The impact of liver dysfunction on outcome in patients with multiple injuries.

Multiple organ dysfunction syndrome (MODS) is the leading cause of late deaths after traumatic injury. The relative importance of dysfunction of individual organ systems in determining outcome from MODS has not been clearly defined. Some studies have suggested that hepatic dysfunction associated with MODS increases mortality, whereas others have suggested that it contributes little to outcome in trauma patients. To clarify the role of the hepatic dysfunction after traumatic injury we retrospectively reviewed all trauma patients with an Injury Severity Score > or = 14 admitted from January 1, 1994 through June 30, 1997 for the presence of hepatic dysfunction defined as a serum bilirubin > or = 2.0 mg/dL. Of the 1962 patients who met the entry criteria 154 developed hepatic dysfunction during their hospital stay. Patients with hepatic dysfunction were older (46 +/- 2 versus 41 +/- 1 years), were more severely injured (Injury Severity Score 31.5 +/- 0.9 versus 23.3 + 0.2), and had a lower prehospital blood pressure (102 +/- 3 versus 117 +/- 1 mm Hg) compared with patients who did not develop hepatic dysfunction. Patients with hepatic dysfunction were more likely to present with shock as reflected in a lower initial emergency room blood pressure (109 +/- 3 versus 128 +/- 1 mm Hg) and base deficit (-6.9 +/- 0.6 versus -3.5 +/- 0.1 mEq/L). Patients who developed hyperbilirubinemia had longer lengths of stay in the intensive care unit (15.8 +/- 1.2 versus 3.4 +/- 0.2 days) and the hospital (27.4 +/- 1.7 versus 11.1 +/- 0.2 days) and a higher in-hospital mortality (16.2% versus 2.5%). These data demonstrate that the development of hepatic dysfunction reflects the severity of injury and is associated with a significantly worse outcome after traumatic injury.

Low-dose vasopressin in the treatment of vasodilatory septic shock.

BACKGROUND: Despite appropriate therapy, refractory hypotension often occurs in septic shock. A double-blinded placebo controlled clinical trial was performed to assess the role of low-dose vasopressin (VP) as a pressor agent in septic shock. METHODS: Patients admitted to a trauma intensive care unit with vasodilatory septic shock were randomized to receive either VP at 0.04 U/min (n = 5) or placebo (n = 5). Vasodilatory septic shock was defined as a need for catecholamine agents to maintain a mean arterial pressure more than or equal to 70 mm Hg, despite a cardiac index more than 2.5 L/min and a minimal pulmonary artery wedge pressure more than 12 mm Hg. After 1 hour of initiation of the study drug, attempts to discontinue norepinephrine, phenylephrine, and/or dopamine, in respective order, were undertaken provided that the mean arterial pressure remained more than or equal to 70 mm Hg. RESULTS: A vasopressin infusion increased systolic arterial pressure (98 +/- 5 to 125 +/- 8 mm Hg, p < 0.008) because of peripheral vasoconstriction (systemic vascular resistance increased from 878 +/- 218 to 1,190 +/- 213 dynes/s per cm(-5) p < 0.05). Arterial pressure and systemic vascular resistance were statistically unaffected in the placebo group. Before study termination, measured at 24 hours after drug initiation, two patients in the placebo group died of refractory hypotension. However, all patients receiving VP survived the 24-hour study period and had all other catecholamine pressors withdrawn and blood pressure maintained solely with a low-dose VP infusion. CONCLUSION: A VP infusion improved arterial pressure and permitted the withdrawal of catecholamine vasopressors. VP is a useful agent in the treatment of refractory septic shock.

Timing fracture repair in patients with severe brain injury (Glasgow Coma Scale score <9)

BACKGROUND: Trauma patients with severe brain injury are at risk of secondary brain injury. Femur fractures, if present, should be repaired when potential causes of secondary brain injury have been corrected. METHODS: Sixty-one patients with severe or moderate closed head injury and femur fractures were identified. Patients were divided into groups by time until femur fracture reduction. RESULTS: An inversely proportional trend was demonstrated when comparing time until surgery with the percentage of patients who experienced hypotensive events during surgery. Patients in the 0- to 2-hour group were eight times more likely to become hypotensive during femur repair than patients in the >24-hour group. Seventy-four percent of patients with intracranial pressure monitoring experienced cerebral perfusion pressure <70 mm Hg. CONCLUSIONS: Operation in similar patients should be done when risks are minimized by adequate resuscitation. Secondary brain injury is more common in early femur repair. Operation delay of 24 hours may be necessary to prevent hypoxia, hypotension, and low cerebral perfusion pressure.

