Obesity should not influence the management of appendicitis.

BACKGROUND: Obesity implies an adverse effect on outcome after appendectomy. This study aimed to determine whether obese patients with appendicitis should be managed differently than nonobese patients. METHODS: After appendectomy, all patients were enrolled in a prospective clinical pathway and followed from initial presentation to full outpatient recovery. RESULTS: In 1 year, 272 adults underwent appendectomy, 55 (22%) of whom were obese. The obese patients were slightly older (35 vs 33 years; p < 0.001). The time to diagnosis (8.5 vs 8.6 h), and the need for computed tomography (CT) scanning (40% vs 49%) was similar in both populations. The obese patients had similar rates of perforation (35% vs 35%) and laparoscopy (47% vs 41%). The median hospital length of stay (LOS) (2 days) and complications, including wound complications (9.1% vs 10.9%) and intraabdominal abscesses (3.6% vs 3.1%), were similar. Subgroup analysis showed a longer LOS for the obese patients with perforation than for the nonobese patients (6 vs 5.5 days; p = 0.036). CONCLUSION: Obese patients had no greater delay in diagnosis, had no greater need for CT scan, gained no additional benefit from laparoscopy, and did not incur significantly worse outcomes after appendectomy except for an increased LOS among those with perforation.

Laparoscopic appendectomy significantly reduces length of stay for perforated appendicitis.

INTRODUCTION: Though ruptured appendicitis is not a contraindication to laparoscopic appendectomy (LA), most surgeons have not embraced LA as the first-line approach to ruptured appendicitis. In fact, in 2002, the Cochrane Database Review concluded: 1) the clinical effects of LA are "small and of limited clinical relevance," and 2) the effects of LA in perforated appendicitis require further study. OBJECTIVE: To study the effects of LA vs open appendectomy (OA) among adults with appendicitis. METHODS: In 2003, 272 adults underwent appendectomy at a large County hospital, and were enrolled in a prospective clinical pathway that detailed their hospital course from time of diagnosis to discharge. Data included patient demographics, time elapse from diagnosis to surgery, surgical technique (LA vs. OA), operative diagnosis (acute vs perforated appendicitis) and post-operative length of stay (LOS). RESULTS: Complete data was obtained for 264 (97%) patients. Patient demographics were similar in the LA and OA groups (p > 0.05). Patients with LA had a significantly shorter LOS than OA by 1.6 days (p < 0.05). This LOS was significantly shorter among those with ruptured appendicitis vs. non-ruptured appendicitis (2.0 days vs. 0.3 day reduction, p = 0.0357). Rank-order multiple regression analysis, controlling for all other factors, showed laparoscopy to have a significant effect on postoperative LOS in all appendicitis cases, especially ruptured appendicitis. CONCLUSIONS: The two-day reduction in LOS among those with ruptured appendicitis who underwent LA was significant enough to overcome the smaller benefit of LA in acute appendicitis. From a hospital utilization point of view, LA should be considered as the first-line approach for all patients with appendicitis.

Effect on outcome of early intensive management of geriatric trauma patients.

BACKGROUND: Despite significant injuries elderly patients (aged 70 years or more) often do not exhibit any of the standard physiological criteria for trauma team activation (TTA), i.e. hypotension, tachycardia or unresponsiveness to pain. As a result of these findings the authors' TTA criteria were modified to include age 70 years or more, and a protocol of early aggressive monitoring and resuscitation was introduced. The aim of the present study was to assess the effect of the new policy on outcome. METHODS: This trauma registry study included patients aged 70 years or more with an Injury Severity Score (ISS) greater than 15 who were admitted over a period of 8 years and 8 months. The patients were divided into two groups: group 1 included patients admitted before age 70 years and above became a TTA criterion and group 2 included patients admitted during the period when age 70 years or more was a TTA criterion and the new management protocol was in place. The two groups were compared with regard to survival, functional status on discharge and hospital charges. RESULTS: There were 336 trauma patients who met the criteria, 260 in group 1 and 76 in group 2. The two groups were similar with respect to mechanism of injury, age, gender, ISS and body area Abbreviated Injury Score. The mortality rate in group 1 was 53.8 per cent and that in group 2 was 34.2 per cent (P = 0.003) (relative risk (RR) 1.57 (95 per cent confidence interval 1.13 to 2.19)). The incidence of permanent disability in the two groups was 16.7 and 12.0 per cent respectively (P = 0.49) (RR 1.39 (0.59 to 3.25)). In subgroups of patients with an ISS of more than 20 the mortality rate was 68.4 and 46.9 per cent in groups 1 and 2 respectively (P = 0.01) (RR 1.46 (1.06 to 2.00)); 12 of 49 survivors in group 1 and two of 26 in group 2 suffered permanent disability (P = 0.12) (RR 3.18 (0.77 to 13.20)). CONCLUSION: Activation of the trauma team and early intensive monitoring, evaluation and resuscitation of geriatric trauma patients improves survival.

