Ascorbic acid dynamics in the seriously ill and injured.

BACKGROUND: In addition to the known beneficial effects of ascorbic acid on wound healing and the immune response, it is also a potent extracellular antioxidant. Recent work in septic rats suggests that high-dose ascorbic acid total parenteral nutrition (TPN) supplementation may protect cells from free radical injury and improve survival. In this study, we determined ascorbic acid levels in the immediate post-injury/illness period and evaluated the ability of early short-term high levels of ascorbic acid in TPN to normalize plasma levels. MATERIALS AND METHODS: Ascorbic acid levels were determined in 12 critically injured patients and 2 patients with severe surgical infections. Each patient received TPN supplemented with increasing doses of ascorbic acid over a 6-day period. Therapeutic responses were determined by plasma and urine measurements using high-pressure liquid chromatography. RESULTS: The initial mean +/- SEM baseline plasma ascorbic acid concentration was depressed (0.11 +/- 0.03 mg/dl) and unresponsive following 2 days on 300 mg/day supplementation (0.14 +/- 0.03; P = 1.0) and only approached low normal plasma levels following 2 days on 1000 mg/day (0.32 +/- 0.08; P = 0.36). A significant increase was noted following 2 days on 3000 mg/day (1.2 +/- 0.03; P = 0.005). CONCLUSION: We confirmed extremely low plasma levels of ascorbic acid following trauma and infection. Maximal early repletion of this vitamin requires rapid pool filling early in the post-injury period using supraphysiologic doses for 3 or more days.

Penetrating colon injuries requiring resection: diversion or primary anastomosis? An AAST prospective multicenter study.

BACKGROUND: The management of colon injuries that require resection is an unresolved issue because the existing practices are derived mainly from class III evidence. Because of the inability of any single trauma center to accumulate enough cases for meaningful statistical analysis, a multicenter prospective study was performed to compare primary anastomosis with diversion and identify the risk factors for colon-related abdominal complications. METHODS: This was a prospective study from 19 trauma centers and included patients with colon resection because of penetrating trauma, who survived at least 72 hours. Multivariate logistic regression analysis was used to compare outcomes in patients with primary anastomosis or diversion and identify independent risk factors for the development of abdominal complications. RESULTS: Two hundred ninety-seven patients fulfilled the criteria for inclusion and analysis. Overall, 197 patients (66.3%) were managed by primary anastomosis and 100 (33.7%) by diversion. The overall colon-related mortality was 1.3% (four deaths in the diversion group, no deaths in the primary anastomosis group, p = 0.012). Colon-related abdominal complications occurred in 24% of all patients (primary repair, 22%; diversion, 27%; p = 0.373). Multivariate analysis including all potential risk factors with p values < 0.2 identified three independent risk factors for abdominal complications: severe fecal contamination, transfusion of > or = 4 units of blood within the first 24 hours, and single-agent antibiotic prophylaxis. The type of colon management was not found to be a risk factor. Comparison of primary anastomosis with diversion using multivariate analysis adjusting for the above three identified risk factors or the risk factors previously described in the literature (shock at admission, delay > 6 hours to operating room, penetrating abdominal trauma index > 25, severe fecal contamination, and transfusion of > 6 units blood) showed no statistically significant difference in outcome. Similarly, multivariate analysis and comparison of the two methods of colon management in high-risk patients showed no difference in outcome. CONCLUSION: The surgical method of colon management after resection for penetrating trauma does not affect the incidence of abdominal complications, irrespective of associated risk factors. Severe fecal contamination, transfusion of > or = 4 units of blood within the first 24 hours, and single-agent antibiotic prophylaxis are independent risk factors for abdominal complications. In view of these findings, the reduced quality of life, and the need for a subsequent operation in colostomy patients, primary anastomosis should be considered in all such patients.

Trauma in the cirrhotic patient.

