Contribution of protein to caloric expenditure following injury.

1. There is a common clinical impression that because the nitrogen excretion after injury roughly parallels the increased resting metabolic expenditure and weight loss, the primary source of extra fuel is derived from protein. This study has been undertaken to evaluate the caloric contribution of protein to the daily resting metabolic expenditure (RME). 2. Under the most extreme circumstances of nitrogen excretion, massive soft tissue injury, the caloric contribution of protein is only 20 percent of the RME. Body fat stores are the only other major source of fuel from which the semistarved patient can meet the increased demands for energy. 3. Any form of severe injury impairs the mechanisms by which protein breakdown and nitrogen excretion are reduced. 4. Patients undergoing elective operation in this study did not have a significant rise in RME or nitrogen excretion.

Radionuclide diagnosis of diaphragmatic rupture with hepatic herniation.

Seven surgically proven cases of a traumatic rupture of the right hemidiaphragm with a hepatic herniation were preoperatively diagnosed by radionuclide liver-spleen imagings, and they were retrospectively analyzed. All injuries resulted from blunt traumatic injury including automobile accidents, and there were associated pelvic and rib fractures in five cases. All patients developed some degree of dyspnea in the relatively immediate phase. All chest radiographs showed an apparent elevation of right hemidiaphragm. Radionuclide liver-spleen imaging with 99mTc sulfur colloid characteristically demonstrated a distortion of liver configuration with superior and posterior displacement of the right lobe. Four patients had a large tear in the central tendon of the right hemidiaphragm, and none had a tear in the anterior part or in left lobe of the liver. The differential diagnosis of elevated right hemidiaphragm is briefly discussed. It is concluded that the correct preoperative diagnosis of the diaphragmatic rupture with liver hernia could be made with an awareness of this condition following trauma and radionuclide liver-spleen imaging.

Primary small bowel volvulus: cause and management.

Most reports of patients with primary small bowel volvulus have indicated that the ingestion of a high-bulk vegetable diet in some way contributes to the development of this condition. During a recent 13-month period at Nangarhar University Hospital at Jalalabad, Afghanistan, the frequency of occurrence among 26 patients was found to be related to abrupt changes in dietary intake. The first and last months of the study were Ramadan, the annual period in which Mohammedans abstain from all oral intake during daylight hours and take a single large meal after dark. During these two isolated months, there was a ten fold and nine fold increase, respectively, in the incidence of the condition. Early diagnosis and surgical intervention offer the only possibility for minimizing an otherwise excessive mortality.

A university-staffed, private hospital-based air transport service. The initial two-year experience.

During the first two years of a cooperative effort between the University of Texas Medical School at Houston and Hermann Hospital, Houston, a program designed to extend the emergency center to the patient by helicopter treated and moved 1,702 patients. A physician and flight nurse attended patients on each mission. Of all flights, 68.3% were because of major multiple trauma and 28.8% were to the scene of an accident. The magnitude of these injuries was reflected by a mortality of 11% at the scene of the accident and 7% in the emergency room of those transported. The primary purpose of the program is to minimize the time between the catastrophic event and the institution of appropriate medical therapy. Our experience with this program of early stabilization and rapid transport has led to the following observations: (1) single-organ injury is virtually nonexistent in the patient with multiple trauma; (2) clotting abnormalities, even disseminated intravascular coagulopathy, are seen regularly in patients with apparently isolated head injuries; and (3) patients with apparently isolated head injuries often have serious pulmonary function abnormalities.

Delayed complications of nonoperative management of blunt adult splenic trauma.

OBJECTIVE: To determine the incidence and type of delayed complications from nonoperative management of adult splenic injury. DESIGN: Retrospective medical record review. SETTING: University teaching hospital, level I trauma center. PATIENTS: Two hundred eighty patients were admitted to the adult trauma service with blunt splenic injury during a 4-year period. Men constituted 66% of the population. The mean (+/-SEM) age was 32.2+/-1.0 years and the mean (+/-SEM) Injury Severity Score was 22.8+/-0.9. Fifty-nine patients (21%) died of multiple injuries within 48 hours and were eliminated from the study. One hundred thirty-four patients (48%) were treated operatively within the first 48 hours after injury and 87 patients (31%) were managed nonoperatively. MAIN OUTCOME MEASURES: We reviewed the number of units of blood transfused, intensive care unit length of stay, overall length of stay, outcome, and complications occurring more than 48 hours after injury directly attributable to the splenic injury. RESULTS: Patients managed nonoperatively had a significantly lower Injury Severity Score (P<.05) than patients treated operatively. Length of stay was significantly decreased in both the number of intensive care unit days as well as total length of stay (P<.05). The number of units of blood transfused was also significantly decreased in patients managed nonoperatively (P<.05). Seven patients (8%) managed nonoperatively developed delayed complications requiring intervention. Five patients had overt bleeding that occurred at 4 days (3 patients), 6 days (1 patient), and 8 days (1 patient) after injury. Three patients underwent splenectomy, 1 had a splenic artery pseudoaneurysm embolization, and 1 had 2 areas of bleeding embolization. Two patients developed splenic abscesses at approximately 1 month after injury; both were treated by splenectomy. CONCLUSION: Significant numbers of delayed splenic complications do occur with nonoperative management of splenic injuries and are potentially life-threatening.

