Anterior mediastinal abscess after closed sternal fracture.

BACKGROUND: Although sternal fractures after blunt chest trauma are markers for significant impact, the fracture itself is generally not associated with any specific wound complications. Mediastinal abscess and sternal osteomyelitis rarely occur after blunt trauma or cardiopulmonary resuscitation. Management of such complications is difficult, and requires a spectrum of operative procedures that range from simple closure to muscle flap reconstruction. METHODS: The trauma registry of a Level I trauma center was used to identify patients suffering a sternal fracture between January of 1994 and August of 1997. Records were reviewed for the mechanism of injury, length of hospital stay, and posttraumatic mediastinal abscess. RESULTS: Twenty-six patients were identified with sternal fracture. No clinically significant cardiac or aortic complications were noted. Three patients, all with a history of intravenous drug abuse and requiring central venous access in the emergency room, developed methicillin resistant Staphylococcus aureus mediastinitis. Sternal re-wiring and placement of an irrigation system successfully treated all three patients. CONCLUSION: Posttraumatic mediastinal abscess is an uncommon complication of blunt trauma in general and sternal fracture in particular. It can be recognized by the development of sternal instability. Risk factors include the presence of hematoma, intravenous drug abuse, and source of staphylococcal infection. Treatment with early debridement and irrigation can avoid the need for muscle flap closure.

Cost-effectiveness of enoxaparin versus low-dose heparin for prophylaxis against venous thrombosis after major trauma.

We attempted to determine health and economic outcomes from the perspective of an integrated health system of administering enoxaparin 30 mg twice/day versus heparin 5000 U twice/day for prophylaxis against venous thrombosis after major trauma. A decision-analytic model was developed from best literature evidence, institutional data, and expert opinion. We assumed that 40% of proximal deep vein thromboses (DVTs) and 5% of distal DVTs are diagnosed and confirmed with initial or repeat duplex scanning; 50% of undiagnosed proximal DVTs result in pulmonary embolism; 2% and 1% of undiagnosed proximal DVTs will lead to readmission for DVT and pulmonary embolism, respectively, and pulmonary embolism-related mortality rates range from 8-30%. Length of hospital stay data and 1996 institutional drug use and acquisition cost data were used to estimate the cost of enoxaparin and heparin therapy. Diagnosis and treatment costs for DVT and pulmonary embolism were derived from institutional charge data using cost:charge ratios. A second analysis of patients with lower extremity fractures was completed. One-way and multiway sensitivity analyses were performed. For 1000 mixed trauma patients receiving enoxaparin versus heparin, our model showed that 62.2 (95% CI -113 to -12) DVTs or pulmonary emboli would be avoided, resulting in 67.6 (8 to 130) life-years saved at a net cost increase of $104,764 (-$329,300 to $159,600). Enoxaparin versus heparin resulted in a cost of $1684 (-$3600 to $9800) for each DVT or pulmonary embolus avoided and a discounted cost/life-year saved of $2303 (-$8100 to $19,000). For 1000 patients with lower extremity fractures, enoxaparin versus heparin resulted in a cost of $751 (-$4200 to $3300) for each DVT or pulmonary embolus avoided and a discounted cost/life-year saved of $1017 (-$10,200 to $6300). Although enoxaparin increases overall health care costs, it is associated with a cost/additional life-year saved of only $2300, which is generally lower than the commonly used hurdle rate of $30,000/life-year saved. The cost-effectiveness ratio is more favorable in patients with lower extremity fractures than in the general mixed trauma population.

A comparison of rigid -v- video thoracoscopy in the management of chest trauma.

Between December 1, 1994 and April 1,1998, 44 thoracoscopic procedures were performed in 42 patients following chest injuries. Indications included exploration in 15, retained haemothorax in 10, continued bleeding after chest tube placement in 3, air leak in 5 and empyema in 11. Video thoracoscopy was used in 24 cases and rigid thoracoscopy in 20, including 14 patients in whom video thoracoscopy was contraindicated. There was no difference in the operative times, length of stay or incidence of complications. Two formal and 3 "mini" thoracotomies were used in the video thoracoscopy group. Three "mini" thoracotomies were required in the rigid thoracoscopy group. Rigid thoracoscopy is an effective tool that, in selected cases, increases the utility of thoracoscopy in the management of chest trauma and its complications.

