of MyD88 and TLR4 in the LPS-mimetic activity of Taxol.

Taxol can mimic bacterial lipopolysaccharide (LPS) by activating mouse macrophages in a cell cycle-independent, LPS antagonist-inhibitable manner. Macrophages from C3H/HeJ mice, which have a spontaneous mutation in Toll-like receptor 4 (TLR4), are hyporesponsive to both LPS and Taxol, suggesting that LPS and Taxol may share a signaling pathway involving TLR4. To determine whether TLR4 and its interacting adaptor molecule MyD88 are necessary for Taxol's LPS mimetic actions, we examined Taxol responses of primary macrophages from genetically defective mice lacking either TLR4 (C57BL/10ScNCr) or MyD88 (MyD88 knockout). When stimulated with Taxol, macrophages from wild-type mice responded robustly by secreting both TNF and NO, while macrophages from either TLR4-deficient C57BL/10ScNCr mice or MyD88 knockout mice produced only minimal amounts of TNF and NO. Taxol-induced NF-kappa B-driven luciferase activity was reduced after transfection of RAW 264.7 macrophages with a dominant negative version of mouse MyD88. Taxol-induced microtubule-associated protein kinase (MAPK) activation and NF-kappa B nuclear translocation were absent from TLR4-null macrophages, but were preserved in MyD88 knockout macrophages with a slight delay in kinetics. Neither Taxol-induced NF-kappa B activation, nor I kappa B degradation was affected by the presence of phosphatidylinositol 3-kinase inhibitors. These results suggest that Taxol and LPS not only share a TLR4/MyD88-dependent pathway in generating inflammatory mediators, but also share a TLR4-dependent/MyD88-independent pathway leading to activation of MAPK and NF-kappa B.

Mathematical coupling does not explain the relationship between right ventricular end-diastolic volume and cardiac output.

OBJECTIVE: To evaluate the clinical significance of mathematical coupling on the correlation between cardiac output and right ventricular end-diastolic volume (RVEDV) through measurement of cardiac output by two independent techniques. DESIGN: Prospective, observational study. SETTING: Surgical intensive care unit in a level 1 trauma center. PATIENTS: Twenty-eight critically ill surgical patients who received mechanical ventilation and hemodynamic monitoring with a pulmonary artery catheter. INTERVENTIONS: A pulmonary artery catheter designed to measure right ventricular ejection fraction (RVEF) and cardiac output by the intermittent bolus thermodilution (TDCO) method and continuous cardiac output by the pulsed thermal energy technique was placed. A computerized data logger was used to collect data simultaneously from the RVEF/TDCO system and the continuous cardiac output system. MEASUREMENTS AND MAIN RESULTS: Two hundred forty-nine data sets from 28 patients were compared. There is statistical correlation between TDCO and continuous cardiac output measurements (r = 0.95, p < 0.0001) with an acceptable bias (-0.11 L/min) and precision (+/-0.74 L/min). The correlation was maintained over a wide range of cardiac outputs (2.3-17.8 L/min). There is a high degree of correlation between RVEDV and both TDCO (r = 0.72, p < 0.0001) and independently measured continuous cardiac output (r = 0.68, p < 0.0001). These correlation coefficients are not statistically different (p = 0.15). CONCLUSIONS: The continuous cardiac output technique accurately approximates cardiac output measured by the TDCO method. RVEDV calculated from TDCO correlates well with both TDCO and independently measured continuous cardiac output. Because random measurement errors of the two techniques differ, mathematical coupling alone does not explain the correlation between RVEDV estimates of preload and cardiac output.