Pulmonary contusion: are children different?

BACKGROUND: Pulmonary contusion (PC) is a common sequelae of blunt trauma in adults and children; previous reports suggest that children have more favorable outcomes because of differences in mechanisms of injury, associated injury, and physiologic response. Our objective was to determine whether children who sustain PC have different outcomes compared with similarly injured adults. STUDY DESIGN: Our Level I Trauma Registry was reviewed for a 4-year period and identified 251 consecutive patients who sustained PC. Their charts were reviewed retrospectively for demographics, injury mechanism, injury severity scores, associated injuries, and outcomes (measured by the need for intubation, ventilation days, pneumonia, acute respiratory distress syndrome, and death). Data are expressed as the mean +/- SEM. The Student's t-test was used to compare the groups. A p value less than 0.05 was considered significant. RESULTS: Of the study patients, 41 (16%) were children (ages 2-16, mean 10 years) and 210 (84%) were adults (ages 17-80, mean 34 years). The most common injury mechanisms in children were motor vehicle accidents (56%) and auto-pedestrian accidents (39%), but in adults, motor vehicle accidents (80%, p = 0.02) predominated. Injury severity score was not significantly different between groups (children, 26 +/- 2 and adults 25 +/- 1). Similarly, the incidence of associated injuries was not different between children and adults: head 78% versus 62%, abdomen 59% versus 43%, and skeletal fractures 41% versus 29%, respectively. Neither need for intubation, ventilator days, pneumonia, acute respiratory distress syndrome, or death differed significantly between groups. CONCLUSIONS: Although children and adults differ in regard to injury mechanism, their overall injury severity, associated injuries, and outcomes are quite similar. Thus, contrary to previous reports, children do not have a more favorable outcome after PC.

Delayed diagnosis of blunt duodenal injury: an avoidable complication.

BACKGROUND: There is controversy about the impact on morbidity from delayed diagnoses of blunt hollow viscus injuries. A recent study suggested that the increased morbidity was primarily from delayed diagnosis of blunt duodenal injury (BDI). STUDY DESIGN: We studied the medical records from a 10-year period from June 1987 to June 1997 examining the data on 22,163 cases of blunt trauma. We assessed the incidence and consequences of delayed diagnoses of BDI, and identified preoperative factors associated with these delayed diagnoses. RESULTS: Thirty-five patients (0.2%) were identified in the retrospective study of the records from 22,163 blunt trauma patients to have sustained BDI. Of these, 25 patients (71%) were male. Ages ranged from 1 to 58 years (mean 18.8 years), and the predominant mechanism was motor vehicle accident in 18 patients (51%). Seven patients (20%) (group I) had a diagnostic delay of > 6 hours; 28 patients (80%) (group II) were diagnosed in < 6 hours. Six of the seven group I patients (86%) were evaluated initially with CT scans, and five (83%) showed findings suggestive of BDI. Among the 28 group II patients, 14 (50%) underwent initial diagnostic peritoneal lavage (DPL), and 14 (50%) had a CT scan. In seven of the group II patients (50%) who were initially evaluated by CT scan, there were findings suggestive of BDI. Diagnostic peritoneal lavage was initially equivocal (red blood cell count=5,000 to 100,000) in the remaining one group I patient compared with three of the group II patients who had DPL. Deterioration found on physical examinations prompted followup CT scans in 6 group I patients (86%), and the scans were diagnostic for BDI in all cases. CONCLUSIONS: Blunt duodenal injury is an uncommon entity. Despite the presence of suggestive CT and DPL findings, the diagnosis was delayed in 20% of the 35 patients whose records were examined in the study; this delayed diagnosis was associated with increased abdominal complications. Patients with persistent abdominal complaints and equivocal CT or DPL findings should undergo laparotomy or repeat CT scan evaluations.

Systemic absorption of bacitracin after peritoneal lavage.