Trauma pneumonectomy revisited: the role of simultaneously stapled pneumonectomy.

OBJECTIVE: The aim of this study was to compare simultaneously stapled pneumonectomy (SSP) with individual ligation (IND) as a method for performing urgent pneumonectomy (Py) for trauma. METHODS: Twelve patients who required Py were reviewed. SSP was performed in nine cases and IND in three cases. The two groups had statistically similar injury severity scores, presenting systolic blood pressures, and Trauma and Injury Severity Score derived probabilities of survival. An animal model of Py was developed, in which seven animals underwent SSP and seven underwent IND methods. Burst pressures of the pulmonary artery and bronchus were calculated after 14 days. RESULTS: There were no differences noted in survival rates between SSP (5 (56%)) and IND (1 (33%)), nor in incidence of bronchopleural fistula. The SSP group had a significantly shorter operative time compared with that of IND (88.9 +/- 14.3 minutes vs 213 +/- 57.8 minutes, respectively, p - 0.01). The animal study revealed no difference in burst pressures of the bronchus (SSP = 662.9 +/- 169.9 mm Hg vs. IND = 591.4 +/- 193.2 mm Hg, p = 0.752) or of the pulmonary artery (SSP = 554.3 +/- 195.1 mm Hg vs. IND = 477.7 +/- 247.5 mm Hg, p = 0.529). CONCLUSION: Survival after pulmonary injuries that require Py depends upon the rapidity of hilar control and of the procedures itself. Simultaneously stapled pneumonectomy is an effective and rapid method of dealing with such rare injuries.

Use of absorbable mesh as an aid in abdominal wall closure in the emergent setting.

A surgeon has many options available to aid in the closure of abdominal wall defects in the elective setting. In the emergent setting, active infection or contamination increases the likelihood of infection of permanent prosthetic material and limits the surgical options. In such settings, we have used absorbable mesh (Dexon) as an adjunct to fascial closure until the acute complications resolve. To evaluate the effectiveness of this technique, we reviewed the outcome of such closures in 26 critically ill patients. Between July 1987 and June 1993, 26 patients were identified who had placement of absorbable mesh as part of an emergent laparotomy at a major urban trauma center. Through a retrospective chart review, the incidence of complications and outcome of the closure were tabulated. Seven patients were initially operated on for trauma. Two of the patients had mesh placement at their initial procedure secondary to fascial loss from trauma. The remainder of the patients hd mesh placement during a subsequent laparotomy for complications related to their initial procedure. Indications for these laparotomies included combinations of wound dehiscence, intra-abdominal abscess, anastomotic disruption, and perforation. Mesh placement in patients with intra-abdominal infection created effectively open abdominal wounds that allowed continued abdominal drainage, but required extensive wound care. Despite the absorbable nature of the mesh and often prolonged hospital stay in these ill patients, none of them required reoperation for dehiscence, recurrence of intra-abdominal abscess, or infection of the mesh.(ABSTRACT TRUNCATED AT 250 WORDS)

Primary common bile duct closure following exploration: an effective alternative to routine biliary drainage.

Primary closure of the common bile duct following exploration has been safely and effectively performed, as advocated by Halsted, provided no evidence of pancreatitis, cholangitis, or ampullary obstruction exists. Using this precedent, the operative management and clinical course of 29 patients undergoing common bile duct exploration (CBDE) for choledocholithiasis from 1986 to 1992 were reviewed. Ten patients had primary closure of the common bile duct (CBD) following choledochotomy and exploration, and 17 patients had t-tube placement. Two patients had CBDE through an enlarged cystic duct that was then ligated. Patients were selected for t-tube placement if they had pancreatitis, ascending cholangitis, evidence of retained stones, or ampullary obstruction. Two patients in this series died. No patient with primary closure of the CBD suffered a biliary complication including retained stones, biliary fistula, pancreatitis, or bile peritonitis. Serious systemic complications were comparable in both groups. The results of this series support the safety of primary common bile duct closure in selected cases.

Coagulation defects resulting from ambient temperature-induced hypothermia.