Healing of traumatic diaphragm injuries: comparison of laparoscopic versus open techniques in an animal model.

BACKGROUND: Minimally invasive surgical techniques have become routinely applied to the evaluation and treatment of patients with isolated diaphragmatic injuries due to penetrating trauma. The objective of the study was to compare the healing of diaphragm injuries as determined by macroscopic inspection, histologic appearance, and tensile strength following repair by open suturing, laparoscopic suturing, and laparoscopic stapling techniques in an animal model. METHODS: Using a pig model, three injuries were created and repaired in each hemidiaphragm of five animals, for a total of 30 lacerations. These injuries were repaired using single-layer open repair, single-layer laparoscopic repair, or laparoscopic stapling. After a 6-week healing period the animals were sacrificed. The gross integrity, histologic appearance using H+E and trichrome satins, and tensile strength of each repair were assessed. RESULTS: All injuries were grossly intact without dehiscence or herniation. Histologic examination revealed no difference in the collagen deposition between the three groups. The tensile strengths of each type of repair were similar. CONCLUSION: Laparoscopic techniques used to repair diaphragmatic injuries allow for adequate healing equivalent to open sutured repairs. Simple approximation of the peritoneum with laparoscopic staples allows full-thickness healing of these injuries.

Old age as a criterion for trauma team activation.

BACKGROUND: Elderly trauma patients have been shown to have a worse prognosis than young patients. Age alone is not a criterion for trauma team activation (TTA). In the present study, we evaluated the role of age > or = 70 years as a criterion for TTA. METHODS: The present study was a trauma registry study that included injured patients 70 years of age or older. Patients who died in hospital, were admitted to the intensive care unit (ICU) within 24 hours, or had a non-orthopedic operation were assumed to benefit from TTA. RESULTS: During a 7.5-year period, 883 elderly (> or = 70 years) trauma patients meeting trauma center criteria were admitted to our center. Overall, 223 patients (25%) met at least one of the standard TTA criteria. The mortality in this group was 50%, the ICU admission rate was 39%, and a non-orthopedic operation was required in 35%. The remaining 660 patients (75%) did not meet standard TTA criteria. The mortality was 16%, the need for ICU admission was 24%, and non-orthopedic operations were required in 19%. Sixty-three percent of patients with severe injuries (Injury Severity Score > 15) and 25% of patients with critical injuries (Injury Severity Score > 30) did not have any of the standard hemodynamic criteria for TTA. CONCLUSION: Elderly trauma patients have a high mortality, even with fairly minor or moderately severe injuries. A significant number of elderly patients with severe injuries do not meet the standard criteria for TTA. It is suggested that age > or = 70 years alone should be a criterion for TTA.

TRISS methodology: an inappropriate tool for comparing outcomes between trauma centers.