Cirrhotic patients requiring emergency abdominal surgery exhibit a significant increase in mortality. Unlike the elective surgical patient in whom there is often the opportunity to control ascites, improve nutritional status, and correct coagulation abnormalities, the trauma patient may need to undergo immediate emergency surgery to control bleeding or contamination. The operation may present significant technical difficulties in achieving hemostasis. Indicators of poor outcome at admission include ascites, hyperbilirubinemia, elevated prothrombin time, multiple injuries, and blunt abdominal trauma requiring celiotomy.

Maternal-fetal trauma.

The injured pregnant patient is actually two patients--both in need of expert care. Initial management should be performed as a team effort, with prompt obstetrical consultation available if the mother is seriously injured. The ABCs of resuscitation must be followed in the pregnant patient, just as they are in other injured patients, and the gravid uterus should not cause undo alarm or distraction. Diagnostic studies necessary for the evaluation of the mother should not be withheld, and timely operative intervention (if indicated) offers the best chance of a favorable outcome for mother and fetus.

Current status of nonoperative management of liver injuries.

The successful use of nonoperative management of liver injuries requires a hemodynamically stable patient and early access to computed tomography (CT). Extensive intraperitoneal blood and extravasation of contrast on CT predict potential clinical failures. The CT appearance of the liver injury has poor correlation with clinical outcome. Angiographic embolization complements nonoperative management in the stable patient with an ongoing blood requirement. The follow-up CT scan is not required provided the hematocrit and the patient's clinical status remain stable. Common errors in nonoperative management include attributing evidence of blood loss to nonhepatic sources and continuing transfusions in anticipation that the bleeding will stop without intervention.

Traumatic lumbar hernia.

Lumbar hernias occur infrequently; however, after trauma, they can present challenging problems in management. Unlike congenital or primary acquired lumbar hernias, posttraumatic lumbar hernias result from a disruption in normal anatomic boundaries and may require extensive reconstruction. We describe a case of lumbar hernia in a patient who had been crushed between two train cars, review the anatomy of the lumbar region, and identify treatment options.

Transcatheter arterial embolization in blunt hepatic trauma.

Patients with blunt hepatic injury can safely be managed nonoperatively if they show hemodynamic stability. Transcatheter arterial embolization (TAE) is a useful adjunct in the treatment of patients who show evidence of continued hemorrhage or who have pooling of contrast material on computed tomography (CT). In these patients, TAE may reduce transfusion requirements and allow healing of the injury without operation. Complications are uncommon and are usually managed nonoperatively.

Scalp laceration: an obvious 'occult' cause of shock.

Scalp lacerations are often present in patients requiring emergency care for blunt trauma. These injuries are most commonly seen in unrestrained drivers or occupants involved in motor vehicle crashes in which the victim is partially or totally ejected. Patients with scalp lacerations often have associated injuries that redirect the clinician's attention to other injury sites. Some scalp lacerations are severe enough to cause hypovolemic shock and acute anemia. If the patient arrives in shock, the perfusion pressure may be low, and there may be minimal active scalp bleeding. Under such circumstances, the scalp wound may be initially dismissed as trivial and attention appropriately turned to assuring an adequate airway, establishing intravenous lines, initiating volume resuscitation, and searching for more "occult" sources of blood loss. However, as the blood pressure returns toward normal, bleeding from the scalp wound becomes more profuse and presents a hemostatic challenge to the clinician. A case presentation illustrates some of these issues and confirms the effectiveness of an often overlooked but simple technique to control scalp hemorrhage--Raney clip application.

Perforation of the colon after blunt trauma.

Blunt rupture of the colon follows a direct blow to the abdomen. Physical findings suggesting peritoneal irritation are usually present early in the postinjury period and lead to further evaluation and operation. In unresponsive patients, physical findings may be masked, diagnosis delayed, and outcome compromised. Perioperative antibiotics and early celiotomy with complete intra-abdominal exploration and primary repair of the colon injury usually provide excellent results.

Nonoperative management of solid organ injuries. Past, present, and future.