Ambient temperature-induced hypothermia noted in trauma patients is frequently accompanied by a bleeding diathesis despite "laboratory normal" coagulation values. To document this impression, the following experiment was conducted. Coagulation studies and platelet function studies were performed in ten minipigs during induced whole body hypothermia (40 degrees C to 34 degrees C) and rewarming. Cooling was achieved in 2 to 3 hours and rewarming took 4 to 5 hours. In addition, similar coagulation and platelet function studies were conducted on plasma samples from the same animals that were cooled and then rewarmed in a water bath. Platelet counts and function as measured by Sonoclot analysis and aggregation did not decrease significantly with hypothermia in either model. Plasma cooled in a water bath demonstrated abnormal PT and aPTT (p < 0.001). Whole body hypothermia demonstrated abnormal bleeding time and PT (p < 0.001). Ambient temperature-induced hypothermia produced significant coagulation defects in a porcine model. Some of the coagulation defects were most pronounced during rewarming.

The management of massive lower gastrointestinal bleeding.

To evaluate what has been the most effective surgical treatment for massive lower gastrointestinal bleeding, we reviewed the records of 31 patients who underwent colon resection for hemodynamic instability and/or the need for continued transfusions. These 31 patients underwent either segmental colectomy (21 patients) or subtotal colectomy (10 patients). Resections were performed for diverticular disease (19 patients), angiodysplasia (eight patients), acute ulceration (three patients), and polyps (one patient). The re-bleeding rate (mean follow-up 1 year) for subtotal colectomy was 0 per cent, segmental resection with positive angiography was 14 per cent, and segmental resection with negative angiography was 42 per cent. The complication rate including myocardial infarction, ARDS, pneumonia, and renal failure was highest (83 per cent) in those patients receiving segmental resection with a negative angiogram. The mortality rate was also highest for segmental resection patients with negative angiography (57 per cent). The results of this review suggest that segmental resection should be performed when the bleeding site is identified angiographically. Subtotal colectomy should be reserved for massive bleeding with negative angiography.

Arterial injuries of the thoracic outlet: a ten-year experience.

Arterial injuries of the thoracic outlet are complex and require a precise plan for adequate management and prompt exposure of injured vessels. Our 10-year experience with 28 such injuries is reviewed. Arteriography was performed whenever possible in stable patients (15) and aided in planning the operative approach. Unstable patients with active bleeding, pulsatile or expanding hematoma, or pulse deficit were taken to the operating room without delay. A thoracic approach was required in 15 patients, and the exposure was extrathoracic in 12 patients. Airway was secured with liberal use of emergency endotracheal intubation (16 patients). Primary repair was possible in 16 patients, with grafting performed in eight and ligation in three. One vertebral artery injury was successfully controlled with embolization. Venous injuries were repaired in six patients and ligation was necessary in eight; there was no significant morbidity. Two patients died in this series from complications of severe hemorrhage. Significant morbidity was encountered from associated neurologic injuries in 15 patients. Stroke was evident in two patients, both of whom were moribund preoperatively. Proximal subclavian artery injuries were particularly more problematic and frequently required an interim anterior thoracotomy for early control of exsanguinating hemorrhage. Our philosophy in the management of these injuries and choices of exposure are discussed in detail.

Severe pancreatico-duodenal injuries: the effectiveness of pyloric exclusion with vagotomy.

The operative management and clinical course of 17 patients treated for severe pancreatico-duodenal injuries from 1983 to 1990 was reviewed. The etiology of these injuries was gunshot wound in 15 patients; stab wound in 1 patient; and a motor vehicle accident in 1 patient. Seven patients presented in shock with a systolic blood pressure of less than 80. At exploration, 57 associated injuries were found in the 17 patients including 16 major vascular injuries. All patients were treated with pyloric exclusion and drainage. Vagotomy was performed in eight patients. None of these 17 patients were felt to have extensive enough damage to require pancreatico-duodenectomy. Two patients died in the immediate postoperative period of severe coagulopathy and two patients died of sepsis. Seven patients had complications related to the pancreatico-duodenal injury. All seven developed pancreatic fistulas; three also had pancreatitis and two developed multiple enterocutaneous fistulas. Systemic complications included pulmonary complications in eight patients and sepsis in five patients, including two patients with abdominal abscesses. Six patients bled in the immediate postoperative period secondary to coagulopathy. Three patients had complications related to pyloric exclusion. One developed afferent loop syndrome necessitating reoperation. The other two had marginal ulcers, which either perforated or bled and required reoperation. Of interest, neither of these two patients had vagotomy initially. The results of this series confirm the effectiveness of pyloric exclusion with vagotomy for severe pancreatico-duodenal injury.

