The role of nephrectomy in the acutely injured.

HYPOTHESIS: The high mortality in patients who undergo nephrectomy after trauma is not secondary to the nephrectomy itself but is the consequence of a more severe constellation of injuries associated with renal injuries that require operative intervention. DESIGN: A retrospective review of all patients identified using International Classification of Diseases, Ninth Revision codes as having sustained renal injuries over a 62-month period. PATIENTS: Seventy-eight patients with renal injuries who underwent exploratory laparotomy were identified. METHODS: All medical records were reviewed for patient management, definitive care, and outcome. Based on outcome, patients were assigned to either the survivor or nonsurvivor group. For patients who underwent nephrectomy, intraoperative core temperature changes, estimated blood loss, and operative time were also reviewed. RESULTS: Seventy-eight patients with renal injuries who underwent exploratory laparotomy were identified. Twenty-nine patients underwent laparotomy with conservative management of the renal injury, of whom 5 (17.2%) died. Twelve patients had renal injuries repaired and all survived. Thirty-seven patients underwent nephrectomy, of whom 16 (43.2%) died. Compared with nephrectomy survivors, nephrectomy nonsurvivors had a significantly lower initial systolic blood pressure, higher Injury Severity Score, higher incidence of extra-abdominal injuries, shorter operative duration, and higher estimated operative blood loss. The nephrectomy survivors' core temperature increased a mean of 0.5 degrees C in the operating room, while the nephrectomy nonsurvivors' core temperature cooled a mean of 0.8 degrees C. CONCLUSIONS: Patients who undergo trauma nephrectomy tend to be severely injured and hemodynamically unstable and warrant nephrectomy as part of the damage control paradigm. That a high percentage of patients die after nephrectomy for trauma demonstrates the severity of the overall constellation of injury and is not a consequence of the nephrectomy itself.

Nonoperative management of solid abdominal organ injuries from blunt trauma: impact of neurologic impairment.

The role of nonoperative management of solid abdominal organ injury from blunt trauma in neurologically impaired patients has been questioned. A statewide trauma registry was reviewed from January 1993 through December 1995 for all adult (age >12 years) patients with blunt trauma and an abdominal solid organ injury (kidney, liver, or spleen) of Abbreviated Injury Scale score > or =2. Patients with initial hypotension (systolic blood pressure <90 mm Hg) were excluded. Patients were stratified by Glasgow Coma Score (GCS) into normal (GCS 15), mild to moderate (GCS 8-14), and severe (GCS < or =7) impairment groups. Management was either operative or nonoperative; failure of nonoperative management was defined as requiring laparotomy for intraabdominal injury more than 24 hours after admission. In the 3-year period 2327 patients sustained solid viscus injuries; 1561 of these patients were managed nonoperatively (66 per cent). The nonoperative approach was initiated less frequently in those patients with greater impairment in mental status: GCS 15, 71 per cent; GCS 8 to 14, 62 per cent; and GCS < or =7, 50 per cent. Mortality, hospital length of stay, and intensive care unit days were greater in operatively managed GCS 15 and 8 to 14 groups but were not different on the basis of management in the GCS < or =7 group. Failure of nonoperative management occurred in 94 patients (6%). There was no difference in the nonoperative failure rate between patients with normal mental status and those with mild to moderate or severe head injuries. Nonoperative management of neurologically impaired hemodynamically stable patients with blunt injuries of liver, spleen, or kidney is commonly practiced and is successful in more than 90 per cent of cases. No differences were noted in the rates of delayed laparotomy or survival between normal, mild to moderately head-injured, and severely head-injured patients.

Evolution in damage control for exsanguinating penetrating abdominal injury.

