Clinical features of clostridial bacteremia: a review from a rural area.

Blood samples, which were obtained from patients who lived in a rural area with approximately 500 acute-care hospital beds, were cultured from 1990 through 1997. We retrospectively reviewed the blood cultures that yielded Clostridium species (74 [0.12%] of 63,296 cultures). These were obtained from 46 different hospitalized patients (incidents per hospital, 0.03%). The source of the Clostridium species was a gastrointestinal site in 24 patients (52.2%). The most frequently identified Clostridium species was Clostridium perfringens (in 10 [21.7%] of patients), followed by Clostridium septicum (in 9 [19.6%]). Thirty-one patients (67.4%) were aged > or =65 years, 13 patients (28.3%) had diabetes mellitus, and underlying malignancy was present in 22 patients (47.8%). The mortality rate of patients whose condition had been managed surgically was 33%; for those patients whose conditions required medical management, the mortality rate was 58%. Clostridium bacteremia in these patients usually had a gastrointestinal source, it often occurred in patients with serious underlying medical conditions, and it rarely was the result of traumatic farm accidents.

Significance of minimal or no intraperitoneal fluid visible on CT scan associated with blunt liver and splenic injuries: a multicenter analysis.

BACKGROUND: The use of ultrasound (U/S) for the evaluation of patients with blunt abdominal trauma is gaining increasing acceptance. Patients who would have undergone computed tomographic (CT) scan may now be evaluated solely with U/S. Solid organ injuries with minimal or no free fluid may be missed by surgeon sonographers. OBJECTIVE: The purpose of this study was to describe the incidence and clinical importance of liver and splenic injuries with minimal or no free intraperitoneal fluid visible on CT scan. We hypothesized that these solid organ injuries occur infrequently and are of minor clinical significance. METHODS: Patient records and CT scans were reviewed for the presence of and outcome associated with blunt liver and splenic injuries with minimal (<250 mL) or no free fluid detected by an attending radiologist. Data were collected from six major trauma centers during a 4-year period before the introduction of U/S and included demographics, grade of injury (American Association for the Surgery of Trauma scale), need for operative intervention, and outcome. RESULTS: A total of 938 patients with liver and splenic injuries were identified. In this group, 11% of liver injuries and 12% of splenic injuries had no free fluid visible on CT scan and could be missed by diagnostic peritoneal lavage or U/S. Of the 938 patients, 267 (28%) met the inclusion criteria; 161 had injury to the spleen and 125 had injury to the liver. In the 267 patients studied, 97% of the injuries were managed nonoperatively. However, 8 patients (3%) required operative intervention for bleeding. Compared with the liver, the spleen was significantly more likely to bleed (p = 0.01), but the grade of splenic injury was not related to the risk for hemorrhage (p = 0.051). CONCLUSION: Data from this study suggest that injuries to the liver or spleen with minimal or no intraperitoneal fluid visible on CT scan occur more frequently than predicted but usually are of minimal clinical significance. However, patients with splenic injuries may be missed by abdominal U/S. We found a 5% associated risk of bleeding. Therefore, abdominal U/S should not be used as the sole diagnostic modality in all stable patients at risk for blunt abdominal injury.

Nonoperative management of blunt liver trauma: the value of follow-up abdominal computed tomography scans.

Our hypothesis was that follow-up abdominal CT scans are not routinely necessary in patients with blunt liver injury treated nonoperatively. We conducted an 8-year retrospective review of hospital chart and outpatient clinic records. We reviewed all admission and follow-up CT scans. There were 42 adults and 12 children. There were 1 (2%) grade I, 15 (28%) grade II, 28 (52%) grade III, 8 (15%) grade IV, and 2 (4%) grade V liver injuries. Two patients died during the first 24 hours, both from associated injuries. Nonoperative management was successful in 51 (98%) of the remaining 52 patients. No follow-up abdominal CT scans were performed on 21 (40%) patients; none developed hepatic complications. An initial follow-up CT scan was obtained in 31 (60%) patients. Information from these scans directly affected management in 3 (9%) patients; in each case, the scans were prompted by a change in clinical status. One significant biloma with bile leak was managed by nasobiliary stenting and percutaneous drainage. One hepatic artery-to-portal vein fistula was obliterated by transarterial embolization. A single missed diaphragm rupture necessitated laparotomy. Additional late follow-up CT scans were obtained in 13 patients; no clinically useful information was evident on any of these examinations. We conclude that follow-up abdominal CT scans are not routinely necessary in patients with liver injuries treated nonoperatively. Selective criteria based on the severity of liver injury, presence of associated intra-abdominal pathology, and clinical parameters should dictate the need for follow-up imaging studies.

Pediatric trauma management in a rural Wisconsin trauma center.

