Intra-abdominal hypertension and abdominal compartment syndrome in burn patients.

BACKGROUND: Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are known to occur in patients after major abdominal surgery. The incidence of IAH and ACS in the burn population is not known. METHODS: We prospectively recorded the intra-abdominal pressures of major burn patients admitted to our burn center from February 1999 to September 1999. A bladder pressure greater than 25 mm Hg was diagnosed as IAH. ACS was diagnosed when pulmonary compliance decreased in association with persistent IAH and was treated with abdominal decompression. RESULTS: Ten patients were placed on the protocol; of these, seven developed IAH. Five responded to conservative treatment. Two patients with 80% body surface area burns developed ACS and required decompression. CONCLUSIONS: IAH occurs commonly in major burn patients, and ACS is seen regularly in patients with more than 70% body surface area burns. We recommend bladder pressure measurements after infusion of more than 0.25 L/kg during the acute resuscitation phase and for peak inspiratory pressures greater than 40 cm H2O. Whereas ACS warrants surgical decompression of the abdominal cavity, IAH usually responds to conservative therapy.

Abdominal compartment syndrome in patients with burns.

Abdominal compartment syndrome (ACS) is a well-recognized perioperative complication that occurs in patients who undergo intra-abdominal operations and who require extensive fluid resuscitation. The classic presentation of this syndrome includes high peak airway pressures; oliguria, despite adequate filling pressures; and intra-abdominal pressures of more than 25 mm Hg. A decompressive laparotomy performed at the bedside can alleviate ACS. If left untreated, sustained intra-abdominal hypertension is often fatal. In the literature, ACS has been described in pediatric patients with burns but not in adult patients with burns. This article describes 3 adults who sustained burns of more than 70% of their body surface areas, who required more than 20 L of crystalloid resuscitation, and who developed ACS during their resuscitation after the burn injury. The mortality rate among these patients was 100%, which confirms the grave consequences of this syndrome. In our institution, intra-abdominal pressure is now routinely measured as part of the burn resuscitation process in an attempt to diagnose and treat this syndrome earlier and more efficaciously. It is recommended that the possibility of ACS be considered when diagnosing any patient with burns who develops high airway pressures, oliguria, or both.

Dilatational percutaneous tracheostomy: modification of technique.

BACKGROUND: Major inherent risks associated with percutaneous dilatational tracheostomy include loss of airway during endotracheal tube manipulation, inability to cannulate the trachea below the endotracheal tube, and difficulties related to neck anatomy. METHOD: Percutaneous dilatational tracheostomy technique was modified to make the incision in the suprasternal area, and the use of air leak technique confirmed tracheal penetration below the endotracheal cuff. Bronchoscopy was not used. RESULTS: One hundred patients underwent percutaneous dilatational tracheostomy using the modification mentioned above. Although three patients had minor bleeding complications, there was no loss of airway; nor were there other complications. CONCLUSION: This technique provides improved safety from loss of airway and illuminates the need for concomitant bronchoscopy.

Management of blunt splenic trauma in patients older than 55 years. Southern Connecticut Regional Trauma Quality Assurance Committee.

BACKGROUND: Many experts have suggested that blunt splenic trauma in patients older than 55 years should not be managed by observation because of supposed increased fragility of the spleen and decreased physiologic reserve in elderly patients. We sought to determine the outcome of nonoperative management of blunt splenic trauma in patients older than 55 years. METHODS: For the years 1994 through 1996, data for patients with splenic injury older than 55 years from seven trauma centers in a single state were reviewed. RESULTS: Blunt splenic trauma occurred in 41 patients older than 55 years. Eight patients were excluded from further analysis because of death from massive associated injuries within 24 hours of admission. The remaining 33 patients (mean age, 72+/-10 years) were divided into two groups: immediate exploration (10 patients) and observation (23 patients). Observation of blunt splenic injury failed in 4 of 23 patients (17%). No patient deaths were related to the method of management of the splenic injury. CONCLUSIONS: Observation of the elderly patient with blunt splenic trauma has an acceptable failure rate of 17%.

Nonoperative management of blunt abdominal trauma: the role of sequential diagnostic peritoneal lavage, computed tomography, and angiography.