All patients with injuries to the solid organs of the abdomen and who are hemodynamically stable should be considered candidates for nonoperative management after their injuries have been staged by abdominal CT scanning, but because the CT stage of the injury does not always predict which patients require laparotomy, these patients must remain under the care of experienced trauma surgeons who can not only recognize the presence of an associated hollow viscus injury in need of repair but also will be readily available to operate if the nonoperative approach fails. Until continued bleeding can be safely ruled out, a period of close monitoring in an ICU-like setting seems warranted. Although delayed bleeding from the liver seems extremely rare, delayed rupture of the spleen and continued hemorrhage into the retroperitoneum from an injured kidney are not unusual, so patients with splenic and renal injuries should be considered candidates for repeat imaging procedures before discharge. Others likely to benefit from a second look at their injuries include patients with subcapsular hematomas, patients with recognized extravasation on the initial scan, and athletes anxious to return to contact sports. Experience from major trauma centers suggests that the incidence of missed intestinal injuries is low in adults and children managed nonoperatively, but surgeons must be diligent in monitoring for increasing abdominal pain, abdominal distention, vomiting, and signs of inflammation, which may be delayed manifestations of intestinal disruption. Patients with vascular injuries (grade V injuries to the spleen, liver, or kidney) may be candidates for radiologic procedures, such as angioembolization or stenting, but some of these patients are best served by immediate laparotomy. Selected patients with penetrating injuries may also be candidates for the nonoperative approach, but further research in this area is needed before this approach can be widely embraced. As we approach the year 2000, the nonoperative approach to hepatic, splenic, and renal injuries will continue to have a major role in the treatment of trauma patients. Currently, the morbidity and mortality rates of nonoperative management are acceptably low, but surgeons still must monitor their results carefully as they apply these methods more liberally among injured patients.

Chest tube decompression of blunt chest injuries by physicians in the field: effectiveness and complications.

OBJECTIVE: Recent literature suggests that patients who undergo emergent tube thoracostomy in the field are at increased risks for complications. This study evaluates indications, complications, and effectiveness of field placement of chest tubes by an aeromedical service. METHODS: In a prospective study, 624 consecutive patients with chest injuries (Abbreviated Injury Scale score 1-6) were included. All patients were treated at the scene by a physician-staffed aeromedical service and transported by air to a Level I trauma center. Indications, clinical findings before and after chest tube insertion, and subsequent radiologic diagnosis by chest roentgenography were documented prospectively. RESULTS: Seventy-six chest tubes (50 unilateral, 13 bilateral) were inserted laterally in 63 patients (10%) by blunt dissection. Clinical findings included pneumothorax in 30 patients and hemothorax in 18 patients. In 15 patients receiving field chest tubes, neither pneumothorax nor hemothorax was confirmed. Six patients (<1%) arrived at the trauma center with unsuspected pneumothoraces and required chest tube insertion. No tension pneumothoraces escaped field detection and treatment. Four chest tubes placed in the field required repositioning in the hospital because of malfunction or malpositioning. Radiologic findings excluded intraparenchymal tube placements in all patients. No pleural infections were observed in these 63 patients during their hospital stay. No antibiotics were administered as a result of prehospital chest tube placement. CONCLUSION: Prehospital chest tube thoracostomy is safe, effective, and associated with low morbidity. Nontherapeutic chest tube placements occurred in 15 of 624 patients (2.4%); missed pneumothoraces occurred in 6 of 624 patients (<1%). Aggressive prehospital physician management of blunt chest trauma leads to an earlier treatment of potentially life-threatening injuries. Significant morbidity can be avoided by prompt pleural decompression using proper techniques.

Heterotopic bone formation within a missile track.

A case is presented which is thought to be the first described example of heterotopic ossification occurring within the path of a bullet. Although the information was not available from prior medical records, the bullet presumably passed though bone or periosteum, thereby seeding the permanent cavity and facilitating ossification within the surrounding muscle and soft tissue.