BACKGROUND: The TRISS methodology has been used for comparison of survival outcomes between trauma centers. The purpose of this study was to evaluate the role of TRISS in comparing outcomes between a small and a large trauma center and evaluate its usefulness in various groups of patients. STUDY DESIGN: Trauma registry study that compared the survival outcomes between a large academic level I trauma center and a small community level II center. The comparison was made with the standard TRISS probability of survival, M value, and Z score. In the second part of the study the patients from the small center were matched for age, gender, injury severity score, Glasgow Coma Scale, head Abbreviated Injury Score, BP, prehospital respiratory assistance, and transport mode with an equal number of patients from the large center. The Z scores were calculated for each center. In the third part of the study the TRISS usefulness and limitations were evaluated in various subgroups of patients by calculating its sensitivity, specificity, positive predictive value, negative predictive value, and misclassification rate. RESULTS: The Z value of the large center (3,315 patients) was 2.24, indicating a considerably higher mortality than expected when compared with the Major Trauma Outcomes Study population. The Z value of the small center (331 patients) was -0.92, indicating fewer than the Major Trauma Outcomes Study expected deaths. In the second part of the study, 297 patients from the small center were matched with an equal number from the large center. The Z scores were -0.40 and -0.95, respectively, indicating slightly better outcomes than those of the Major Trauma Outcomes Study. Additional evaluation of the TRISS prediction of survival in various subgroups of patients showed a high misclassification rate in severe trauma, in some groups higher than 25%. CONCLUSIONS: The TRISS methodology is not a reliable tool for comparing outcomes between trauma centers and has an unacceptably high misclassification rate in patients with severe trauma.

Selective nonoperative management in 1,856 patients with abdominal gunshot wounds: should routine laparotomy still be the standard of care?

OBJECTIVE: To evaluate the safety of a policy of selective nonoperative management (SNOM) in patients with abdominal gunshot wounds. SUMMARY BACKGROUND DATA: Selective nonoperative management is practiced extensively in stab wounds and blunt abdominal trauma, but routine laparotomy is still the standard of care in abdominal gunshot wounds. METHODS: The authors reviewed the medical records of 1,856 patients with abdominal gunshot wounds (1,405 anterior, 451 posterior) admitted during an 8-year period in a busy academic level 1 trauma center and managed by SNOM. According to this policy, patients who did not have peritonitis, were hemodynamically stable, and had a reliable clinical examination were observed. RESULTS: Initially, 792 (42%) patients (34% of patients with anterior and 68% with posterior abdominal gunshot wounds) were selected for nonoperative management. During observation 80 (4%) patients developed symptoms and required a delayed laparotomy, which revealed organ injuries requiring repair in 57. Five (0.3%) patients suffered complications potentially related to the delay in laparotomy, which were managed successfully. Seven hundred twelve (38%) patients were successfully managed without an operation. The rate of unnecessary laparotomy was 14% among operated patients (or 9% among all patients). If patients were managed by routine laparotomy, the unnecessary laparotomy rate would have been 47% (39% for anterior and 74% for posterior abdominal gunshot wounds). Compared with patients with unnecessary laparotomy, patients managed without surgery had significantly shorter hospital stays and lower hospital charges. By maintaining a policy of SNOM instead of routine laparotomy, a total of 3,560 hospital days and $9,555,752 in hospital charges were saved over the period of the study. CONCLUSION: Selective nonoperative management is a safe method for managing patients with abdominal gunshot wounds in a level 1 trauma center with an in-house trauma team. It reduces significantly the rate of unnecessary laparotomy and hospital charges.

"Insignificant" mechanism of injury: not to be taken lightly.