OBJECTIVE: To determine the results of pediatric trauma care managed with a cooperative effort by general surgeons and pediatric intensivists in comparison to national standards. DESIGN: Retrospective chart review. SETTING: Referral level II trauma center in rural Wisconsin. PATIENTS: All pediatric trauma patients age 16 and younger admitted to the hospital from 1990 to 1993. METHODS: Demographics, mechanisms of injury, revised trauma score (RTS), injury severity score (ISS), surgical procedures, need for intensive care, and outcome were examined. All patients were primarily managed by the trauma surgery service. Those patients requiring intensive care were managed jointly by the trauma surgery service and pediatric intensivists. Outcome was predicted by TRISS analysis; patients identified as "unexpected deaths" underwent critical clinical review to determine potential for survival. RESULTS: There were 531 pediatric trauma admissions. The mean age was 9.0 +/- 6.2 (SEM) years and two thirds of the patients were boys. Over half of all injuries were from falls, recreational activities, and motor vehicle crashes. There were few penetrating injuries. The mean RTS was 7.58 +/- 0.05, and the majority of patients had an ISS below 10. Sixty-two percent of patients required surgical procedures, most of which were orthopedic. Fourteen percent of patients were admitted to the pediatric intensive care unit. There were 13 deaths for a mortality rate of 2.4%. TRISS analysis identified six deaths as unexpected. Four drownings were not included in TRISS analysis, and there were no unexpected survivors. Of the six unexpected deaths, there were no significant management errors identified on careful review. CONCLUSIONS: Cooperation between general surgeons and pediatric intensivists can result in excellent pediatric trauma care in a rural level II trauma center.

Shotgun wound management: a comparison of slug and pellet injuries.

Shotgun slug injuries have received little attention while shotgun pellet wounds have been well described. Twenty-two shotgun pellet and 13 shotgun slug injuries treated over a 14-year period were retrospectively reviewed. Extremity and thoracic wounds were most frequent in both groups. The incidence of vascular and nerve injuries was similar for slug and pellet wounds. Angiography was more often used to evaluate pellet wounds for vascular disruption. The rate of wound infection was 38% for slug wounds versus 32% for pellet injuries. Tissue grafting was more frequently necessary for reconstruction after pellet injury. Long-term disability was documented in 15% of patients with pellet wounds and 23% with slug wounds. Despite similarities in wound location and outcomes, the ballistic differences between shotgun slugs and pellets resulted in significant differences in wounding characteristics and extent of injury which have important ramifications in management.

Nonoperative management of splenic injury: are follow-up computed tomographic scans of any value?

OBJECTIVE: To determine the value of follow-up abdominal computed tomography in patients with splenic trauma managed nonoperatively. DESIGN: Retrospective chart review. MATERIALS AND METHODS: A total of 108 consecutive patients with splenic injuries treated at a single institution from 1990 to 1996 were studied. All admission and follow-up computed tomographic (CT) scans were reviewed by the authors. RESULTS: Initial management was surgical in 35 patients (32%) and intentionally nonoperative in 73 patients (68%). Nonoperative management was successful in 45 of 49 adults (92%) and 21 of 24 children(88%). Sixty-two follow-up abdominal CT scans were obtained in 49 patients. Information that affected management was evident on only one follow-up CT scan performed in the absence of clinical indications. Potential savings in hospital and physician charges for routine follow-up CT scans in this study were $54,302.00. CONCLUSIONS: Follow-up abdominal CT scans are not routinely necessary in patients with splenic injuries managed nonoperatively.

Spectrum of general surgery in rural America.

OBJECTIVES: To define the types of surgery performed by rural surgeons, to compare their experience to that of graduating US surgical residents and to document rural surgical mortality. DESIGN: Prospective registry of consecutive cases recorded by 7 rural general surgeons working in one department of surgery from December 31, 1994, through March 30, 1996. Comparison with the 1995 Report C (Resident Operative Logs) of the Residency Review Committee. National survey of surgical residency programs regarding formal gynecology experience. SETTING: Nine rural community hospitals in the Midwest. PATIENTS: Patients undergoing surgery in 9 cities with populations of fewer than 10000. MAIN OUTCOME MEASURES: Type of surgery and postoperative (30-day) mortality. RESULTS: Two thousand four hundred twenty procedures were performed by 7 surgeons practicing in 9 cities with populations of 1500 to 8000. There were 6 (0.25%) postoperative deaths. Case types are as follows: endoscopy, 686 (28.3%); gynecology, 498 (20.6%); hernia, 241 (10%); colorectal, 194 (8%); biliary, 183 (7.6%); cesarean sections, 130 (5.4%); breast, 129 (5.3%); orthopedic, 115 (4.8%); carpal tunnel, 63 (2.6%); otolaryngology, 35 (1.4%); and endocrine, 1 (0.4%); for a total of 2420 (100%). Report C indicated 1995 graduating chief residents averaged 8 obstetric and and gynecologic and 5.3 orthopedic cases during their residency. Of 204 surgical residency programs surveyed, 106 (52%) offered no obstetrics and gynecology rotation. CONCLUSIONS: A large volume of surgery was performed with low mortality by 7 rural general surgeons. The operative experience of 1995 residency graduates differed from our rural surgeons. We recommend a rural surgical track in selected training programs to prepare graduates better for rural practice. Senior level rotations in endoscopic, gynecologic, obstetric, and orthopedic surgery and mentorship with rural surgeons would be optimal.