Rupture of the deep femoral artery from blunt trauma.

Massive hemorrhage from the deep femoral artery is an uncommon entity in the setting of blunt extremity trauma without femur fracture. A case of deep femoral artery injury causing massive hemorrhage treated by angiographic embolization is reported. In this patient, persistent unexplained hypotension warranted angiographic analysis of a pelvic fracture. Because of a swollen right thigh, the negative pelvic angiogram was extended to include the lower extremity, confirming the diagnosis of a ruptured branch of the deep femoral artery. Bleeding was controlled with embolization that promptly resolved the patient's hemodynamic instability. The salient feature in common with previous reported cases of deep femoral artery injury was hemodynamic instability beyond accountable blood loss. We recommend angiographic analysis with radiological and surgical intervention in the setting of thigh swelling without femur fracture and unexplained hypotension. This management strategy was well tolerated, and the patient received minimal transfusions.

Intrahepatic absorbable fine mesh packing of hepatic injuries: preliminary clinical report.

A previous report from the authors' institution reported the effectiveness of hepatic packing with absorbable fine mesh (AFMP) for the control of hemorrhage in an animal model with an otherwise lethal hepatic injury. The technique has subsequently been applied to 12 abdominal trauma patients with hemodynamic instability and actively hemorrhaging hepatic injuries. Two patients expired in the operating room owing to uncontrolled hemorrhage from hepatic and associated injuries for a mortality of 16.7%. AFMP was successful in controlling hemorrhage in the remaining 10 patients. Hepatic injuries ranged from grade II to grade V, and all were actively hemorrhaging at the time of exploration. None of the surviving 10 patients experienced early or late recurrent bleeding attributable to the hepatic injuries, and there were no intraabdominal abscesses or late deaths. Liver function studies returned to normal prior to discharge in all surviving patients. Follow-up included serial computed tomographic scans, which demonstrated fibrosis incorporating the mesh packing. Complete resolution of injury and mesh appears to proceed over approximately a 6-month period. AFMP is a safe, effective method for controlling hepatic hemorrhage. It is easy to perform in the operating room, offers an excellent matrix for hemostasis, provides tamponade of bleeding sites, and does not require reoperation for removal of packing material, as is necessary with conventional, nonabsorbable packing techniques.

[Value of computerized tomography in diagnosis of small intestine injuries after blunt abdominal trauma]. / Die Wertigkeit der Computertomographie in der Diagnostik von Dünndarmverletzungen nach stumpfem Bauchtrauma.

Intestinal injury is increasing in frequency among persons sustaining blunt abdominal trauma, and the consequences of delayed recognition of intestinal injuries are serious. This critical retrospective analysis evaluates the role for CT in the diagnosis of blunt abdominal trauma, including hollow visceral injury. CT scan, when used in conjunction with a history emphasizing the mechanism of injury and a careful physical examination, is highly accurate in detecting small bowel injuries. CT is less helpful in distinguishing between different types of small bowel injury. Intestinal wall thickening with low-density fluid in the abdominal cavity strongly suggests rupture. Until further experience is gained with CT, free intraperitoneal fluid in the absence of solid organ injury should be regarded as an indication for exploratory laparotomy.

Tube thoracostomy for occult pneumothorax: a prospective randomized study of its use.

Occult pneumothorax is defined as a pneumothorax that is detected by abdominal computed tomographic (CT) scanning, but not routine supine screening chest roentgenograms. Forty trauma patients with occult pneumothorax were prospectively randomized to management with tube thoracostomy (n = 19) or observation (n = 21) without regard to the possible need for positive pressure ventilation, to test the hypothesis that tube thoracostomy is unnecessary in this entity. Eight of the 21 patients observed had progression of their pneumothoraces on positive pressure ventilation, with three developing tension pneumothorax. None of the patients with tube thoracostomy suffered major complications as a result of the procedure. Hospital and ICU lengths of stay were not increased by tube thoracostomy. Patients with occult pneumothorax who require positive pressure ventilation should undergo tube thoracostomy.