STUDY OBJECTIVE: To determine the usefulness of sequential nonoperative diagnostic studies in the evaluation and treatment of stable patients after blunt abdominal trauma. DESIGN AND SETTING: Retrospective review of a prospective treatment plan in a large urban Level I trauma center. PARTICIPANTS: Fifty-two patients deemed stable after initial evaluation following blunt abdominal trauma. INTERVENTIONS: Patients with a positive diagnostic peritoneal lavage for red blood cells underwent abdominal computed tomography (CT) scanning. If CT demonstrated a visceral injury, it was followed by diagnostic angiography. Attempts were made to treat on-going bleeding by transcatheter embolization. RESULTS: Fifteen patients had negative CT scans and were successfully observed. In the other 37 patients, CT identified 17 liver, 16 splenic, and eight kidney injuries; eight extra-peritoneal bleeds; and one mesenteric hematoma. Six of these patients were observed. Thirty underwent diagnostic angiograms. Twelve had no active bleeding, and all were observed successfully. Seventeen underwent successful embolization of the bleeding site(s). One had injuries not controllable by embolization and required exploration. Six patients required laparotomy later in their course, but none had intra-abdominal bleeding or a missed intestinal injury. Despite being performed after diagnostic peritoneal lavage, CT missed only two injuries. There was one main complication, delayed recognition of a diaphragmatic injury. Three patients died, two from multiple organ failure and one from a pulmonary embolus; none was believed to be related to this technique. With our algorithm, 45 patients (86%) were spared laparotomy. CONCLUSION: Diagnostic peritoneal lavage and CT are complementary when evaluating blunt abdominal trauma. Diagnostic peritoneal lavage is an effective screening tool. CT may be reserved for stable patients with a positive diagnostic peritoneal lavage to specify the organs injured. Bleeding often may be treated by embolization, limiting the rate of surgery.

The management of vascular injuries of the extremity associated with civilian firearms.

A penetrating extremity trauma registry was created to prospectively study the physical findings, use of arteriography, nonoperative management with embolization or observation and operation in the management of vascular injuries. During a recent ten month period, 228 patients with 320 injuries of the extremity secondary to firearms were admitted to the Trauma Service. Twenty-four percent of the patients had more than one injury, and there were six perioperative deaths related to associated injuries. Fifty-one patients had 50 arterial and 17 venous injuries. Limb salvage was 100 percent. Twenty-two patients with obvious arterial injuries were taken directly to the operating room without arteriography. Arteriography was performed immediately after admission in 41 patients and the findings were positive in 46.4 percent of the patients; nine required operation. Arteriography was performed for injuries in proximity to a major vessel as the indication in 153 injuries and revealed seven arterial injuries (4.6 percent). Three patients underwent operation. Five patients with arterial injuries had successful embolization during the initial arteriography and five patients with intimal injuries were observed, four healed and one patient was lost to follow-up evaluation. Operative repair of arterial injuries included the use of saphenous vein (21 patients), prosthetic grafts (seven patients) and ligations (four patients). Seventeen venous injuries were either repaired (eight patients) or ligated (nine patients). In the patients undergoing operative repairs, 68.7 percent had fasciotomies performed. The excellent results in the current study (no amputations with 51 survivors of arterial injuries) were obtained by a multidisciplinary approach, involving selective arteriography to avoid unnecessary operation and operative repair in those with extensive vascular injuries. The use of arteriography for proximity characterized a few vascular injuries requiring operation or observation. It should serve as the standard for evaluating noninvasive diagnostic studies and for studying the natural history of asymptomatic injuries.

Packing and re-exploration for patients with nonhepatic injuries.

We retrospectively reviewed the clinical records of 11 patients admitted to the trauma service at Kings County Hospital who underwent packing and temporary closure for severe nonhepatic injuries. The mean ISS was 37 and the mean Abdominal Trauma Index value was 48. Operative findings included 17 major vascular injuries. Although the mean blood pressure was 105 mm Hg during the procedure, the patients required an average of 17 units of blood and all were acidotic, hypothermic, and coagulopathic. Acidosis persisted in all patients and the mean base excess was -13 at closure. A conscious decision was made to terminate the procedure when surgical bleeding was controlled. Patients were resuscitated and warmed in the ICU and returned to the operating room within 48 hours. Seven of the 11 patients survived. Of the eight patients who survived to return to the operating room, all required gastrointestinal procedures at re-exploration. This preliminary experience supports packing to control coagulopathic bleeding, use of temporary abdominal closure, and further ICU resuscitation with a planned second laparotomy for definitive management of gastrointestinal injuries in patients with severe nonhepatic injuries.

