Operative stabilization of a flail chest six years after injury.

We report a case of operative stabilization of an incompetent upper chest wall 6 years following flail chest. The indications for stabilization were chronic pain and dyspnea associated with rib malunion and loss of hemithorax volume. At operation, multiple pseudoarthroses were encountered and partial resection of ribs three and four was required. Malleable plates were used to bridge the gaps created by the resection and were secured in place with sternal wire. The patient reported a dramatic relief of symptoms and, at 18 months postoperatively, continues to work full-time on his cattle ranch essentially pain-free.

Cervical spine clearance and neck extension during percutaneous tracheostomy in trauma patients.

INTRODUCTION: The lack of cervical spine clearance and inability to extend the neck are assumed to be relative contraindications for percutaneous tracheostomy. OBJECTIVE: To determine the necessity of cervical spine clearance and neck extension in trauma patients receiving percutaneous tracheostomy. DESIGN: Prospective analysis of case series from August 1, 1995 to August 31, 1998. SETTING: A university-based Level I trauma center. PATIENTS: A total of 88 consecutive trauma patients receiving percutaneous tracheostomy. Patients were divided into two groups based on the radiographic or clinical status of their cervical spine: cleared and noncleared. RESULTS: The overall success and complication rate were 99% (87/88) and 11% (10/88), respectively. There were no procedure-related deaths. The cleared group consisted of 60 patients; three patients in this group who had "bull" or "thick" necks did not have full neck extension during percutaneous tracheostomy. The noncleared group consisted of 28 patients, 13 of which had known cervical spine fractures; 27 noncleared patients were maintained in the neutral position (no extension) during percutaneous tracheostomy, whereas one patient with low suspicion of spinal injury was partially extended. Of the 13 patients with cervical spine fractures, six patients had been stabilized with a halo or operative fixation, and seven patients were stabilized with a cervical collar at the time of percutaneous tracheostomy. The success rate was 100% (60/60) for the cleared group compared with 96% (27/28) for the noncleared group (p > .05). The complication rate was 13% (8/60) for the cleared group compared with 7.1% (2/28) for the noncleared group (p > .05). We had a 100% success rate and no complications in the seven patients with cervical spine injury who were stabilized with a cervical collar. No patient had spinal cord injury caused by percutaneous tracheostomy. CONCLUSION: Percutaneous tracheostomy can be safely performed in trauma patients without cervical spine clearance and neck extension, including patients with stabilized cervical spine or spinal cord injury.

Weaning injured patients with prolonged pulmonary failure from mechanical ventilation in a non-intensive care unit setting.

BACKGROUND: Injured patients with pulmonary failure often require prolonged length of stay in an intensive care unit (ICU), which includes weaning from ventilatory support. In the last decade, noninvasive ventilation modes have been established as safe and effective. One method for accomplishing this mode of ventilation uses a simple bilevel ventilator. Because this ventilator has been successfully used in hospital wards, we postulated that bilevel ventilators could provide sufficient support during weaning from mechanical ventilation of injured patients in a non-ICU setting. METHODS: A retrospective review of trauma patients (August 1996-January 1999) undergoing bilevel positive pressure ventilation as the final phase of weaning was conducted. Before ward transfer with bilevel ventilation, conventionally ventilated ICU patients were changed to bilevel ventilation and were required to tolerate this mode for at least 24 hours. All patients had a tracheostomy as a secure airway. Outcomes analyzed included ICU length of stay, hospital length of stay, duration of mechanical ventilation, weaning success, complications, and survival. RESULTS: Fifty-one patients (39 men, 12 women) with a mean age of 53 received more than 24 hours of bilevel positive pressure ventilation. Mean Injury Severity Score was 29, with blunt mechanisms of injury occurring in 90%. Chest or spinal cord injuries that affected pulmonary mechanics were present in 75% of patients. Ventilator-associated pneumonia was treated in 43% of patients. Mean ICU length of stay and hospital length of stay were 21 and 34 days, respectively. Weaning was successful in 89% of patients, whereas 11% were discharged to skilled nursing facilities still receiving bilevel positive pressure ventilation. Two patients died, neither from a pulmonary nor airway complication. Of the remaining 49 patients, 12 were weaned in the ICU and 37 were transferred to the ward with bilevel ventilatory support. The average length of ward ventilation was 6.5 +/- 5.4 days (n = 37). CONCLUSIONS: Implementation of a program using bilevel ventilation to support the terminal phase of weaning seriously injured patients from mechanical ventilation was successful. After initiating this mode in the ICU, it was satisfactorily continued in standard surgical wards. Because this method enabled the withdrawal of ventilatory support in a non-ICU setting, its major advantage was reducing ICU length of stay.