Nine patients underwent intraoperative peritoneal lavage with a solution containing 50,000 units of bacitracin in 200 ml of 0.9 per cent sodium chloride. The solution was removed by suction at 2 or 5 minutes, and venous blood samples were obtained at 15 minute intervals for 2 hours after lavage. Concentrations of bacitracin in serum were determined by agar diffusion assay. In the majority of patients, peak concentrations of bacitracin in serum occurred by 15 minutes post lavage. The mean peak serum concentration was 3.8 units/ml, which exceeds peak concentrations after intramuscular injection of 50,000 units. Due to potential nephrotoxicity, bacitracin should be used cautiously in peritoneal lavage solutions and should be abandoned in patients who have renal impairment in whom prolonged elevated serum concentrations could develop.

Peritoneal lavage and angiography in the management of patients with pelvic fractures.

One hundred consecutive patients with pelvic fractures who had undergone peritoneal lavage and abdominal and pelvic angiography were retrospectively analyzed. Sixty-four patients with negative lavages were treated successfully without laparotomy despite a 20 percent incidence of subcapsular or intraparenchymal hematomas of the liver or spleen. Thirty percent of the patients with positive peritoneal lavages were successfully managed without laparotomy when abdominal angiography failed to identify a source of active bleeding. Abdominal angiography was 92 percent accurate in predicting the presence or absence of hemorrhage in 25 patients who underwent laparotomy. There were no false-positive angiograms. The overall false-negative rate was 2.12 percent. These occurred in two patients with torn mesenteric vessels. Pelvic angiography identified arterial pelvic bleeding in 18 percent of the patients. Eighty-four percent of patients with major pelvic bleeding had successful embolization with prompt cessation of arterial bleeding. We conclude that abdominal and pelvic angiography can be a useful adjunct to peritoneal lavage in detecting intraperitoneal hemorrhage and can be of therapeutic value for arterial pelvic bleeding.

Vacuum-assisted wound closure provides early fascial reapproximation in trauma patients with open abdomens.

BACKGROUND: Damage control and decompressive laparotomies salvage severely injured patients who would have previously died. Unfortunately, many of these patients develop open abdomens. A variety of management strategies exist. The end result in many cases, however, is a large ventral hernia that requires a complex repair 6 to 12 months after discharge. We instituted vacuum-assisted wound closure (VAWC) to achieve early fascial closure and eliminate the need for delayed procedures. METHODS: For 12 months ending June 2000, 14 of 698 trauma intensive care unit admissions developed open abdomens and were managed with VAWC dressing. This was changed every 48 hours in the operating room with serial fascial approximation until complete closure. RESULTS: Fascial closure was achieved in 13 patients (92%) in 9.9 +/- 1.9 days, and 2.8 +/- 0.6 VAWC dressing changes were performed. There were 2 wound infections, no eviscerations, and no enteric fistulas. CONCLUSIONS: Use of VAWC can safely achieve early fascial closure in more than 90% of trauma patients with open abdomens.

Operative treatment of truncal vascular injuries in children and adolescents.

BACKGROUND/PURPOSE: Pediatric truncal vascular injuries are rare, but the reported mortality rate is high (35% to 55%), and similar to that in adults (50% to 65%). This report examines the demographics, mechanisms of injury, associated trauma, and results of treatment of pediatric patients with noniatrogenic truncal vascular injuries. METHODS: A retrospective review (1986 to 1996) of a pediatric (< or = 17 years old) trauma registry database was undertaken. Truncal vascular injuries included thoracic, abdominal, and neck wounds. RESULTS: Fifty-four truncal vascular injuries (28 abdominal, 15 thoracic, and 11 neck injuries) occurred in 37 patients (mean age, 14+/-3 years; range, 5 to 17 years); injury mechanism was penetrating in 65%. Concomitant injuries occurred with 100% of abdominal vascular injuries and multiple vascular injuries occurred in 47%. Except for aortic and one SMA injury requiring interposition grafts, these wounds were repaired primarily or by lateral venorrhaphy. Nonvascular complications occurred more frequently in patients with abdominal injuries who were hemodynamically unstable (systolic blood pressure [BPS] <90) on presentation (19 major complications in 11 patients versus one major complication in five patients). Thoracic injuries were primarily blunt rupture or penetrating injury to the thoracic aorta (nine patients). Thoracic aortic injuries were treated without bypass, using interposition grafts. In patients with thoracic aortic injuries, there were no instances of paraplegia related to spinal ischemia (clamp times, 24+/-4 min); paraplegia occurred in two patients with direct cord and aortic injuries. Concomitant injuries occurred with 83% of thoracic injuries and multiple vascular injuries occurred in 25%. All patients with thoracic vascular injuries presenting with BPS of less than 90 died (four patients), and all with BPS 90 or over survived (eight patients). There were 11 neck wounds in 9 patients requiring intervention, and 8 were penetrating. Overall survival was 81%; survival from abdominal vascular injuries was 94%, thoracic injuries 66%, and neck injuries 78%. CONCLUSIONS: Survival and subsequent complications are related primarily to hemodynamic status at the time of presentation, and not to body cavity or vessel injured. Primary anastomosis or repair is applicable to most nonaortic wounds. The mortality rate in pediatric abdominal vascular injuries may be lower than previously reported.