OBJECTIVE: Damage control (DC) has proven valuable in exsanguinated patients. The purpose of this study was to quantify and qualify the impact of current damage control principles applied in a penetrating abdominal injury (PAI) population. METHODS: Over a 3-year period (June 1997-May 2000), of 271 laparotomies for PAI, 24 patients underwent DC (8.9%). Demographics, injury grade, resuscitative and operative parameters, acid-base status, coagulation profiles, fluid/transfusion requirements, definitive repairs, abdominal closure, complications, and outcomes were reviewed. Data were compared with our DC experience a decade earlier. Fisher's exact test was used for comparisons. RESULTS: Overall survival improved for equivalent Injury Severity Score, Revised Trauma Score, TRISS, admission systolic blood pressure, operating room systolic blood pressure, and Penetrating Abdominal Trauma Index score. Solids (1.2 vs. 1.3), hollow organ (1.5 vs. 1.7), and major vascular injuries (0.5 vs. 0.8) per patient remain unchanged. Currently, there was less hypothermia with equivalent operating room times. In intensive care unit survivors, acid-base status was similar but coagulopathy and hypothermia were less severe. Definitive colon management has shifted from ostomies to anastomoses. Eventual fascial closure occurred in 14 of 19 (74%) compared with 12 of 14 (86%) in the historical group. There were three gastrointestinal fistulae (one pancreatic), one anastomotic leak, and three intra-abdominal abscesses. CONCLUSION: Continued application of DC principles has led to improved survival with PAI. Better control of temperature, experience with the open abdomen, and intensive care unit care may be causative.

Anaphylactic shock from a latex allergy in a patient with spinal trauma.

Allergy to latex is a condition that affects patients as well as health care workers. It is a spectrum of immunologic disorders that ranges from mild hypersensitivity to life-threatening anaphylaxis. Beginning in the early 1970s, the health care community has become more aware of this entity, leading to many improvements in the understanding, diagnosis and treatment of patients with latex allergy. Many hospitals have developed protocols and procedures for patients with latex sensitivity. However, some physicians remain unaware of the logistics of taking care of patients with this disorder. We present a case of a severe anaphylactic reaction to latex in a trauma patient with a spinal cord injury. The difficulty of treating the acutely injured patient with this disorder is illustrated. A list of equipment that may be included in a latex-free emergency kit is provided.

The injured elderly in the trauma intensive care unit.

The injured elderly patient in the ICU presents many challenges. Demographic changes in western society will dramatically increase the patient population in question, and new, older, subsets are growing. The association of severe injury, preinjury comorbidity, and the aging process narrows the ability of the patient to respond to the stress of injury. When compared with younger patients, the elderly have greater mortality, morbidity, and higher costs. Age alone, however, does not predict outcome. Although aggressive or maximally supportive care is advocated, controlled data supporting this approach are lacking. Significant economic, sociologic, and ethical issues confront the care providers in almost every case. Continued and heightened study of all aspects of our injured elders focusing on the determinants of outcome is required. A realistic appraisal of the limitations of care and a reassessment of the financial implications of providing extended care are critical to the continuing ability to respond to this growing need.

Journey towards recovery following physical trauma.

Journey towards recovery following physical trauma Convalescence and recovery following illness are of central importance to nursing. These themes have been explored increasingly in the literature. The focus, however, has been primarily on the process of integrating chronic illness into one's life. Recovery from physical injury is rarely addressed. A body of work focusing on physical trauma demonstrates that recovery is often not complete after injuries that have not been viewed as disabling. To illuminate understanding of recovery following physical trauma, the purpose of our 1997 study was to describe more thoroughly the nature of recovery. A total of 63 adults, in a convenience sample, who survived serious physical trauma, were interviewed 2.5 years after injury using an open-ended semistructured interview guide. Three themes were identified: event, fallout, and moving-on. These themes provided the organizing structure for exploring the journey to recovery. This journey, as disclosed by the seriously injured, does not necessarily correspond with the views of most trauma clinicians. Traumatic events create a line of demarcation, separating lives into before and after. The event becomes the starting point of a journey to resume one's life. The event itself is more than the trauma; it is the perceptual and contextual experience that needs to be incorporated into a person's essence. Fallout from the injury is multifaceted and includes physical, psychological, social, and spiritual dimensions. Moving-on in this journey is nonlinear as survivors recognize their lives are forever different. The survivors' accounts suggest that nurses should carefully consider the question, 'What is successful recovery?'

