Predictors of outcome in 101 patients requiring emergent thoracotomy for penetrating pulmonary injuries.

BACKGROUND: Operative interventions are uncommonly required for penetrating pulmonary injuries. Similarly, because their incidence is low, few series appear sporadically in the literature. Objectives of this study are to identify predictors of outcome for patients requiring emergent thoracotomy for penetrating pulmonary injuries and evaluate the use of tissue sparing versus resective techniques for their management. STUDY DESIGN: This is a retrospective 169-month study of all patients with penetrating pulmonary injuries requiring thoracotomy. The main outcome measures are: physiologic parameters, AAST-OIS injury grade, surgical procedures and mortality. Statistical analysis includes univariate and stepwise logistic regression. RESULTS: 101 patients required thoracotomy for penetrating pulmonary injuries. Mechanism of injury includes: gunshot wounds (GSW)-73 (72%), stab wounds (SW)-28 (33%). Mean systolic BP 97 ± 47, mean HR 92 ± 47, and mean admission pH 7.22 ± 0.17. Mean RTS 6.25 ± 2.7, mean ISS 36 ± 22. The mean estimated blood loss (EBL) was 5277 ± 4955 mls. Predictors of outcome are: admission pH (p = 0.0014), admission base deficit (p < 0.0001), packed red blood cells (PRBCs) transfused (p = 0.023), whole blood transfused (p < 0.01). A total of 143 procedures were required in 101 patients: tissue sparing 114 (80%) versus resective procedures 29 (20%). Only pneumonectomy (p = 0.024) predicted outcome. Overall survival 64/101-64%. American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS) injury grades I-III versus IV-VI predicts survival (p < 0.001). Stepwise logistic regression identified AAST-OIS injury grades IV-VI (p = 0.007; OR 6.38 [95% CI 1.64-24.78]), intraoperative dysrhythmias (p = 0.003; OR 17.38 [95% CI 2.59-116.49]) and associated cardiac injuries (p = 0.02; OR 8.74 [95% CI 1.37-55.79]) as independent predictors of outcome. CONCLUSIONS: Predictors of outcome for penetrating pulmonary injuries requiring thoracotomy are identified and must be taken into account in their operative management. Tissue sparing techniques-stapled pulmonary tractotomy is once again validated, and it remains effective as the mainstay for their management; however, only pneumonectomy predicts outcome. AAST-OIS injury grades IV-VI predict outcome with higher injury grades requiring resective procedures.

Penetrating cardiac injuries: predictive model for outcomes based on 2016 patients from the National Trauma Data Bank.

BACKGROUND: Penetrating cardiac injuries are uncommon and lethal. The objectives of this study are to examine the national profile of cardiac injuries, identify independent predictors of outcome, generate, compare and validate previous predictive models for outcomes. We hypothesized that National Trauma Data Bank (NTDB) given its large number of patients, would validate these models. METHODS: The NTDB was queried for data on cardiac injuries, using survival as the main outcome measure. Statistical analysis was performed utilizing univariate and stepwise logistic regression. The stepwise logistic regression model was then compared with other predictive models of outcome. RESULTS: There were 2016 patients with penetrating cardiac injuries identified from 1,310,720 patients. Incidence: 0.16%. Mechanism of injury: GSWs-1264 (63%), SWs-716 (36%), Shotgun/impalement-19/16 (1%). Mean RTS 1.75, mean ISS 27 ± 23. Overall survival 675 (33%). 830 patients (41%) underwent ED thoracotomy, 47 survived (6%). Survival stratified by mechanism: GSWs 114/1264 (10%), SWs 564/717 (76%). Predictors of outcome for mortality-univariate analysis: vital signs, RTS, ISS, GCS: Field CPR, ED intubation, ED thoracotomy and aortic cross-clamping (p < 0.001). Stepwise logistic regression identified cardiac GSW's (p < 0.001; AOR 26.85; 95% CI 17.21-41.89), field CPR (p = 0.003; AOR 3.65; 95% CI 1.53-8.69), the absence of spontaneous ventilation (p = 0.008; AOR 1.08, 95% CI 1.02-1.14), the presence of an associated abdominal GSW (p = 0.009; AOR 2.58, 95% CI 1.26-5.26) need for ED airway (p = 0.0003 AOR 1386.30; 95% CI 126.0-15251.71) and aortic cross-clamping (p = 0.0003 AOR 0.18; 95% CI 0.11-0.28) as independent predictors for mortality. Overall predictive power of model-93%. CONCLUSION: Predictors of outcome were identified. Overall survival rates are lower than prospective studies report. Predictive model from NTDB generated larger number of strong independent predictors of outcomes, correlated and validated previous predictive models.