Neuropsychological function in restrained versus unrestrained motor vehicle occupants who suffer closed head injury.

It is known that using seatbelts reduces the incidence and severity of closed head injury (CHI) from motor vehicle crashes. One would expect unrestrained occupants in motor vehicle crashes to suffer more severe CHIs than restrained occupants, as reflected by Glasgow Coma Scale (GCS) scores. One might also expect an increased risk of focal injury due to contact forces in unrestrained occupants. The purpose of this study was to test the hypothesis that failure to use seatbelts results in increased severity of neuropsychological sequelae, even with GCS controlled. We also examined the impact of demographic variables on seatbelt use. Subjects included patients admitted to a hospital trauma service who were suspected of having suffered CHI. All patients completed neuropsychological testing, which was entered into a data base along with demographic and clinical information. People who had documented use of seatbelt restraints were compared with those who were unrestrained. Results confirmed that certain demographic variables are associated with the use of seatbelts. Results also suggested that failure to use seatbelt restraints is associated with more severe impairment on tests that are sensitive to frontal lobe dysfunction.

Impact of skull fracture on neuropsychological functioning following closed head injury.

The role of skull fracture in affecting morbidity following closed head injury (CHI) has received a significant amount of attention from researchers. While there is fairly widespread agreement that skull fractures increase the risk of complications such as haematoma, it us unclear whether the presence of skull fracture has predictive value in terms of the neuropsychological sequelae of CHI. The purpose of the current study was to further investigate the role of skull fracture in predicting neuropsychological dysfunction following CHI. Subjects included patients admitted to the trauma service of a large teaching hospital who were suspected of having suffered CHI. All patients completed neuropsychological testing and had normal computerized tomography (CT) scans. Patients who had suffered skull fracture were compared to those who had not suffered skull fracture on selected neuropsychological measures. Groups did not differ in terms of CHI severity as assessed by the Glasgow Coma Scale (GCS). Multivariate analysis of variance revealed that the groups did differ in terms of neuropsychological functioning. Results are interpreted as suggesting that the presence of a skull fracture is predictive of additional neuropsychological dysfunction, even in the absence of intracranial pathology or more severe disturbance of consciousness on the GCS.

Early tracheostomy in trauma patients.

A retrospective analysis of 118 trauma patients who underwent tracheostomy for airway and pulmonary management was undertaken. Timing of the procedure was defined as early (0-3 days), intermediate (4-7 days), and late (> 7 days). Head injury patients received tracheostomy early (p < 0.00003). Aspiration evaluated by modified bedside aspiration test was a frequent occurrence in all three groups with no difference in incidence (p < 0.34). Pneumonia was less frequent in the early group compared with the intermediate and late groups (p < 0.0034). The incidence of pneumonia in the early group was not different from that observed in early extubated patients (n = 282; p < 0.23). Our study suggests that early tracheostomy may decrease pulmonary septic complications in trauma patients. Although no change in length of stay can be attributed to the early performance of tracheostomy, preventing pneumonia in the intensive care unit setting with its resulting high expense is beneficial.

Delayed rupture of the spleen--myths, facts, and their importance: case reports and literature review.

Over a 1-year period, three patients were seen in our trauma service with delayed bleeding (> or = 7 days) from an initially inapparent splenic injury. This entity was defined as a late occurrence of signs and symptoms attributed to splenic injury not detected by diagnostic computed tomographic (CT) scanning during the initial examination. We believe that this represents an "injury in evolution" minor enough to go undetected on initial CT scans of the abdomen. A high index of suspicion and liberal utilization of imaging techniques are essential for the identification of delayed splenic rupture. Further multicenter studies are required to delineate the true incidence of its occurrence and its clinical significance. We conclude that "delayed rupture" of the spleen is a true clinical entity. The occurrence of a delayed rupture may prove hazardous to patients discharged early from the hospital after blunt abdominal injury. A classification system to assess this type of injury is suggested.

Diving injuries: a preventable catastrophe.

During a 5-year period from January 1987 through January 1992, 58 patients were admitted to the Allegheny General Hospital trauma center for non-scuba, non-suicidal diving injuries. There were 46 men and 12 women (mean age, 23 years). Forty-five patients were injured in swimming pools. Twenty-two patients had blood alcohol levels > 100 mg/dL. Cervical spine injury was the most common pathologic entity encountered in this group of patients. Closed head injury, pelvic fracture, thoracic vertebral fracture, and rib fractures were other injuries identified. Some patients had multiple organ failure syndrome. Aquatic recreational activities carry a risk for injury that is preventable. The mechanism, clinical data, and complications of 58 patients are presented and the importance of prevention is discussed.