[Primary management of polytrauma. Comparison of a German and American air rescue unit]. / Primärversorgung des Polytraumas. Vergleich eines deutschen und amerikanischen Luftrettungssystems.

Hospital-based helicopter services from German and American university-affiliated trauma centers were reviewed. All multitrauma patients transported via helicopter from the scene of the accident to the trauma center during a 1-year period were included. The patients were comparable regarding mechanism of injury, age, flight times, mean ISS, ISS distribution, and number of severe injuries per body region (patients with AIS > 3 for head, thorax and abdomen). Overall mortality for the German system was 21/221 (9.5%) and 21/186 (11.3%) for the American system (not significant). Survivor-based TRISS analysis yielded Z-statistics of +2.459 for the German, and +1.049 for the American system. There were 9 unexpected survivors (Ps < 0.5) in the German, 6 in the American system. There was a significant higher (P < 0.01) number of early deaths (< 6 h) in the American population (12, ISS 56) than in the German (4, ISS 64). Analysis of the prehospital data demonstrated significant differences in the mean volume of IV fluids infused: 1800 cc German, 825 cc American (P < 0.05); rate of intubation: 82/221 (37.1%) German, 24/186 (13.4%) American (P < 0.001); and thoracic decompressions: 20/221 (9.1%) German, 1/186 (0.5%) American (P < 0.001). Pre-hospital care in the German system is directed on-scene by a trauma surgeon member of the flight crew, compared to a nurse/paramedic team with remote medical control in the American system. Compared to an American trauma system, the German system demonstrates improved overall outcome as measured by survivor-based TRISS Z-statistics. More favorable German Z-statistics are in part related to fewer early deaths.(ABSTRACT TRUNCATED AT 250 WORDS)

On-scene helicopter transport of patients with multiple injuries--comparison of a German and an American system.

Hospital-based helicopter services from a German (GER) and an American (AMR) university-affiliated trauma center were reviewed. All patients with multiple injuries transported via helicopter from the scene to the trauma centers during a 1-year period were included. The patients were comparable regarding mechanism of injury, age, flight times, mean ISS, ISS distribution, and number of severe injuries per body region (patients with AIS score > 3 for head, thorax, and abdomen). Overall mortality was 21 of 221 (9.5%) for GER and 21 of 186 (11.3%) for AMR (NS). Survivor-based TRISS analysis yielded Z statistics of +2.459 for GER (p < 0.025) and +1.049 for AMR (NS). M statistics were 0.89 for GER, 0.874 for AMR; the W statistic +1.35 for GER. There were nine unexpected survivors (Ps < 0.50) for GER and six for AMR. There was a significantly higher (p < 0.01) number of early deaths (< 6 hours) in AMR (12; ISS = 56) than in GER (four; ISS = 64). Analysis of the prehospital data demonstrated significant differences in the mean volume of IV fluids infused: 1800 mL, GER; 825 mL, AMR (p < 0.05); rate of intubation: 82 of 221 (37.1%) GER; 24 of 186 (13.4%) AMR (p < 0.001); and thoracic decompressions: 20 of 221 (9.1%) GER; 1 of 186 (0.5%) AMR (p < 0.001). Prehospital care in the GER system is directed on scene by a trauma surgeon member of the flight crew compared with a nurse/paramedic team with remote medical control in the AMR system.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparability of alcohol and drug use in injured drivers.

During a recent 5-month period, 201 injured drivers were admitted to a level 1 trauma center. Blood alcohol concentrations (BACs) and drug screens were obtained in 187 and 164 subjects, respectively. BACs were positive in 37% and other drugs were confirmed in 40%, suggesting that alcohol and drug use among injured drivers is comparable. More than half of the drivers using alcohol also had drugs detected on the screening examination. Other investigators have previously established driving impairments associated with some of these drugs. These results indicate that the drug problem on our highways may be greater than previously recognized.