Management of penetrating neck injuries. The controversy surrounding zone II injuries.

Penetrating neck injuries present a difficult challenge in management, given the unique anatomy of the neck. Controversy surrounds the approach to zone II injuries; mandatory versus selective exploration. On the basis of an extensive literature review, the authors conclude that neither approach is obviously superior. A selective approach is safe in the asymptomatic and hemodynamically stable patient, provided that accurate invasive diagnostic means are immediately available. The mandatory approach is safe, reliable, and time tested. The greatest problem appears to be the accuracy of detection of cervical esophageal injuries: Radiologic evaluation may be inaccurate, rigid esophagoscopy carries a risk of perforation, and the injury may easily be overlooked during surgical exploration.

Hernia through the foramen of Winslow: a complication of cholecystectomy. A case report.

In 151 years since first described, there have been 112 reported cases of hernia through the foramen of Winslow (HFW). All thus far have described HFW as a primary entity. The case reported appears to be unique with HFW as a surgical complication. HFW is the least common of internal hernias. The primary symptom is pain referred from the herniated organ and the hepatoduodenal ligament. An interesting sign is that the patient is found curled up or stooped over for pain relief. Anatomic factors implicated in HFW are an enlarged epiploic foramen, a floppy cecum and ascending colon, or abnormal length of small bowel mesentery. Tension on these structures causes pain with the torso extended. Distention of bowel in the lesser sac mimics gastric obstruction. Organs herniated are: small bowel (63%); cecum, ascending colon, and terminal ileum (30%); and transverse colon (7%). Of 25 cases reported since 1966, cecal herniation comprised two-thirds. The diagnosis may be made radiologically and the treatment is surgical. The case and a review of the literature are presented with attention to the anatomy. Also provided are the signs and symptoms of this interesting and perplexing diagnosis.

Nonoperative management of blunt splenic and hepatic trauma in the pediatric population: significant differences between adult and pediatric surgeons?

Although operative management was the preferred method of treating blunt abdominal trauma in the past, recent literature and practice recommend a nonsurgical approach to most pediatric splenic and hepatic injuries. The majority of data supporting the safety and efficacy of this nonoperative approach are derived from university trauma programs with a pediatric center where care was managed by pediatric surgeons only. To evaluate the applicability of this approach in a regional trauma center where pediatric patients are managed by pediatric and non-pediatric surgeons we reviewed the experience at a Level II community trauma center. Fifty-four children (16 years of age or less) were admitted between April 1992 and April 1998 after sustaining blunt traumatic splenic and/or hepatic injuries. There were 37 (69%) males and 17 (31%) females; the average age was 11 years (range 4 months to 16 years). Of the 54 patients 34 (63%) sustained splenic injuries, 17 (31%) sustained hepatic injuries, and three (6%) sustained both splenic and hepatic injuries. All of these injuries were diagnosed by CT scan or during laparotomy. The average Injury Severity Score was 14.9 with a range from four to 57. Of the 47 patients initially admitted for nonoperative management one patient failed nonoperative management and required operative intervention. In our study 98 per cent (46 of 47 patients) of pediatric patients were successfully managed nonoperatively. Complications of nonoperative management occurred in two patients. Both developed splenic pseudocysts after splenic injury, which required later operative repair. These data are comparable with those from university trauma programs and confirm that nonoperative management is safe in a community trauma center. The majority of children with blunt splenic and hepatic trauma can be successfully treated without surgery, in a regional trauma center treated by nonpediatric trauma surgeons, if the decision is based on careful initial evaluation, aggressive resuscitation, and close observation of their hemodynamic stability.

Cost savings associated with changes in routine laboratory tests ordered for victims of trauma.

Not all trauma victims evaluated by the trauma service require a full complement of laboratory tests upon admission. This study set out to determine the cost savings and safety of limited laboratory testing of trauma victims. Before 1998, our admission trauma protocol included 11 laboratory tests for all trauma victims. In 1998, we created two categories: Trauma Blue--severe injury likely (Glasgow Coma Score <13; systolic blood pressure <100 mm Hg at any time; significant head, chest, abdominal, or proximal long bone injury; or clinical suspicion of need for operative or intensive care unit management) and Trauma Yellow--severe injury unlikely. The triage decision was made by the team leader or attending physician. Trauma Blue laboratory tests included an arterial blood gas, blood alcohol, type and screen or crossmatch, and urine dipstick. All patients who did not meet Trauma Blue criteria were entered in the Trauma Yellow group. There were only two tests for the Trauma Yellow group, a venous blood gas and blood alcohol. All arterial and venous blood gases measured pH, pO2, pCO2, HCO3, base deficit, hemoglobin, sodium, potassium, and ionized calcium. Other laboratory tests were done if requested by the trauma team leader or attending physician. All trauma admissions for a 3-month period were entered into this prospective study. The admitting trauma surgeon was surveyed after each admission to evaluate any problems in patient care. The test group was compared with a historical control of 100 consecutive patients under the original laboratory trauma protocol. One hundred and forty-eight (148) patients were entered into the study. Average laboratory cost per patient was $29.82 less with the study protocol. No patient care problem was identified. A cost savings of $29.82 per patient or $20,000.00 a year was realized for our institution, with no change in the quality of patient care. Trauma protocols designed to reflect a patient's potential for serious injury can result in a significant cost savings while preserving patient safety.