BACKGROUND: Trauma resources should be spent rationally. The mechanism of trauma is used extensively to triage patients to appropriate levels of care. We examine the hypothesis that patients with "insignificant" mechanism of trauma may have major injuries that require expert trauma care. STUDY DESIGN: Over 9 months at a high-volume Level I trauma center, a prospective study was done on patients who sustained ground-level falls (GLF), low-level falls (LLF) from less than 10 feet, or were found down (FD) with no external evidence of significant trauma, and required evaluation by the trauma team. Of 301 patients included, 110 (37%) had GLF, 95 (31%) LLF, and 96 (32%) FD. Our main outcomes measure was significant injuries, defined as visceral or intracranial injuries, long-bone, pelvic, facial, or spinal fractures. RESULTS: One hundred ten patients (37%) had significant injuries, 20 (7%) were admitted to the ICU, 14 (5%) required an operation, and 4 (1%) died. The most common injuries were intracranial and skeletal. Almost all patients were evaluated by CT (95%), but only one-quarter had abnormal findings on it. LLF, age more than 55 years, and the absence of severe intoxication (blood alcohol level of less than 200 mg/dL) were independent risk factors for significant injuries. A statistical prediction model showed that, when all risk factors are present, the probability of significant injuries is 73%; when all risk factors are absent, there is still a 16% chance for significant injuries. Patients with significant injuries had more operations, longer hospital stays, and higher hospitalization costs compared with patients without significant injuries. CONCLUSIONS: Low-energy trauma may produce significant injuries, predominantly intracranial and skeletal. Trauma care providers should be cautious about dismissing such patients based on the trivial mechanism of injury. Patients with LLF who are older than 55 years and not severely intoxicated have a high likelihood for significant injuries. Resources should be spent rationally for patients who do not have these characteristics, because the probability of significant injuries among them is low, but not zero.

Prophylactic antibiotics after severe trauma: more is not better.

After severe trauma, physicians frequently use multiple antibiotics for prolonged periods of time to prevent sepsis, based on intuition rather than scientific evidence. Over a 1-year period (January-December 1999) we included prospectively 112 critically injured patients who required an operation and/or chest tube insertion and stayed for more than 2 days in the intensive care unit (ICU). Of these patients, 46 received a single prophylactic antibiotic for 24 hours (group SING+SHORT), and 66 received one or more prophylactic antibiotics for more than 24 hours (group MULT+LONG), based on physician discretion. Twenty-seven outcome parameters were collected to compare the effect of the different prophylactic antibiotic regimens. The two groups were similar in regard to overall injury severity, age, gender, mechanism of injury, and physiologic condition on admission. However, more SING+SHORT patients had an abdominal operation (83% versus 62%, P = 0.02), and more MULT+LONG patients had an orthopedic operation (35% versus 15%, P = 0.03). There was no difference in sepsis (41% versus 42%, P = 1.0), organ failures (37% versus 50%, P = 0.18), mortality (7% versus 12%, P = 0.52), ICU stay (14 +/- 2.5 versus 16 +/- 2 days, P = 0.57), hospital stay (26 +/- 3 versus 28 +/- 2 days, P = 0.53), or any other outcome parameter. Independent risk factors for sepsis were blunt mechanism of trauma, Injury Severity Score > or = 25, and more than two units of blood transfused over the first 24 hours, but not the amount of prophylactic antibiotics given. In conclusion, we found that 24-hour prophylaxis with a single broad-antibiotic is as effective as prophylaxis for longer periods of time with multiple spectrum antibiotics for critically injured patients at high risk for sepsis.

Reliable variables in the exsanguinated patient which indicate damage control and predict outcome.

BACKGROUND: Exsanguination as a syndrome is ill defined. The objectives of this study were to investigate the relationship between survival and patient characteristics--vital signs, factors relating to injury and treatment; determine if threshold levels of pH, temperature, and highest estimated blood loss can predict survival; and identify predictive factors for survival and to initiate damage control. MATERIAL AND METHODS: A retrospective 6-year study was conducted, 1993 to 1998. In all, 548 patients met one or more criteria: (1) estimated blood loss > or =2,000 mL during trauma operation; (2) required > or =1,500 mL packed red blood cells (PRBC) during resuscitation; or (3) diagnosis of exsanguination. Analysis was made in two phases: (1) death versus survival in emergency department (ED); (2) death versus survival in operating room (OR). Statistical methods were Fisher's exact test, Student's t test, and logistic regression. RESULTS: For 548 patients, mean Revised Trauma Score 4.38, mean Injury Severity Score 32. Penetrating injuries 82% versus blunt injuries 18%. Vital statistics in emergency department: mean blood pressure 63 mm Hg, heart rate 78 beats per minute. Mean OR pH 7.15 and temperature 34.3 degrees C. Mortality was 379 of 548 (69%). Predictive factors for mortality (means): pH < or =7.2, temperature <34 degrees C, OR blood replacement >4,000 mL, total OR fluid replacement >10,000 mL, estimated blood loss >15 mL/minute (P <0.001). Analysis 1: death versus survival in ED, logistic regression. Independent risk factors for survival: penetrating trauma, spontaneous ventilation, and no ED thoracotomy (P <0.001; probability of survival 0.99613). Analysis 2: death versus survival in OR, logistic regression. Independent risk factors for survival: ISS < or =20, spontaneous ventilation in ED, OR PRBC replacement <4,000 mL, no ED or OR thoracotomy, absence of abdominal vascular injury (P <0.001, max R(2) 0.55, concordance 89%). CONCLUSIONS: Survival rates can be predicted in exsanguinating patients. "Damage control" should be performed using these criteria. Knowledge of these patterns can be valuable in treatment selection.