Imaging in thoracic trauma: the trauma surgeon's perspective.

Thoracic trauma is a common cause of significant disability and mortality. Most thoracic injury in developed countries results from motor vehicle crashes (MVC). Imaging of patients with thoracic trauma must be accurate and timely to avoid preventable death. Trauma surgeons prioritize imaging options based on the patient's hemodynamic status, associated injuries, and age. The screening test for the detection of life-threatening thoracic injury is the supine anteroposterior (AP) chest radiograph. Rib fractures are a marker for serious associated injuries, including abdominal injuries. Rib fractures are especially ominous in children and the elderly. Thoracic aortic injury is associated with high-speed mechanisms of injury and can occur in the absence of radiographic signs. Chest computed tomography (CT) can be used as a screening and diagnostic tool for suspected aortic injury. Aortography is reserved for patients with high suspicion of aortic injury or for confirmation of CT scan diagnosis.

Acute cervical spinal cord injury secondary to air bag deployment without proper use of lap or shoulder harnesses.

The authors present a case report of a patient with cervical central spinal cord syndrome caused by a hyperextension injury after a motor vehicle collision in which the air bag deployed in the absence of shoulder or lap belt harnesses. The potential for cervical spine and spinal cord hyperextension injuries in passengers positioned in front of air bags without proper use of shoulder or lap belt harnesses is discussed. Cervical central spinal cord quadriplegia occurred with cervical spondylosis and kyphosis that was managed by early three-level cervical corpectomy in a 58-year-old patient. Early improvement in the patient's neurological status occurred but was incomplete at the time of this report. Cervical hyperextension injuries are possible in passengers positioned in the front seat of cars with air bags when shoulder or lap belt harnesses are not used properly. Previous biomechanical studies have documented the potential for these types of injuries.

Fatal cerebroembolism from nonbacterial thrombotic endocarditis in a trauma patient: case report and review.

Nonbacterial thrombotic endocarditis (NBTE) is a rare condition that may result in an unexpected and usually fatal cerebroembolism. It occurs in a variety of clinical situations, including malignancy, immune disorders, and sepsis, but it has rarely been reported after trauma. The formation of NBTE appears to require a hypercoagulable state and changes in valvular morphology, e.g., during a hyperdynamic state. Patients with disseminated intravascular coagulation have a 21% incidence of NBTE. Although NBTE is usually found at autopsy, premorbid detection by echocardiography is currently possible and feasible. Untreated patients have a high incidence of embolic events, but anticoagulation with heparin may be life-saving. A lethal case of NBTE in a severely injured patient is reported here with the purpose of increasing awareness among medical personnel caring for trauma patients. Recommendations have been made for surveillance echocardiography in high-risk patients, e.g., critically ill patients with sepsis or disseminated intravascular coagulation.

Bedside open abdominal surgery. Utility and wound management.

Abdominal pathology in the critically ill or injured patient frequently leads to the use of open abdominal techniques or the actual performance of abdominal surgery in the ICU. All individuals responsible for the care of patients in the ICU should be familiar with the concepts and techniques of open abdomen wound management. ICU bedside abdominal surgery may be indicated if the patient is too unstable for transport to the operating room and the surgeon believes a limited procedure, such as a decompression of IAH, will be life-saving. Smaller procedures are also feasible, such as intra-abdominal packing changes for which the operating room is unnecessary. Development of a successful Surgery Outside the Operating Room program depends on mature cooperation between the surgeons and other professional ICU staff. Logistic details of such a program should be discussed and a scheduling protocol should be prepared before an emergent need for bedside surgery.

Surveyed opinion of American trauma surgeons on the prevention of the abdominal compartment syndrome.