Neurologic consequences of cerebrovascular injury.

Because of ongoing controversy, the issue of vascular repair or ligation for patients with cerebrovascular injuries and preoperative central neurologic deficits is frequently debated. A total of 133 patients with penetrating cerebrovascular injuries were analyzed. The frequency of preoperative neurologic deficit was 20% (27 patients). The common carotid and internal carotid arteries were the most frequently injured structures, with a 29% and 15% incidence of preoperative neurologic deficits, respectively. The results of carotid repair in all patients whose preoperative deficit was limited to weakness or paralysis were favorable (seven patients normal or improved, two patients unchanged). The results of repair in patients whose preoperative deficit was characterized by obtundation were variable (four patients improved, four patients worsened or died). The results of carotid ligation were also variable (one improved, one unchanged, three worsened or died). Limited numbers of patients with preoperative neurologic deficits and the retrospective nature of this review prohibit definite conclusions. Therefore a multicenter, prospective, randomized trial of ligation or vascular repair for comatose patients with cerebrovascular injuries is proposed.

Coagulopathy and intraoperative blood salvage (IBS).

The use of potentially contaminated shed blood and the contribution of autotransfused blood to coagulopathy are controversial issues associated with intraoperative blood salvage (IBS) in trauma patients. Intraoperative blood salvage was used in 154 trauma patients and resulted in reinfusion of 7.97 units per patient. Moderate to severe abnormalities of the prothrombin time (PT) and partial thromboplastin time (PTT) occurred in 39 patients (31%). Prolongation of the PT and PTT occurred with increasing transfusion. Coagulopathy was seen in patients receiving greater than 15 IBS units and in patients receiving greater than 50 combined units of blood. Of the 66 patients with bowel injury, 58 patients received shed blood. Patients with bowel injury showed no increase in infection but did develop prolongation of PT and PTT at lower levels of IBS transfusion. Based on the results of this study, patients receiving greater than 15 units of IBS transfusion require careful monitoring and factor replacement, and IBS transfusion should be limited to less than 10 units in patients with bowel injury.

Management of general surgical emergencies in pregnancy.

The management of 25 pregnant patients (gestational age 4-40 weeks) treated at Henry Ford Hospital from 1980-86 was reviewed. Eleven women were treated for a variety of nontraumatic general surgical emergencies including cholecystitis, appendicitis, pancreatitis, and gastrointestinal obstruction. Fourteen women were treated after sustaining traumatic injuries. Ten patients were managed without operation and 15 required surgical intervention as part of their treatment. Diagnostic studies that proved helpful included diagnostic peritoneal lavage, ultrasonography, intravenous pyelography, and roentgenograms of the chest and abdomen. There were no maternal deaths, but two fetal deaths occurred as a result of traumatic injuries. Five women and one neonate developed major complications requiring prolonged hospitalization. Early aggressive resuscitation and thorough diagnostic evaluation are required to achieve a favorable outcome in the management of the pregnant patient who presents with an emergent general surgical problem.

Comparative accuracy of diagnostic peritoneal lavage, liver-spleen scintigraphy, and visceral angiography in blunt abdominal trauma.

Diagnostic peritoneal lavage (DPL), liver-spleen scintigraphy (LSS), and visceral angiography (VA) have been cited as useful in the evaluation of patients sustaining blunt abdominal trauma to determine the existence of injuries requiring operative intervention. We have reviewed the clinical courses of 44 patients who sustained blunt abdominal trauma and had various combinations of DPL, LSS, and VA employed in their diagnostic evaluation. The predictive value and efficiency of these tests have been compared in this group of patients. DPL is sensitive and specific for the presence of intraperitoneal blood. LSS is sensitive and specific for parenchymal irregularity in the liver and spleen. VA is sensitive and specific for vascular abnormality, severe hemorrhage, and arteriovenous shunting. None of these tests are completely sensitive and specific for the spectrum of surgically significant injuries produced by blunt abdominal trauma. In this group of patients who had multiple studies because of diagnostic uncertainty, DPL had the highest predictive value and the highest efficiency. LSS results did not by themselves dictate a change in management for any patient. In some patients VA was helpful in determining operative or nonoperative management.