Percutaneous antegrade ureteral stenting as an adjunct for treatment of complicated ureteral injuries.

We report our use of percutaneous antegrade ureteral stenting (PAUS) as an adjunct for the management of dehisced ureteral repairs and delayed-presentation ureteral injuries secondary to penetrating trauma. This procedure was performed in treating six patients with ureteral injuries. Four patients had dehiscence of a lacerated ureter that had been primarily repaired. Two other patients had ureteral contusions that subsequently became full-thickness disruptions postoperatively. One of these patients developed a pancreaticoureteral fistula. The sepsis resolved in all six patients and in five of the six patients the ureteral disruption healed within 2 months after PAUS without operative intervention. In one patient the ureter healed with stricture, necessitating ureteral reanastomosis. All urinomas resolved with percutaneous drainage. The PAUS technique was used to successfully treat four dehisced ureteral repairs and was the primary method used to successfully treat two disrupted ureteral contusions that were associated with multiple collections and fistulas. These techniques can be utilized for complex ureteral injuries associated with pancreatic leaks, colon or duodenal injuries, and multiple abscesses.

Abdominal computed tomography in lupus mesenteric arteritis.

We report the abdominal computed tomography (CT) findings in a patient with systemic lupus erythematosus who developed signs of an acute abdomen secondary to mesenteric arteritis. Initial CT scan demonstrated ascites and wall thickening of the duodenum and jejunum. After treatment with high dose intravenous steroids, follow-up CT scan demonstrated a normal duodenum and small bowel. This is the first surgically proven case of lupus mesenteric arteritis resulting in bowel ischemia that is demonstrated on CT before and after medical therapy. Lupus mesenteric arteritis should be included in the differential diagnosis of causes of bowel wall thickening and ischemia, especially if mesenteric vessels appear prominent.

The role of angiography in penetrating neck trauma.

Seventy-two consecutive patients who underwent neck arteriography were reviewed to assess recent suggestions that angiography is not indicated in asymptomatic patients with penetrating neck trauma. Proximity to major neck vessels without signs or symptoms of vascular trauma was the reason for angiography in ten of 26 patients with proven arterial injuries. Physical examination had a specificity of 80% and a sensitivity of 61% in this series. There was no correlation between mechanism or location of penetration and the likelihood of clinically significant injury. We conclude that recent recommendations suggesting that arteriography is unnecessary in asymptomatic patients with penetrating neck trauma are premature. Further investigations of larger patient samples are necessary to determine if "proximity" should be abandoned as an indication for arteriography. We advocate that, until additional data are accumulated, urgent arteriography and esophagography or operative exploration are indicated in stable asymptomatic patients with neck wounds which violate the platysma.

Central venous oxygen saturation: a useful clinical tool in trauma patients.

An accurate method of estimating acute blood loss is essential in the evaluation of injured patients. Central venous oxygen (CVO2) saturation has been shown to be a sensitive and reliable correlate of blood loss in an animal model but its clinical validity is unproven. We evaluated 26 consecutive patients with an injury mechanism suggesting blood loss but who were deemed stable after initial evaluation. Vital signs (pulse, blood pressure, pulse pressure, urine output, CVP) and CVO2 saturation were serially measured. Blood loss was estimated by direct intracavitary collection or serial hematocrits and acute transfusion requirements. Despite stable vital signs, ten patients (39%) had CVO2 saturations under 65%. These patients had more serious injuries, significantly larger estimated blood losses, and required more transfusions than those patients with CVO2 saturation greater than 65%. Linear regression analysis demonstrated the superiority of CVO2 saturation to predict blood loss with a p value less than 0.005 relative to any of the normally followed parameters. CVO2 saturation is a reliable and sensitive method for detecting blood loss. It is a useful tool in the evaluation of acutely injured patients.