Rapid sequence induction for intubation by an aeromedical transport team: a critical analysis.

Airway control is the initial priority in the management of the injured patient. The purpose of this investigation was to evaluate the experience of an aeromedical transport team in the utilization of rapid sequence induction (RSI) for endotracheal intubation in the prehospital setting. Records of a consecutive series of injured patients undergoing RSI between June 1988 and July 1992 by a university-based aeromedical transport team were reviewed for demographics, intubation mishaps, and pulmonary complications. The relationship between intubation mishaps and pulmonary complications was analyzed. Eighty-four patients were studied with a mean age of 30.8 +/- 15.3 years. The mean Revised Trauma Score was 11.3 +/- 2.4, and the mean Injury Severity Score (ISS) was 19.6 +/- 11.5. Intubation mishaps occurred in 15 patients (18%), and pulmonary complications developed in 22 (29%) of the 75 patients surviving longer than 24 hours. There was no relationship between intubation mishaps and pulmonary complications. Abbreviated Injury Scale (AIS) face score was significantly higher in patients with intubation mishaps, compared with patients without mishaps (1.1 +/- 1.2 and 0.5 +/- 0.9, respectively, P < .05, Wilcoxon rank-sum). ISS and AIS chest were higher in patients with pulmonary complications, compared with those without (25.7 +/- 12.6 and 17.4 +/- 10.3 and 2.2 +/- 1.8 and 1.0 +/- 1.5, ISS and AIS respectively; P < .05, Wilcoxon rank-sum). Eighty-one patients (96%) underwent successful RSI, 73 (87%) on the first attempt. Failure to intubate occurred in three patients (4%). Performed under strict protocol by appropriately trained aeromedical transport personnel, RSI is an effective means to facilitate endotracheal intubation in the injured patient requiring definitive airway control. Pulmonary complications were related to injury severity and not to intubation mishaps.

Determining anatomic injury with computed tomography in selected torso gunshot wounds.

BACKGROUND: Changes in the management of torso gunshot wounds (TGSWs) have evolved in recent years as a result of differences between military and civilian injuries and increasing interest in avoiding nontherapeutic invasive procedures. The objective of this study was to establish the utility and accuracy of computed tomography (CT) in the evaluation of selected patients with TGSWs. METHODS: Retrospective review for a 6-year period of patients who sustained TGSWs and underwent CT solely for the purpose of trajectory determination. Patients had complete physical examinations and plain radiographic evaluations by a dedicated group of in-house trauma surgeons. When trajectory was indeterminate after evaluation, CT was performed. In some cases, CT was used when trajectory was determined to be intracavitary but organ injury was believed to be unlikely or amenable to nonoperative management. RESULTS: Fifty TGSW patients underwent 52 computed tomographic scans. Abdominal/pelvic CT was performed in 37 patients, and thoracic CT was performed in 15 patients. All patients were stable and none sustained complications attributable to CT or delay in therapy. Twenty of 37 abdominal/pelvic computed tomographic scans excluded transabdominal or pelvic trajectory. Seventeen of 37 scans proved transabdominal or pelvic trajectory; nine laparotomies were performed, and eight patients were observed. Nine of 15 thoracic computed tomographic scans excluded transmediastinal trajectory. Six of 15 scans suggested vascular proximity and prompted further workup, which was positive in two cases. CONCLUSION: CT of selected TGSW patients is safe and may reduce the incidence of invasive diagnostic procedures. A prospective evaluation of CT for TGSW patients is warranted.

Penetrating chest injury: who warrants aggressive treatment?