The role of contrast radiography in presumed bowel obstruction.

A retrospective review of 229 patients with a final diagnosis of small-bowel obstruction was undertaken to evaluate the role of contrast radiography in the management of their conditions. In 84 patients (37%) the clinical findings and plain abdominal roentgenograms were sufficient for diagnosis and subsequent management. Of the remaining 145 patients with equivocal findings, 27% had an upper gastrointestinal series, 29% a barium enema, and 44% had both. Useful information (complete obstruction, unobstructed passage of contrast, or diagnosis other than adhesional obstruction) was obtained from 86% of the radiographic studies. Three patients had negative contrast studies yet eventually underwent adhesiolysis (enterolysis) and were classified as false-negative. Two patients had evidence of high-grade obstruction yet had nonoperative resolution and were classified as false-positive. The mortality in the contrast group (7%) was not statistically different than that in the no-contrast group (7%). Contrast radiography is a safe and effective means of increasing diagnostic accuracy in patients with presumed small-bowel obstruction.

Urban trauma: a chronic recurrent disease.

Urban trauma, often presumed to be an acute episodic event, may actually be a chronic recurrent disease related to the lifestyle, environment, and other factors of its victims. To test this idea an attempt was made to obtain 5-year followup for 501 consecutive survivors of violent trauma seen at one hospital, 1980-1981. Followup information for these patients was obtained from medical records at four local Level I trauma centers, death certificates, Medical Examiner's records, and police crime computer files. Of the 501 patients, 263 had medical followup including 148 patients with one trauma and 115 patients with recurrent trauma. Of these 263 patients, 200 (76%) were unemployed and 164 (62%) abused alcohol or drugs. From 1982-1987 142 out of 263 patients were involved in 133 crimes and 52 died. These data suggest that urban trauma is a chronic disease with a recurrent rate of 44% and a 5-year mortality rate of 20%.

Catheter aspiration for simple pneumothorax. Experience with 114 patients.

Between 1983 and 1987, 114 adult patients with 131 pneumothoraces were treated utilizing catheter aspiration for simple pneumothorax as an alternative to tube thoracostomy. The causes of simple pneumothorax were as follows: 79 needle-induced, 36 spontaneous, and 16 traumatic. Thirty-eight of the pneumothoraces were small (less than 20% of volume), 55 were moderate (20% to 40% of volume), 36 were large (greater than 40% of volume), and 2 were of unknown size. Overall, catheter aspiration for simple pneumothorax was successful in 90 patients (69%). The success rate was 75% with needle-induced, 53% with spontaneous, and 75% with traumatic pneumothoraces. Small pneumothoraces were successfully managed with catheter aspiration for simple pneumothorax in 87% of patients, moderate-sized in 60%, and large in 61%. There were three complications (2.3%), including one hemothorax and two retained sheared catheter tips. The average cost per patient was +868 for catheter aspiration, and $6402 for a tube thoracostomy. These data support catheter aspiration as a safe, cost-effective, and successful technique for managing simple pneumothorax.

Antibiotics for penetrating abdominal trauma: a prospective comparative trial of single agent cephalosporin therapy versus combination therapy.

In this prospective, comparative study, 129 patients who sustained penetrating abdominal trauma were randomized to receive preoperatively, and for 3-5 days postoperatively, one of three antibiotic regimens: Group I--cefotaxime (CTX) (2 Gm Q8H), Group II--cefoxitin (2 Gm Q6H), or Group III--clindamycin (900 mg Q8H) and gentamicin (3-5 mg/kg/day in divided doses Q8H). The three groups were similar in terms of the following: age, sex, severity of injury, number of organs injured, colon injuries, shock, blood transfusions, or positive intraoperative cultures. Septic complications occurred as follows: Group I--6.9%, Group II--2.3%, and Group III--6.9%. The three regimens ranked as follows in terms of therapy costs: CTX less than cefoxitin less than clindamycin and gentamicin. It is concluded that single agent therapy with a cephalosporin is preferable to combination therapy on the basis of equivalent effectiveness, lower toxicity, and lower costs.