Prehospital intubation in patients with severe head injury.

BACKGROUND: Prehospital intubation and airway control is routinely performed by paramedics in critically injured patients. Despite the advantages provided by this procedure, numerous potential risks exist when this is performed in the field. We reviewed the outcome of patients with severe head injury, to determine whether prehospital intubation is associated with an improved outcome. METHODS: A retrospective review of registry data of patients admitted to an urban trauma center with severe head injury (field Glasgow Coma Scale score of < or =8 and head Abbreviated Injury Scale score of > or =3) was performed. Patients were stratified by methods of airway control performed by prehospital personnel: not intubated, intubated, or unsuccessful intubation. Mortality was determined for each group. To control for significant variables between these populations, matching and multivariate analysis were performed. RESULTS: Patients requiring prehospital intubation or in whom intubation was attempted had an increased mortality (81% and 77%, respectively) when compared with nonintubated patients (43%). The mortality for patients who had prehospital intubation performed did not demonstrate an improved survival using matching. In fact, intubated patients had a significantly higher relative risk (RR) of mortality when compared with nonintubation (RR = 1.74,p < 0.001) and unsuccessful intubation patients (RR = 1.53, p = 0.008) CONCLUSION: For patients with severe head injury, prehospital intubation did not demonstrate an improvement in survival. Further prospective randomized trials are necessary to confirm these results.

Helical computed tomographic scan in the evaluation of mediastinal gunshot wounds.

BACKGROUND: The standard evaluation of mediastinal gunshot wounds usually requires angiography and either esophagoscopy or esophagography. In the present study, we have evaluated the role of helical computed tomographic (CT) scanning in reducing the need for angiographic and esophageal studies. METHODS: This was a prospective study of patients with mediastinal gunshot wounds who were hemodynamically stable and would otherwise require angiography and esophageal evaluation. All patients underwent CT scan of the chest with intravenous contrast to delineate the missile trajectory. If the missile tract was in close proximity to the aorta, great vessels, or esophagus, then traditional evaluation with angiographic or esophageal evaluation was pursued. RESULTS: A total of 24 patients met the inclusion criteria and underwent CT scan evaluation of their mediastinal gunshot wounds. One patient was taken for sternotomy to remove a missile embedded in the myocardium solely on the basis of the result of the CT scan. Because of proximity of the bullet tract, 12 patients required additional evaluation with eight angiograms and nine esophageal studies. One of these patients had a positive angiogram (bullet resting against the ascending aorta) and underwent sternotomy for missile removal; all other studies were negative. The remaining 11 patients were found to have well-defined missile tracts that approached neither the aorta nor the esophagus, and no additional evaluation was pursued. There were no missed mediastinal injuries in this group. Overall, 12 of 24 patients (50%) had a change in management (either received an operation or avoided additional radiographic or endoscopic evaluation) on the basis of the CT scan. CONCLUSION: The helical CT scan provides a rapid, readily available, noninvasive means to evaluate missile trajectories. This permits accurate assessment of potential mediastinal injury and reduces the need for routine angiographic and esophageal studies.

Angiographic embolization of bilateral internal iliac arteries to control life-threatening hemorrhage after blunt trauma to the pelvis.