To determine the degree of severity in penetrating chest injuries that predicts survival, we conducted a logistic regression analysis. All patients suffering penetrating chest injuries (n = 310) admitted to an urban level I teaching hospital in the USA between January 1993 and December 1994 were evaluated. The Injury Severity Score (ISS), Glasgow Coma Scale (GCS), Trauma Score (TS), and Revised Trauma Score were used to compare injury survivors with nonsurvivors. We used the trauma scores to create a logit to predict the outcome among 160 patients in 1993 and tested the validity of this logit in another 150 patients in 1994. With death = 0, survival = 1, the equation lnPd/Ps = b0 + b1 ISS + b2 GCS + b3 TS was obtained from logistic regression, where b0 was the constant of the equation and b1, b2, and b3 were the coefficients of ISS, GCS, and TS, respectively. A logit score greater than 0.5 was found to be predictive of death with a sensitivity of 80.0%, a specificity of 97.5%, and an accuracy of 94.0%. Aggressive resuscitation should be aimed at patients with a logit score greater than 0.5 to reduce mortality. This knowledge may aid in the management of patients with severe chest injuries.

The impact of true partnership between a university Level I trauma center and a community Level II trauma center on patient transfer practices.

OBJECTIVE: To examine the effect of a clinical and administrative partnership with an academic urban Level I trauma center on the patient transfer practices at a suburban/rural Level II center. METHODS: Data for 2 years before affiliation (PRE) abstracted from inpatient charts and the trauma registry were compared with that for 2 years after (POST). The following data were collected: number of, reason for, and destination and demographics of transfers. Chi(2) test and t test analyses were used; p < 0.05 defined significance; data are mean +/- SEM. RESULTS: Transfer rate increased from 4% PRE to 6.9% (p = 0.001) POST with no significant difference in age, Glasgow Coma Scale score, Injury Severity Score, or Revised Trauma Score. Repatriation occurred in 12.8% POST (none PRE). The current Level I facility accepted 1.8% of all transfers PRE and 36.4% POST (p = 0.0001). PRE/POST rates by reason are as follows: pediatric, 14.6%/9.0% (p = 0.04); intensive care unit, 0.4%/1.7% (p = 0.13); complex orthopedic, 100%/0% (p = 0.005); vascular, 50%/0% (p = 0.008); spinal cord injury, 100%/100%; and ophthalmologic, 0%/100% (p = 0.005). CONCLUSIONS: In this experience of Level I/II partnership (1) transfer patterns were altered, (2) select patient cohort transfers decreased (pediatric, complex orthopedic, vascular), whereas others increased (aortic work-up), and (3) repatriation rates were low.

Solid viscus injury predicts major hollow viscus injury in blunt abdominal trauma.