OBJECTIVE: To determine the current opinion of American trauma surgeons on the use of the open abdomen to prevent the abdominal compartment syndrome (ACS). METHODS: On a questionnaire survey of expert trauma surgeons regarding 12 clinical factors influencing fascial closure at trauma celiotomy, surgeons graded their willingness to close the fascia in various scenarios on a scale of 1 to 5. The impact of six signs of clinical deterioration on willingness to perform abdominal decompression in a patient with postceliotomy elevated intra-abdominal pressure (IAP) was also queried. Of 292 members of the American Association for the Surgery of Trauma active in abdominal trauma management, 248 members (85%) had experience with ACS one or more times in the previous year. RESULTS: Surgeons' responses to factors found at trauma celiotomy were divided into two distinct categories: factors decreasing willingness to close the fascia, and factors not changing or increasing willingness to close the fascia (p < 0.001). Factors disfavoring fascial closure were pulmonary or hemodynamic deterioration with closure, massive bowel edema, subjectively tight closure, planned reoperation, and packing. Factors not changing or favoring fascial closure were fecal contamination/peritonitis, massive transfusion, hypothermia, multiple abdominal injuries, acidosis, and coagulopathy. Five of the six signs of clinical deterioration increased surgeons' willingness to decompress a patient with elevated IAP (increased O2 requirement, decreased cardiac output, increased acidosis, increased airway pressures, and oliguria). Lowered gastric mucosal pH did not affect willingness. Seventy-one percent of surgeons indicated they would decompress elevated IAP in postceliotomy patient if one or two signs of clinical deterioration were present, but only 14% would decompress a patient for elevated IAP alone. CONCLUSION: A majority of expert American trauma surgeons have experience with ACS and would leave the abdomen open if ACS occurred. A majority would reopen a closed abdomen in cases of elevated IAP with signs of clinical deterioration. A minority would leave the abdomen open when there was only a risk of developing ACS.

Surveyed opinion of American trauma surgeons in management of colon injuries.

BACKGROUND: Primary repair or resection and anastomosis of colon wounds have been advocated in many recent studies, but the proportion of trauma surgeons accepting these recommendations is unknown. OBJECTIVE: To determine the current preferences of American trauma surgeons for colon injury management. METHODS: Four hundred forty-nine members of the American Association for the Surgery of Trauma were surveyed regarding their preferred management of eight types of colon wounds among three options: diverting colostomy (DC), primary repair (PR), or resection and anastomosis (RA). The influence of selected patient factors and surgeons' characteristics on the choice of management was also surveyed. RESULTS: Seventy-three percent of surgeons completed the survey. Ninety-eight percent chose PR for at least one type of injury. Thirty percent never selected DC. High-velocity gunshot wound was the only injury for which the majority (54%) would perform DC. More than 55% of the surgeons favored RA when the isolated colon injury was a contusion with possible devascularization, laceration greater than 50% of the diameter, or transection. Surgeons who managed five or fewer colon wounds per year chose DC more frequently (p < 0.001) and PR less frequently (p < 0.001) than surgeons who managed six or more colon wounds per year. CONCLUSION: The prevailing opinion of trauma surgeons favors primary repair or resection of colon injuries, including anastomosis of unprepared bowel. Surgeons who manage fewer colon wounds prefer colostomy more frequently.

Prevention of abdominal compartment syndrome by absorbable mesh prosthesis closure.

OBJECTIVE: To determine whether prevention of the abdominal compartment syndrome after celiotomy for trauma justifies the use of absorbable mesh prosthesis closure in severely injured patients. DESIGN: Retrospective analysis of case series from July 1, 1989, to July 31, 1996. SETTING: University-based level I trauma center. PATIENTS: Seventy-three consecutive trauma patients requiring celiotomy who received absorbable mesh prosthesis closure and 73 control patients matched for injury severity and trauma type who received celiotomy without a mesh prosthesis closure. INTERVENTIONS: Absorbable mesh prosthesis closure was used in cases of excessive fascial tension, abdominal compartment syndrome, necrotizing fasciitis, traumatic defect, or planned reoperation. MAIN OUTCOME MEASURES: Demographics, Injury Severity Score, Abdominal Trauma Index, highest abdominal Abbreviated Injury Scale score, number of abdominal/pelvic injuries, highest head Abbreviated Injury Scale score, shock, indication for mesh closure, complications, number of operations and time required for closure, days in the intensive care unit, length of stay, and mortality were determined. The highest abdominal Abbreviated Injury Scale score was multiplied by the number of abdominal/pelvic injuries to calculate the abdominal pelvic trauma score. RESULTS: Group 1 consisted of 47 patients who received mesh at initial celiotomy, and group 2, 26 patients who received mesh at a subsequent celiotomy. These 2 groups were statistically similar in demographics, injury severity, and mortality. However, group 2 had a significantly higher incidence of postoperative abdominal compartment syndrome (35% vs 0%), necrotizing fasciitis (39% vs 0%), intra-abdominal abscess/peritonitis (35% vs 4%), and enterocutaneous fistula (23% vs 11%) compared with group 1 (P < .001). Group 1 patients with preoperative abdominal compartment syndrome had more abdominal/ pelvic injuries and higher abdominal trauma index than matched controls (P < .05). There was a trend toward higher abdominal pelvic trauma score in patients who developed abdominal compartment syndrome. The Pearson coefficient of correlation between the abdominal trauma index and the more easily calculated abdominal pelvic trauma score was 0.91 (P < .001). CONCLUSION: The use of absorbable mesh prosthesis closure in severely injured patients undergoing celiotomy was effective in treating and preventing the abdominal compartment syndrome.