Angiographic embolization of bleeding pelvic vessels is increasingly used in patients with pelvic injuries. Temporary angiographic embolization of bilateral internal iliac arteries (TAEBIIA) is occasionally necessary. From November 1991 to March 1998, 30 consecutive patients (mean age of 43 years, mean Injury Severity Score of 25) with complex pelvic fractures underwent TAEBIIA to control severe hemorrhage not responding to subselective embolization. Angiography revealed multiple sources of pelvic bleeding in 28 (93%) patients. In the two remaining patients, no bleeding was identified but TAEBIIA was done empirically. Thirteen patients had laparotomies before TAEBIIA with unsuccessful bleeding control, and the remaining 17 had TAEBIIA as the primary treatment. After TAEBIIA 90 per cent of patients had successful clinical (27 of 30) and radiographic (25 of 28) control of bleeding. Of the three patients who continued to bleed after TAEBIIA two were successfully re-embolized and one died of acute cardiac failure before any further intervention was attempted. TAEBIIA had a success rate of 97 per cent (29 of 30) in controlling pelvic hemorrhage without significant complications related to it. TAEBIIA is a safe and effective alternative to subselective embolization in controlling retroperitoneal bleeding in selected patients with blunt pelvic trauma.

Pediatric falls: is height a predictor of injury and outcome?

Falls account for a significant proportion of pediatric injuries and deaths. A retrospective review of pediatric patients (age 0-14 years) was performed to determine whether patterns of injuries and outcomes could be predicted on the basis of the height of the fall. In addition we evaluated the triage criterion "fall greater than 15 feet" for transport of patients to a trauma center. Patients were stratified by the height of the fall: greater than or less than 15 feet. The end points for analysis were the associated injuries and survival. Patients who fell less than 15 feet had a higher incidence of intracranial injuries (and fewer extremity fractures than patients who fell more than 15 feet). Skull fractures were the most frequent injury and were associated with an increase in intracranial injuries in both subgroups. In conclusion low-level falls are associated with significant intracranial injuries. The evaluation of patients sustaining low-level falls should not be limited on the basis of the height of the fall. Using falls of greater than 15 feet as a triage criterion for transport to a trauma center needs to be prospectively evaluated to ensure that critically injured patients are triaged appropriately.

Endpoints of resuscitation of critically injured patients: normal or supranormal? A prospective randomized trial.

OBJECTIVE: To evaluate the effect of early optimization in the survival of severely injured patients. SUMMARY BACKGROUND DATA: It is unclear whether supranormal ("optimal") hemodynamic values should serve as endpoints of resuscitation or simply as markers of the physiologic reserve of critically injured patients. The failure of optimization to produce improved survival in some randomized controlled trials may be associated with delays in starting the attempt to reach optimal goals. There are limited controlled data on trauma patients. METHODS: Seventy-five consecutive severely injured patients with shock resulting from bleeding and without major intracranial or spinal cord trauma were randomized to resuscitation, starting immediately after admission, to either normal values of systolic blood pressure, urine output, base deficit, hemoglobin, and cardiac index (control group, 35 patients) or optimal values (cardiac index >4.5 L/min/m2, ratio of transcutaneous oxygen tension to fractional inspired oxygen >200, oxygen delivery index >600 mL/min/m2, and oxygen consumption index >170 mL/min/m2; optimal group, 40 patients). Initial cardiac output monitoring was done noninvasively by bioimpedance and, subsequently, invasively by thermodilution. Crystalloids, colloids, blood, inotropes, and vasopressors were used by predetermined algorithms. RESULTS: Optimal values were reached intentionally by 70% of the optimal patients and spontaneously by 40% of the control patients. There was no difference in rates of death (15% optimal vs. 11% control), organ failure, sepsis, or the length of intensive care unit or hospital stay between the two groups. Patients from both groups who achieved optimal values had better outcomes than patients who did not. The death rate was 0% among patients who achieved optimal values compared with 30% among patients who did not. Age younger than 40 years was the only independent predictive factor of the ability to reach optimal values. CONCLUSIONS: Severely injured patients who can achieve optimal hemodynamic values are more likely to survive than those who cannot, regardless of the resuscitation technique. In this study, attempts at early optimization did not improve the outcome of the examined subgroup of severely injured patients.