Atlanto-occipital dislocation: a report of three patients and a review.

Traumatic atlanto-occipital dislocation is usually instantaneously fatal when it occurs. Survival is possible with minimal remaining neurologic deficits if diagnosed quickly and treated appropriately. The authors present three reports of patients who survived the incident, and they review the anatomy of the atlanto-occipital joint, clinical presentation, diagnosis, and treatment of this traumatic injury.

Factors influencing the potential organ donation: a 6-yr experience of the New Jersey Organ and Tissue Sharing Network.

UNLABELLED: The demand for organ transplants in the United States is increasing by 16% every year. Unfortunately, organ donation figures are not increasing at the same rate. Factors that influence the process of organ donation in New Jersey were analyzed. METHODS: A retrospective study in which the charts of actual and potential organ donors identified by the New Jersey Organ and Tissue Sharing Network (OTSN) between January 1990 and December 1995 were reviewed. Potential donors who were not identified by the OTNS or the United Network for Organ Sharing (UNOS) were not considered because no data relative to these cases were available. The conversion ratio (CR) between actual donor from potential donor was determined. A statistical analysis of the data was performed using multivariate regression logistic analysis. RESULTS: Organ donation increased, both in the male and female population, by 14% over the last 6 yr. The 0-5-yr age group experienced an increment in CR from 7.7 to 37.7% (p < 0.001). All other age groups had a continuous improvement, but a statistically significant increase over time was not observed. The CR of all races increased over the 6-yr study period. The Afro-American population donated significantly less than the white population (32.1 vs. 59.9%) (p < 0.001). The three transplant centers in New Jersey had a CR less than that seen in the non-transplant centers (38.1 vs. 44.1%). The number of total donations (78.7 vs. 21.3%) was significantly greater in the non-transplant centers (p < 0.001). Moreover, the number of lost donors was higher at transplant centers (p < 0.001). Over the 6-yr period, the difference between donations coming from non-urban (70.8%) versus urban areas (29.27%) was highly significant (p < 0.001). Traumatic deaths were associated with a greater CR (55.3%) than all other causes of death. The CR for donors dying as a result of motor vehicle accidents (MVA) (p < 0.001), penetrating trauma, and child abuse all increased. Level II trauma centers had a better CR (53.7%) than level I centers (48.4%) and non-trauma centers (51.1%). The donation rate was similar for level II and non-trauma centers (60%). CONCLUSIONS: The organ donation rate in New Jersey is not sufficient to meet the needs of organ recipients in New Jersey. Pediatric donations increased considerably, specifically from child abuse. MVA deaths are associated with the greatest CR. Urban areas have a worse CR than non-urban areas, even if they are associated with transplant or trauma

Functional scoring of multi-trauma patients: who ends up where?

To help map the continuum from injury to return to full function, the Functional Independence Measure (FIM) was used in an acute care setting to identify and track disability, to focus rehabilitative efforts during the acute phase of care, and to help demonstrate what is truly important in getting patients back to full functional status. A total of 109 patients were assessed over a 13-month period. FIM scores were based on a patient's ability to routinely perform certain tasks in 18 areas of function and ranged from 1 to 7. The change in FIM scores from admission to discharge was used to determine those patients to be discharged home and those patients to be discharged to a rehabilitation facility. We conclude that the FIM is a very useful tool that produced a very good measure of a patient's total function, tracked progress or lack of it through acute hospitalization, and correctly categorized and quantitated dysfunction (both cognitive and physical) as discharge planning was being done.

Physician review improves hospital DRG reimbursement in injury.

This was a prospective study of all DRG reimbursed trauma patients discharged during an 11-month period. Initial DRGs were assigned by hospital coding specialists (HCS). A surgeon (SURG) subsequently reviewed each chart and assigned DRGs to maximize reimbursement. The data for 244 patients were: age = 36.5 years, Trauma Score (TS) = 13.8, Injury Severity Score (ISS) = 16.9, and length of stay (LOS) = 10.3 days. Total charges for the 244 patients were $4,261,208 with an initial HCS projected reimbursement of $1,687,963. The SURG review resulted in a total projected reimbursement of $1,956,476, an increase of $268,513 in revenue (p less than 0.001). Charges correlated strongly with LOS and ISS. The HCS-coded and SURG-coded reimbursements also correlated positively with LOS and ISS, but to a lesser extent. The SURG review of DRG assignment improved hospital reimbursement for the injured patients. However, this reimbursement fell well below hospital billings.