The fractured rib in chest wall trauma.

Chest wall trauma and rib fractures are significant sources of morbidity and mortality in countries in which motor vehicle accidents are prevalent. Physicians who care for injured patients should realize that patients with thoracic trauma are at significant risk for mortality, deterioration, and associated injuries. Care must be taken to avoid underestimation of the effect of the injury on subsequent respiratory mechanics. Armed with an understanding of chest injury epidemiology, biomechanics, and pain control, physicians can better serve these high-risk patients.

Fifteen-year results of ambulatory compression therapy for chronic venous ulcers.

A nonoperative approach to venous stasis ulceration of the lower extremity, consisting of initial bedrest, ulcer cleansing, dressing changes, and ambulatory elastic compression stocking therapy, has been maintained for over 15 years. All patients had class III, severe chronic venous insufficiency. One hundred five of 113 patients (93%) experienced complete ulcer healing in a mean of 5.3 months. One hundred two patients were compliant with elastic compression stockings, and 11 patients were noncompliant. Complete ulcer healing occurred in 99 of 102 patients (97%) who were compliant versus six of 11 patients (55%) who were noncompliant (p less than 0.0001). The influence of noncompliance, previous venous ulceration, previous venous surgery, previous known deep venous thrombosis, peripheral arterial insufficiency (ankle brachial systolic blood pressure index less than or equal to 0.60), pretreatment ulcer duration, ulcer size, age, sex, diabetes, smoking, and photoplethysmography venous refill time on ulcer healing was determined by logistic regression analysis. Only noncompliance with elastic compression stockings (p less than 0.0001) and a pretreatment ulcer duration of more than 9 months (p = 0.02) significantly decreased initial ulcer healing. Posthealing follow-up was available in 73 patients for a mean of 30 months. Fifty-eight patients (79%) continued to be compliant with stockings; 15 patients were noncompliant. Total ulcer recurrence in patients who were compliant was 16%. Five-year lifetable recurrence was 29%. All patients who were noncompliant had recurrent ulceration by 36 months. Previous ulceration, previous venous surgery, and peripheral arterial insufficiency had no effect on ulcer recurrence (p greater than 0.05).

The influence of elastic compression stockings on deep venous hemodynamics.

To determine the effect of elastic compression stockings on deep venous hemodynamics we measured ambulatory venous pressure, venous refill time, maximum venous pressure with exercise, amplitude of venous pressure excursion, and duplex-derived common femoral and popliteal vein diameter and peak flow velocities with and without stockings in 10 healthy subjects and 16 patients with chronic deep venous insufficiency. The effects of below-knee and above-knee 30 to 40 torr and 40 to 50 torr gradient stockings were studied. Despite documentation of substantial stocking compressive effects by skin pressure measurements, neither below-knee or above-knee elastic compression stockings significantly improved ambulatory venous pressure, venous refill time, maximum venous pressure with exercise, or the amplitude of venous pressure excursion in healthy patients or in patients with deep venous insufficiency (p greater than 0.05). In patients with deep venous insufficiency stockings modestly increased popliteal vein diameter and flow velocity in the upright resting position (p less than 0.02). After tiptoe exercise without stockings deep venous peak flow velocity increased in healthy patients and in patients with deep venous insufficiency by a mean of 103% in the popliteal vein and 46% in the common femoral vein (p less than 0.01). With the application of elastic compression stockings only modest augmentation of deep venous flow velocity occurred in both groups above that seen in the bare leg after exercise. Thus elastic compression stockings did not improve deep venous hemodynamic measurements in patients with deep venous insufficiency. The beneficial effects of stockings in the treatment of deep venous insufficiency must relate to effects other than changes in deep venous hemodynamics.