Scapulothoracic dissociation caused by blunt trauma.

Scapulothoracic dissociation is an infrequent injury with a potentially devastating outcome. The diagnosis has heretofore relied on the radiographic description of the forequarter disruption. Recent experience with four patients at a single trauma center, along with review of 54 injuries adequately described in the literature, indicates a broader spectrum of injury. Neurologic injuries occurred in 94% and vascular injuries in 88%. A nearly uniform poor outcome with flail extremity in 52% of patients, early amputation in 21%, and death in 10% reflects the severity of injuries reported. Identification of this injury requires clinical suspicion, based upon the injury mechanism and physical findings, to accurately assess the degree of trauma to musculoskeletal, neurologic, and vascular structures. Based upon these clinical findings, a rational approach to diagnostic techniques, injury classification, and appropriate surgical intervention can be achieved. Outcome is dependent on early recognition of the subset of patients with injuries amenable to surgical treatment and rehabilitation.

Rural trauma care: role of the general surgeon.

BACKGROUND: Care of the patient injured in the rural setting poses many unique challenges. This report profiles the experience of a solo, rural general surgeon with patients with multiple injuries during a 7-year period. METHODS: Emergency department (ED) contact sheets for 43,308 patients treated from September 1, 1988 through August 31, 1995 were reviewed. Eighty-four patients met selection criteria based on injuries with Abbreviated Injury Scale score > or = 3 in a single body region or > or = 2 in two or more body regions. Prehospital and hospital records were reviewed. RESULTS: Injury Severity Score ranged from 8 to 43 (mean, 16). Four patients died in the ED, 54 (64%) were transferred to a referral trauma center, and 26 (31%) were admitted to the community hospital. CONCLUSIONS: Roles of the general surgeon in the management of multiple trauma in the rural hospital are: (1) to coordinate trauma care in the community, including educational and organizational efforts; (2) to perform the necessary techniques in the ED to achieve optimal resuscitation and stabilization; (3) to rationally prioritize patients for transfer to a referral trauma center based upon assessment of patient injuries and institutional capabilities; and (4) to provide definitive care for a subset of patients with no need for subspecialty intervention.

Functional outcome after incomplete spinal cord injuries due to blunt injury.

During a 3-year period, 19 patients with incomplete spinal cord injuries caused by blunt trauma were admitted to a single rural referral centre. The mean age was 50 years. Injury mechanisms included falls in eight, road traffic accidents in five, diving mishaps in two, and miscellaneous in four. The level of spinal cord injury was cervical in 11, thoracic in five, and thoracolumbar in three. Initial management included a standard high-dose methylprednisolone protocol for 24 h after injury in eight patients treated since May, 1990. Neurosurgical procedures were performed in 11 patients. There were three deaths, all in patients over 75 years of age with pulmonary complications. Of 16 survivors, 10 demonstrated significant functional neurological improvement by the time of hospital discharge, and 11 by late follow up. Complete recovery occurred in five of the survivors. Complications occurred in 11 patients, including pulmonary (nine), infectious (six), and gastrointestinal (three), but could not be associated specifically with the high-dose steroid protocol. In conclusion, incomplete spinal cord injuries after blunt injury were relatively uncommon in this setting. No significant increase in complications was observed after institution of the high-dose methylprednisolone protocol in May, 1990. However, pulmonary, gastrointestinal, and infectious complications were common. Of the 16 survivors, 11 demonstrated significant functional improvement. Mortality appeared to be related to advanced age and to pulmonary complications.

Gastric rupture after the Heimlich maneuver.

Since 1975, the Heimlich maneuver has been widely applied to relieve upper airway obstruction caused by aspirated material. Life-threatening complications have been documented following this simple procedure. We report two cases of gastric rupture after use of the Heimlich maneuver. Both patients experienced pulmonary and abdominal symptoms. The diagnosis was confirmed in each case by the demonstration of free intraperitoneal air on an upright chest roentgenogram. Full-thickness gastric rupture along the lesser curvature of the stomach was repaired in both patients; one patient died. Abdominal pain or persistent abdominal distention despite nasogastric suction after the Heimlich maneuver should prompt evaluation for possible gastric rupture.

Carotid artery pseudoaneurysm and pellet embolism to the middle cerebral artery following a shotgun wound of the neck.

Arterial missile embolism is a rare complication of penetrating vascular trauma. We report a case of middle cerebral artery pellet embolism and delayed appearance of a carotid artery pseudoaneurysm following a shotgun wound of the neck. The pseudoaneurysm was repaired. Because the patient had no associated neurologic deficits, the pellet embolus was left within the patient middle cerebral artery. He remains well 4 years after injury. A selective approach to the management of a pellet embolus to the middle cerebral artery based on clinical signs or symptoms and status of arterial patency is recommended. In addition, several principles are suggested to improve the reliability of arteriography for shotgun wounds of the neck.