Vascular complications and special problems in vascular trauma.

The evaluation and management of patients with vascular trauma or injury often involve rapid decision making in less than ideal circumstances. Immediate consequences such as hemorrhage, ischemia, compartment syndrome, thrombosis, and embolization may be life threatening and require immediate intervention. In addition, a number of regional and systemic complications of the initial vascular pathology are possible, such as shock, acute renal failure, myocardial infarction, or stroke. Understanding the disease process, as well as the optimal diagnostic and therapeutic interventions, is critically important to minimize the risk of these highly morbid or potentially mortal complications. The managing physician must be adept and well versed at both the initial management of the specific vascular injury and the many potential complications that may subsequently arise. This article will review a number of vascular-specific complications and provide details of strategies for their prevention or optimal management. These problems include traumatic injuries to the arterial or venous system, failure of vascular repairs or reconstructions, surgical site and graft infections, anastomotic complications, and compartment syndromes. In addition, arterial and venous complications secondary to the use of illicit intravenous drug use and cocaine-related vascular injury will be discussed. Finally, the increasingly important topic of iatrogenic or procedure-related vascular injuries and complications will be reviewed.

Femoral vessel injuries; high mortality and low morbidity injuries.

Femoral vessel injuries are amongst the most common vascular injuries admited in busy trauma centers. The evolution of violence and the increase in penetrating trauma from the urban battlefields of city streets has raised the incidence of femoral vessel injuries, which account for approximately 70% of all peripheral vascular injuries. Despite the relatively low mortality associated with these injuries, there is a high level of technical complexity required for the performance of these repairs. Similarly, they incur low mortality but are associated with significantly high morbidity. Prompt diagnosis and treatment are the keys to successful outcomes with the main goals of managing ischemia time, restoring limb perfusion, accomplishing limb salvage and instituting rehabilitation as soon as possible.

Popliteal vessel injuries: complex anatomy, difficult problems and surgical challenges.

The incidence of popliteal vessel injuries is low, even in busy urban trauma centers. As a result of this fact, few trauma centers and trauma surgeons have developed extensive experience in the management of these injuries. Popliteal vessel injuries in both civilian and military arenas incur significant morbidity. These injuries present a difficult challenge, and, although the overall incidence of these injuries remains low, the sequelae can be devastating. Successful outcomes for limb salvage and survival result from early recognition and rapid surgical intervention by a multidisciplinary approach with a great participation of different surgical specialties. From the historical perspective, anatomy, incidence and associated injuries, to the clinical presentation, diagnosis, management, and morbidity and mortality, the aim of this article is to review the various aspects of these complex injuries.

Iliac vessel injuries: difficult injuries and difficult management problems.

INTRODUCTION: Injury to the iliac vessels poses a serious and frustrating treatment dilemma for all trauma surgeons. Generally, patients present in profound shock secondary to severe hemorrhage from either iliac arterial, venous, or combined injuries. Despite improvements in our emergency medical services (EMS), rapid transport, standard training of trauma surgeons, and improved technology, the morbidity and mortality from iliac vessel injuries remain high, ranging from 25 to 40 %. MATERIALS AND METHODS: A systematic review of the literature, with emphasis placed on the diagnosis, treatment, and outcomes of these injuries, incorporating the author's experience. CONCLUSIONS: Injuries to the iliac vessel remain a daunting task, even after great advances in anatomic injury grading and damage control as well as advances in surgical techniques and critical care. Despite all the advances in treatment and appropriate management strategies, the morbidity and mortality from iliac vessel injuries remain high, demonstrating the complex challenge their treatment presents to even the modern-day trauma surgeon.

Shank vessel injuries: the forgotten vascular injuries.

INTRODUCTION: Vascular injuries in branch vessels of the popliteal artery, such as the tibioperoneal trunk, and shank vessels, such as anterior, posterior tibial, and peroneal vessels, occur in both blunt and penetrating trauma. Their management has evolved significantly in the past few decades. While their incidence is variable, limb loss and morbidity remain significant. MATERIAL AND METHODS: Physical examination, along with measuring an Ankle-Brachial Index (ABI), is still sometimes all that is required for diagnosis and can expeditiously triage those that require urgent operation. Despite our technological advancements and newer algorithms for lower extremity vascular trauma, operative intervention and exposure still remain difficult and pose a great challenge for surgeons that normally do not operate on this area. CONCLUSIONS: Shank vessel injuries still comprise a significant proportion of combat and civilian vascular injuries, and modern advances have led to a dramatic decrease in amputation rates.