Enhanced rim around infarcted, traumatized spleen on computed tomographic scans: case report.

Computed tomography is considered a reliable imaging technique when determining the extent of splenic injury. We present the case of a patient with a traumatic infarct of the spleen detected by computed tomographic scanning of the abdomen. During laparotomy there was an infarction of the spleen from a hilar injury in addition to bleeding from the splenic vein. We conclude that ongoing bleeding from the splenic hilar vessel can lead to a rim of enhancement around the spleen from contrast material. This should be taken into account when a decision is made for nonsurgical management.

Blunt vascular injury associated with closed mid-shaft femur fracture: a plea for concern.

During a period of six years, 765 consecutive patients were treated by the trauma service at Allegheny General Hospital for closed mid-shaft femur fractures that were a component of their injury complex. Thirty-one patients underwent angiography of the involved extremity for indications including loss of pulses in eleven and large hematomas or deformities of the thigh in the remainder. Ten patients (1.3%) were found to have acute vascular injuries. In nine patients there was an intimal flap of the superficial femoral artery (SFA), and in one, a pseudoaneurysm. Two patients had injuries of the femoral nerve. Three patients had no other associated major injuries (Injury Severity Score range, 10-19). Twelve months after the initial injury, one patient developed an arteriovenous fistula of the SFA. Detailed, repeated physical examinations, early utilization of angiography, and intensive follow-up by the trauma surgeon or orthopedic surgeon of patients with closed mid-shaft femur fractures should lead to early recognition of this potentially serious association.

Acute obstructive uropathy secondary to pelvic hematoma compressing the bladder: report of two cases.

Two patients with traumatic retroperitoneal hematomas causing obstructive uropathy required surgical evacuation of the hematoma to relieve the obstruction. Fast recovery of renal function and an instant increase in urine output resulted. The obstruction to the urine outflow by the retroperitoneal hematoma caused near total collapse of the bladder in these patients, which was corrected by angiographic embolization and surgical removal of the hematoma.

Geriatric trauma.

Elderly individuals not only live longer but are also more active than in the past. Accompanying this increase in activity is the number of older trauma victims. The effect of aging on response to injury is reviewed, and the initial evaluation and treatment of geriatric trauma are delineated in this article. Specific injuries of note include head and chest wall injury; pulmonary and cardiac contusion; abdominal trauma; and aortic, spinal, and musculoskeletal injury.

Hypoxemia after blunt chest injury: right-to-left intracardiac shunt managed non-operatively.

A case of patent foramen ovale with right-to-left intracardiac shunt after blunt chest injury is presented. The association of pulmonary contusion, pulmonary hypertension, and patent foramen ovale in a previously healthy subject is discussed. In such a case reduction of the afterload on the right ventricle is the suggested modality of treatment for hypoxemia due to the right-to-left shunt.

ATLS-based videotape trauma resuscitation review: education and outcome.

Trauma resuscitations (TRs) can be improved with ongoing videotape review. Unrecognized errors, delays, and system problems can be identified and corrected. Previous studies have demonstrated the importance of a short TR on survival and that videotape education can shorten TR time. Trauma resuscitation efficiency depends on details of TR including timing, organization, and appropriateness of care. Videotape education review monitors TR detail and improves TR efficiency by eliminating wasted time and treatment errors. Eight hundred eighty-three patients were evaluated. Group I included a control group prior to the incorporation of an ATLS based videotape review process. Group II included patients who were resuscitated after the educational review process was established. Subgroups based on ISS, direct OR transfer, DPL, and CT scan were also compared. Time and outcome were compared. Videotape educational review based on ATLS guidelines has improved TR efficiency. The benefits of ongoing videotape review include more efficient time utilization, correction of conceptual and technical errors, elimination of "wasted time," and improved survival.

Small-bowel obstruction from an extruded Greenfield filter strut: an unusual late complication.

Recently interest has been shown in liberalizing the indications for insertion of vena caval filters. The convenience of percutaneous insertion by radiologists may further perpetuate this trend. However, filter placement is not without morbidity. We report a unique late complication in which a small-bowel obstruction occurred as a result of volvulus around an extruded filter strut.