Nonoperative management of splenic injuries: have we gone too far?

HYPOTHESIS: Patients with severe blunt injuries to the spleen have a high likelihood of failing nonoperative management of splenic injuries (NOMSI). DESIGN: Review of medical records, helical computed tomographic imaging data, and trauma registry data. SETTING: Academic level I trauma center at a large county hospital. PATIENTS: A total of 105 patients with blunt trauma to the spleen, admitted between January 1995 and December 1998, who survived more than 48 hours and had complete records. Of these patients, 53 (56%) were selected for NOMSI. The splenic injury was graded by the Organ Injury Scale of the American Association for the Surgery of Trauma (grades I to V, with grade V being the worst possible injury). MAIN OUTCOME MEASURES: Failure of NOMSI, defined as the need for operation to the spleen after a period of nonoperative management. RESULTS: Compared with patients who had successful NOMSI, the 29 patients (52%) in whom NOMSI failed were older and more severely injured. They also required extra-abdominal operations more frequently, underwent transfusion with more units of blood while being managed nonoperatively, and had higher grades of splenic injury. Splenic injury grade III or higher and transfusion of more than 1 U of blood were identified as independent risk factors for failure of NOMSI. The existence of both risk factors predicted failure in 97% of cases. The grading by computed tomography correlated well with the actual injury to the spleen as seen at operation. CONCLUSIONS: In patients with high-grade splenic injuries who require a transfusion of more than 1 U of blood, NOMSI is very likely to fail. Decreasing the threshold for operation or intensifying the monitoring is highly recommended for such patients.

Surgical critical care: still at risk?

It has been a great honor and privilege to serve as your president and to give this year's presidential address. Considering that this is the last Western Surgical Association presidential address to be given in the 1900s, it seems necessary to mention the rapidly approaching third millennium. With only a little more than 46 days left, I am not particularly excited about having to write a "00" whenever I date something. It just does not seem like a real date to me. I have, however, resisted the temptation to speculate on the 21st century, let alone the next millennium, largely because my crystal ball is no better than any of yours. When I began as a medical student in the mid 1950s, my wildest dreams could not have predicted what dramatic advances would occur in the last half of this century. At that time, the first cardiopulmonary bypass cases were being performed for valvular and congenital disease. Kidneys had only recently been transplanted in Paris, France, and Boston, Massachusetts. Plastic surgery had yet to do a free flap and video-guided endoscopic surgery was still decades away. Intensive care units (ICUs) were just opening up, but they were little more than places where frequent vital signs and reliable intake and outputs were obtained.

Emergency medical services (EMS) vs non-EMS transport of critically injured patients: a prospective evaluation.

BACKGROUND: A previous report of 5,782 trauma patients demonstrated higher mortality among those transported by emergency medical services (EMS) than among their non-EMS-transported counterparts. HYPOTHESIS: Trauma patients who are transported by EMS and those who are not differ in the injury-to-hospital arrival time interval. DESIGN: Prospective cohort-matched observation study. SETTING: Level I trauma center, multidisciplinary study group. PATIENTS: All non-EMS patients were matched with the next appropriate EMS patient by an investigator who was unaware of the outcome and mode of transport. Every 10th EMS patient with an Injury Severity Score (ISS) of 13 or greater was also randomly enrolled. Matching characteristics included age, ISS, mechanism of injury, head Abbreviated Injury Score, and presence of hypotension. An interview protocol was developed to determine the time of injury. Interview responses from patients, witnesses, and friends were combined with data obtained from police, sheriff, and medical examiner reports. MAIN OUTCOME MEASURES: Time to the hospital, mortality, morbidity, and length of stay. RESULTS: A total of 103 patients were enrolled (38 non-EMS, 38 EMS matched, 27 random EMS). Injury time was estimated using all available data made on 100 patients (97%). Independent raters agreed in 81% of cases. Deaths, complications, and length of hospital stay were similar between the EMS- and non-EMS-transported groups. Although time intervals were similar among the groups overall, more critically injured non-EMS patients (ISS > or = 13) got themselves to the trauma center in less time than their EMS counterparts (15 minutes vs 28 minutes; P<.05). CONCLUSIONS: A multidisciplinary approach can be utilized, and an interview protocol created to determine actual time of injury. Critically injured non-EMS-transported patients (ISS > or =13) arrived at the hospital earlier after their injuries.