BACKGROUND: As nonoperative management of blunt abdominal trauma has become more popular, reliable models for predicting the likelihood of concomitant hollow viscus injury in the hemodynamically stable patient with a solid viscus injury are increasingly important. METHODS: The Pennsylvania Trauma Systems Foundation registry was reviewed for the period from January 1992 to December 1995 for all adult (age > 12 years) patients with blunt trauma and an Abbreviated Injury Scale (AIS) score > or = 2 for a solid viscus (kidney, liver, pancreas, spleen). Patients with an initial systolic blood pressure < 90 mm Hg were excluded. Hollow viscus injuries included only lacerations or perforations of the gallbladder, gastrointestinal tract, or urinary tract. RESULTS: In the 4-year period, 3,089 patients sustained solid viscus injuries, 296 of whom had a hollow viscus injury (9.6%). The mean age was 35.6 years, mean Injury Severity Score was 22.2, and mean Revised Trauma Score was 7.3; 63.3% of the patients were male. A solitary solid viscus injury occurred in 2,437 patients (79%), 177 of whom (7.3%) had a hollow viscus injury. The frequency of hollow viscus injury increased with the number of solid organs injured: 15.4% of patients with two solid viscus injuries (n = 547) and 34.4% of patients with three solid viscus injuries (n = 96) suffered a concomitant hollow viscus injury (p < 0.001 vs. one organ). A hollow viscus injury was 2.3 times more likely for two solid viscus injuries and 6.7 times more likely for three solid viscus injuries compared with a solitary solid viscus injury. For solitary solid viscus injury, the frequency of hollow viscus injury varied little with increasing AIS score (AIS score 2, 6.6%; AIS score 3, 8.2%; AIS score 4, 9.2%; AIS score 5, 6.2%) (p = 0.27 between groups), suggesting that the incidence of hollow viscus injury is related more to the number of solid visceral injuries than the severity of individual organ injury. Also, when the sum of the AIS scores for solid viscus injuries was <6, the mean rate of hollow viscus injury was 7.8%. This increased to 22.8% when the sum of the AIS scores for solid viscus injury was > or =6 (p < 0.001). A pancreatic injury in combination with any other solid viscus injury had a rate of hollow viscus injury of >33%. CONCLUSION: A model of organ injury scaling predicted hollow viscus injury. Multiple solid viscus injuries, particularly pancreatic, or abdominal solid viscus injuries with an AIS score > or = 6, were predictive of hollow viscus injury. Identification of these injury patterns should prompt consideration for early operative intervention.

Barrier precautions in trauma resuscitation: real-time analysis utilizing videotape review.

Blood-borne pathogens threaten all individuals involved in emergency health care. Despite recommendations by the Centers for Disease Control and the American College of Emergency Physicians, documented compliance with universal precautions in trauma resuscitation has been poor. The purpose of this study was to determine the factors that predispose to noncompliance with barrier precautions at a level I trauma center. Videotapes of trauma resuscitations performed during 1 month (n = 66) were reviewed. Full compliance with barrier precautions was documented in 89.1% of health care workers. Of the noncompliant health care workers, 50.7% were emergency department personnel and 47.8% were first responders to the trauma resuscitation area. Barrier precaution compliance improved from 62.5% to 91.8% with prenotification of patient arrival. Immediate access to barrier equipment is essential for all potential in-hospital first responders. Prehospital communication systems should be optimized to ensure prenotification.

Hemopneumothorax missed by auscultation in penetrating chest injury.

OBJECTIVE: To determine the frequency and extent of hemothorax, pneumothorax, and hemopneumothorax missed by auscultation in penetrating chest injury. DESIGN: A retrospective chart and chest radiograph review. MATERIALS AND METHODS: One hundred and eighteen patients suffering penetrating chest injuries during 1993 were studied. A missed auscultation was defined as a patient with normal breath sounds but shown by chest radiograph to have a hemothorax, pneumothorax, or hemopneumothorax. The amount of hemothorax was recorded after chest tube placement or at thoracotomy. The degree of pneumothorax was determined by Rhea's method. RESULTS: Seventy-one patients (60%) had a hemothorax, pneumothorax, or hemopneumothorax. Auscultation to detect hemothorax, pneumothorax, or hemopneumothorax had a sensitivity of 58%, a specificity of 98%, and a positive predictive value of 98%. Thirty of 71 patients (42%) were found to have pleural space blood or air missed by auscultation. Twelve patients (41%) had a hemopneumothorax, 11 patients (36%) had hemothorax, and seven patients (23%) had pneumothorax. Auscultation missed hemothorax up to 600 mL, pneumothorax up to 28%, and hemopneumothorax up to 800 mL and 28%. CONCLUSION: Hemopneumothorax and hemothorax are the conditions most likely to be missed by auscultation, especially in patients with gunshot wounds. Auscultation has a high positive predictive value because it indicates injury with a fair degree of certainty; however, a negative auscultation does not rule out injury.

Who pays for failed organ procurement and what is the cost of altruism?