Holster accidents: self-inflicted gunshot injuries of the knee and leg.

A man accidentally shot himself in the knee while holstering his own revolver. Although the pain was minimal, the wound "clean", and the joint flexible, angiography revealed a false aneurysm of the popliteal artery, a short segment of minimal tears below it, and a popliteal arteriovenus fistula slightly distal to the false aneurysm. Any penetrating wound of the popliteal fossa whose trajectory points to the vascular structures should be investigated angiographically.

Clinical pharmacology of intravenous and intraperitoneal aminoglycoside antibiotics in the prevention of wound infections.

Seventeen patients had intraoperative peritoneal lavage with a solution containing one gram of kanamycin in 200 ml of 0.9% NaCl. The solution was removed by suction at two or five minutes. Venous blood samples were obtained at 15 minute intervals for two hours following lavage. Despite diligent attempts, an average of only 60% of the solution was recovered by suction. The peak concentration of kanamycin in serum correlated directly with the kanamycin dose (p less than 0.025). In six patients lavaged for five minutes, peak absorption occurred at 15 minutes with serum concentrations of 20.3 +/- 2.0 microgram/ml. In five patients lavaged for two minutes insignificantly (p greater than 0.1) lower peak serum concentrations (15.3 +/- 1.8 microgram/ml) occurred at 15 minutes. Six additional patients had peak kanamycin serum concentrations which occurred at 75 minutes and reached 23.2 and 24.0 microgram/ml in two patients. In three patients who received intravenous gentamicin prior to surgery, nine paired serum and peritoneal fluid samples obtained during three hours preceding lavage showed no significant differences in gentamicin concentrations (p less than 0.5). These pharmacokinetic data demonstrate the penetration of parenterally administered aminoglycosides into intraoperative peritoneal fluid. Kanamycin lavage for wound prophylaxis should be used cautiously and should be abandoned in patients who have renal impairment where prolonged toxic serum concentrations could develop.

Eosinophilic infiltration of the stomach.

An unusual case of eosinophilic infiltration of the proximal stomach with direct extension into the left hemidiaphragm, liver, and transverse colon is described. Because the lesion was unresectable, a trial of steroid therapy was begun, with an initially good clinical response. Subsequent extensive tumor necrosis and accompanying diaphragmatic perforation, autolysis of the left lower lung, and a chronic gastropleurocutaneous fistula led to death. This case underscores the aggressive nature which this "histologically benign" neoplasm can pursue.

Management of surgical nutritional complications in developing countries.

The problem of sufficient nitrogen and caloric supply for surgical patients with pronounced protein catabolism under the working conditions of a surgical department in a developing country is discussed. The authors report good success with Vivonex in the postoperative nutrition of patients with a small bowel perforation with typhoid fever and of patients with diffuse peritonitis following a perforated appendix. Vivonex proved its usefulness also in the alimentation of patients with tropical myositis and extensive burns.

Angiography and peritoneal lavage in blunt abdominal trauma.

Records of 123 consecutive patients who underwent abdominal angiography for blunt trauma were reviewed. Twenty-four patients underwent abdominal angiography on the basis of positive physical findings. Seven (29%) required intervention as determined by angiography and the diagnosis was confirmed. Ninety-nine patients had abdominal angiography in association with angiographic evaluation of the chest, pelvis, or extremities. In 14 (14%) the angiogram indicated the need for intervention. In 13 this diagnosis was confirmed at laparotomy. The fourteenth patient was embolized angiographically and did well. Fifty-four patients had peritoneal lavage in addition to their angiograms. Sixteen were positive and 38 were negative. In four patients the lavage was negative and the angiographic findings indicated need for intervention. Three of these four were confirmed at laparotomy and the fourth patient was embolized angiographically. Indications for abdominal angiography in blunt trauma are: 1) incidental to needed thoracic aortography; 2) incidental to angiography when done for pelvic fractures; 3) suspected intra-abdominal injuries when clinical and lavage data are not definitive.

The superior gluteal: an artery at risk in blunt pelvic trauma.

Five patients with pelvic fractures were studied arteriographically and all were found to have injury to one or both superior gluteal arteries, in addition to other injuries. In three of the five patients no adjacent bony damage was seen on plain pelvic roentgenograms. A possible explanation for this finding is given in terms of anatomic relationships within the pelvis. The importance of early arteriography in the diagnosis management of blunt pelvic trauma is emphasized.