In vitro activities of nontraditional antimicrobials against multiresistant Acinetobacter baumannii strains isolated in an intensive care unit outbreak.

Fifteen multiresistant Acinetobacter baumannii isolates from patients in intensive care units and 14 nonoutbreak strains were tested to determine in vitro activities of nontraditional antimicrobials, including cefepime, meropenem, netilmicin, azithromycin, doxycycline, rifampin, sulbactam, and trovafloxacin. The latter five drugs were further tested against four of the strains for bactericidal or bacteriostatic activity by performing kill-curve studies at 0.5, 1, 2, and 4 times their MICs. In addition, novel combinations of drugs with sulbactam were examined for synergistic interactions by using a checkerboard configuration. MICs at which 90% of the isolates tested were inhibited for antimicrobials showing activity against the multiresistant A. baumannii strains were as follows (in parentheses): doxycycline (1 microg/ml), azithromycin (4 microg/ml), netilmicin (1 microg/ml), rifampin (8 microg/ml), polymyxin (0.8 U/ml), meropenem (4 microg/ml), trovafloxacin (4 microg/ml), and sulbactam (8 microg/ml). In the kill-curve studies, azithromycin and rifampin were rapidly bactericidal while sulbactam was more slowly bactericidal. Trovafloxacin and doxycycline were bacteriostatic. None of the antimicrobials tested were bactericidal against all strains tested. The synergy studies demonstrated that the combinations of sulbactam with azithromycin, rifampin, doxycycline, or trovafloxacin were generally additive or indifferent.

Approach to the management of complex hepatic injuries.

BACKGROUND: Complex hepatic injuries American Association for the Surgery of Trauma Organ Injury Scale grades IV and V incur high mortality rate ranging from 40 to 80%, respectively. The objective of this study is to assess the clinical experience with an aggressive approach to the management of these, the most complex of hepatic injuries. METHODS: This is a retrospective 6-year study (1992-1997) at an American College of Surgeons urban Level I trauma center of patients sustaining complex hepatic injuries whose interventions included surgery, angiographic embolization, endoscopic retrograde cholangiopancreatography plus biliary stenting and percutaneous computed tomographic-guided drainage. The main outcome measure was survival. RESULTS: A total of 22 patients sustaining complex hepatic injuries; mean age of 26 years (range, 10-52 years), mean Revised Trauma Scale score of 9.9, mean Injury Severity Score of 32 (range, 16-75), American Association for the Surgery of Trauma - Organ Injury Scale grade IV (13 cases); grade V (9 cases). Mean estimated blood loss was 4,600 mL; mean number of units of blood transfused was 15. The patients underwent the following interventions: surgery (n = 22), re-operated (n = 13), mean number of operations 1.6 (range, 1-4), extensive hepatotomy and hepatorrhaphy (n = 17), nonanatomic resection (n = 7), formal hepatectomy (n = 4), packing (n = 10), direct approach to hepatic veins (n = 3); angiographic embolization (n = 15); endoscopic retrograde cholangiopancreatography and stenting (n = 5); computed tomographic guided drainage (n = 6). Mean length of stay in the intensive care unit was 21 days (range, 2-134 days), mean hospital length of stay was 40 days (range, 2-147 days). Overall mortality rate was 14% (3 of 22 cases), hepatic mortality rate was 9% (2 of 22 cases), mortality rate by injury grade was 8% grade IV (1 of 13 cases) and 22% grade V (2 of 9 cases). CONCLUSION: In this select patient population, improvements in mortality rates can be achieved with an aggressive approach to the management of complex hepatic injuries, including surgery, early packing, angiographic embolization, endoscopic retrograde cholangiopancreatography and stenting of biliary leaks, and drainage of hepatic abscesses.