Our objective was to define medical complications and financial charges generated during the care of potential solid organ donors who fail to donate after consent has been obtained. A retrospective review of financial and medical records of potential organ donors was done at an urban level 1 trauma center. Total hospital stay (T1+T2) for the group was broken down into the interval between admission and diagnosis of lethality (T1) and between diagnosis of lethality and death (T2). Medical complications occurring during the hospital stay and charges generated during each time interval were abstracted. After consent was obtained, 19 of 53 (36%) potential donors failed to donate: 9 of 19 (47%) expired prior to legal determination of brain death; 10 patients failed to progress to brain death and were made DNR. Of these, 9 died within 24 hr, 1 survived 16 days; 6 of the 10 patients did not meet brain death criteria, and 4 were rejected by the OPO for reasons of infectious risks. There were 3.1+/-1.3 medical complications per patient. T1 was less than 4 hr in 16/19 (84%) potential donors and constituted a small percentage of the mean total hospital stay (37+/-10 hr). Charges generated during T1+T2 (33,997+/-25,843) and specifically during T2 (17,385+/-9453) were considerable. These charges were passed on to patients' families or third party payers though care was directed solely at organ procurement after diagnosis of lethality. We conclude that multiple medical complications are encountered in the care of potential organ donors; total hospital stays are short but expensive; more than 50% of charges generated during the total hospital stay arise from care provided after determination of lethality; and the goodwill of families to consent to organ donations of their loved ones appears to carry potential for significant financial burden.

Bronchoscopic guidance makes percutaneous tracheostomy a safe, cost-effective, and easy-to-teach procedure.

BACKGROUND: We wanted to assess the efficiency of instituting a modified technique of percutaneous tracheostomy (PET) with bronchoscopic guidance. METHODS: During a 10-month period 48 consecutive trauma patients requiring tracheostomy were divided between a standard tracheostomy control group (ST) and a PET group. All patients were followed prospectively. The hospital charges were reviewed retrospectively. RESULTS: Age, gender, body habitus, and principal diagnosis were similar in the 21 ST patients and the 27 PET patients. All STs and 15 of the PETs were performed in the operating room (OR), and the 12 remaining PETs were done in the intensive care unit (ICU). Four patients in the ST group and six in the PET group died. One of these deaths occurred in a patient in the PET group with severe adult respiratory distress syndrome. Procedure time was shorter for PET (16 versus 45 minutes, p < 0.0001). Junior residents performed more PETs than STs (33% versus 10%), and PET was considered "easier" to perform than ST (81% versus 47%). Hospital charges for PET in the ICU were $3400 less per patient compared with ST or PET in the OR. CONCLUSIONS: PET was performed easily and safely in the OR and at the ICU bedside. PET required one-third the time of ST. Bronchoscopic supervision of PET may have contributed to the small number of complications and the educational experience of junior residents. PET in the ICU can reduce hospital charges significantly and avoids transport of patients to the OR. PET is as safe as ST and should be considered the procedure of choice for an ICU patient requiring an elective tracheostomy.

Gluteal gunshot wounds: who warrants exploration?

It is difficult to determine which stable patients with gluteal gunshot wounds warrant exploration since 22% to 36% will have injuries requiring operative intervention. The ability of preoperative studies to identify major injuries was evaluated to determine which studies could accurately triage patients into a high-risk group that would warrant laparotomy and a low-risk group that could be managed with observation. The findings of abdominal tenderness or gross blood in the urine or rectum were each highly predictive of major injury. The determination of an extrapelvic versus transpelvic bullet trajectory allowed accurate triage of 94% of patients. Nearly 85% of patients with a transpelvic trajectory had injuries that required operative intervention. No patients with an extrapelvic trajectory required laparotomy. Given the density of vital structures above and below the peritoneum in the pelvis, we conclude that any patient with a transpelvic bullet trajectory warrants exploration.