[Management of pancreatic trauma in damage-control laparotomy].

Major pancreatic trauma challenges the trauma surgeon with diagnostic problems and choices of treatment modalities. The most important determinant guiding management is the integrity of the main pancreatic duct. The preoperative and intraoperative assessment and treatment of pancreatic injury may be difficult, especially when concurrent severe injuries are present. There are alternative approaches in the management of the traumatized pancreas when ductal injury is not obvious during initial exploratory laparotomy.

Method of evaluation "MMexico" in emergency medicine.

The systematic evaluation of the patient in the ED is a principal objective. Clinicians should try to maintain the patient's hemodynamic and metabolic stability. The available resources should be used appropriately to obtain an early diagnosis and definitive management. The mnemonic name MMexico is easy to use, simple to memorize, and bilingual. It can be applied as a new method in the evaluation of patients in ED.

[Management of penetrating cardiac injuries].

Penetrating cardiac injury is often fatal. Patients present with a variety of clinical patterns, from a stable patient but with an insidious course, to those admitted with waning vital signs. In all cases prompt diagnosis and treatment are crucial. A series of 98 cases is presented, emphasizing the problems in diagnosing this condition and recommending the way such patients should be triaged and treated.

Bomb-related injuries.

Between 1980 and 1990 there were 12,216 bombing incidents in the United States, the majority involving pipe-bomb type devices. Victims of such devices may suffer a combination of blast, penetrating, and thermal injuries requiring special surgical approaches. A series of cases is presented which illustrates the management dilemmas faced in such situations. Given the nationwide incidence of bombings, both local emergency medical systems and trauma surgeons should be prepared to deal with blast injuries, be aware of their regional incidence of bombings, and have a planned response that is coordinated with law enforcement agencies.

Predictors of outcome in patients who have sustained trauma and who undergo emergency thoracotomy.

OBJECTIVE: To reassess the use of emergency thoracotomy in resuscitating victims of abdominal or thoracic trauma. DESIGN: Retrospective review of records and autopsy reports of patients who underwent an emergency thoracotomy between 1983 and 1989. SETTING: Washington Hospital Center's Level I trauma center. PATIENTS: Two hundred eighty-four hemodynamically unstable trauma patients (212 [75%] with penetrating injuries and 72 [25%] with blunt injuries). INTERVENTION: Emergency thoracotomy performed in the trauma operating room or in one of the trauma bays. MAIN OUTCOME MEASURES AND KEY FINDINGS: In which subset of trauma patients is emergency thoracotomy a useful therapeutic modality? Performance of an emergency thoracotomy for blunt trauma resulted in an overall survival rate of 6% compared with 27% for penetrating trauma. The survival rate for patients with penetrating cardiac trauma was 32% (44% for stab wounds and 21% for gunshot wounds). Tamponade is a major factor associated with survival in this subset of patients and may act as a pathophysiologic filter. CONCLUSIONS: Emergency thoracotomy is a useful therapeutic modality for victims of penetrating trauma who have vital signs on admission to the hospital, and it should be considered in blunt trauma patients who present with any evidence of life. This modality is largely ineffective, however, in resuscitating victims of penetrating and blunt trauma who present to the hospital without vital signs.

Major hepatic trauma.

The intraoperative management of complex liver injuries can be extremely challenging. During the past two decades, there have been some changes in philosophy regarding the optimal techniques for controlling hemorrhage and decreasing mortality and morbidity rates. An overview of these techniques is presented.

Esophageal rupture complicated by a gastrocardiac fistula: review of the literature and report of a successfully treated case.

A 62-year-old man developed a fistula between the right ventricle and the stomach after Thal fundic patching of an emetogenic rupture of the esophagus. He underwent emergency surgical correction of the fistula and survived.

Intra-abdominal vascular injury secondary to penetrating trauma.

There were 85 patients in this series. The overall mortality was 17.6%. Gunshot wounds were responsible for 51 injuries, with a 21% mortality. There were three stabbings and three shotgun blasts, with a mortality of 10% and 33%, respectively. There were 127 intra-abdominal vascular injuries. The majority were to the SMA and its branches: 34. The highest mortality occurred with protal vein and combined aortic and vena caval injuries (80%). Fatalities averaged twice as many vascular injuries as survivors. There were 194 organ injuries. A liver injury predicted the highest mortality as did injuries to the spleen, lung, and pancreas. The presence of shock and the ability to rapidly control the source were the major predictors of survival. Fatalities averaged a Trauma Score of 7.5; survivors averaged a score of 14.0. There were 12 deaths which occurred intra-operatively and three postoperatively, for a total of 15 deaths. Once the patients made their way from surgery, their survival was 96% assured. Early suspicion of an intra-abdominal vascular injury followed by rapid exposure and control of hemorrhage are the keys to successful management.

Spontaneous migration of a bullet in the spinal subarachnoid space causing delayed radicular symptoms.

The authors report a case of a gunshot wound to the left lower quadrant of the abdomen in a patient who initially was neurologically intact. The bullet had lodged at the T-11, T-12 level in the spinal canal. After an exploratory laparotomy, the patient developed severe low back pain radiating to his left lower extremity and an incomplete footdrop. Repeat x-ray films and a myelogram showed that the bullet had migrated to the L-4, L-5 level on the left. Bullet emboli and delayed sequelae of gunshot wounds to the spine are discussed.