Relationship between intensive care complications and costs and initial 24 h events of trauma patients with severe haemorrhage.

BACKGROUND: The correlation between the events occurring in the initial 24 h following traumatic injury and the outcome of patients presenting with hypovolaemic shock is not clear. METHODS: 27 patients who presented to a regional trauma centre with severe hypovolaemic shock were prospectively monitored. Evidence of severe hypovolaemia and shock was noted on admission with a mean systolic blood pressure of 73.8 mm Hg and a mean lactate level of 6.6 mM/l. The patients received a mean of 21.7 litres intravenous fluids during the first 24 h to maintain a mean systolic blood pressure >or=110 mm Hg and urine output of >or=50 ml/h. Multiple metabolic and physiological parameters were obtained prospectively and on an almost hourly basis for the first 24 h after admission. Patients were followed throughout their stay in hospital to record outcome, complications, total hospital costs and length of stay. RESULTS: Using regression and multivariate analysis, adult respiratory distress syndrome was correlated with hypothermia and persistent lactic acidosis (R(2) = 0.65, p = 0.005). Coagulopathy was associated with hypothermia (R(2) = 0.43, p = 0.04). Length of stay and cost of hospitalisation were highly related to intensive care unit days, hospital-acquired infections and ventilator days (R(2) = 0.86, p = 0.03). CONCLUSION: The initial 24 h events of trauma patients with haemorrhagic shock may have a significant impact on hospital costs and on complications developing later during hospitalisation.

Preoperative cardiac preparation.

Preoperative preparation of the cardiac patient is based on matching the cardiac reserve to the blood flow demands imposed by surgical stress and the underlying disease state. Evaluation must include functional assessment of any coronary artery disease or other organic cardiac disease that may place myocardial tissue at risk of ischemia as demand for cardiac output increases. Monitoring should be individualized based on anticipated problems and the risk assessment of the patient. Preoperative therapy should include maneuvers that reduce congestive heart failure, optimize volume status, and provide adequate cardiac output to deliver oxygen sufficient to meet or exceed demand. Underlying electrical and metabolic abnormalities should be corrected and controlled in the perioperative period. Long-term therapy should be evaluated and modified in the context of the anesthetic and surgical plan. Preventive interventions such as fluid loading and low-dose dopamine should be considered prior to surgery.

False pulmonary artery catheter measurements due to the scimitar (hypogenetic lung) syndrome. Potential for iatrogenic pulmonary edema.

In an acute trauma patient with unrecognized scimitar syndrome, physiologic measurements used in patient management decisions were misleading due to the anatomic and physiologic anomalies of the syndrome. Pulmonary artery catheter measurements believed to reflect left atrial pressures were actually measuring central venous pressures because the catheter was terminating in the scimitar vein. These erroneous measurements led to overly aggressive fluid resuscitation and iatrogenic pulmonary edema. The pathologic features of scimitar syndrome are reviewed, and the mechanism for potential mismanagement of patient volume status created by aberrant pulmonary hemodynamics is discussed.

Outcome prediction of emergency patients by noninvasive hemodynamic monitoring.

OBJECTIVES: We used noninvasive hemodynamic monitoring in the initial resuscitation beginning in the emergency department (ED) for the following reasons: (1) to describe early survivor and nonsurvivor patterns of emergency patients in terms of cardiac, pulmonary, and tissue perfusion deficiencies; (2) to measure quantitatively the net cumulative amount of deficit or excess of the monitored functions that correlate with survival or death; and (3) to explore the use of discriminant analysis to predict outcome and evaluate the biological significance of monitored deficits. METHODS: This is a descriptive study of the feasibility of noninvasive monitoring of patients with acute emergency conditions in the ED to evaluate and quantify hemodynamic deficits as early as possible. The noninvasive monitoring systems consisted of a bioimpedance method for estimating cardiac output together with pulse oximetry to reflect pulmonary function, transcutaneous oxygen tension to reflect tissue perfusion, and BP to reflect the overall circulatory status. These continuously monitored noninvasive measurements were used to prospectively evaluate circulatory patterns in 151 consecutively monitored severely injured patients beginning with admission to the ED in a university-run county hospital. The net cumulative deficit or excess of each monitored parameter was calculated as the cumulative difference from the normal value vs the time-integrated monitored curve for each patient. The deficits of cardiac, pulmonary, and tissue perfusion functions were analyzed in relation to outcome by discriminant analysis and were cross-validated. RESULTS: The mean (+/- SEM) net cumulative excesses (+) or deficits (-) from normal in surviving vs nonsurviving patients, respectively, were as follows: cardiac index (CI), +81 +/- 52 vs -232 +/- 138 L/m(2) (p = 0.037); arterial hemoglobin saturation, -1 +/- 0.3 vs -8 +/- 2.6%/h (p = 0.006); and tissue perfusion, +313 +/- 88 vs -793 +/- 175, mm Hg/h (p = 0.001). The cumulative mean arterial BP deficit for survivors was -10 +/- 13 mm Hg/h, and for nonsurvivors it was -57 +/- 24 mm Hg/h (p = 0.078). CONCLUSIONS: Noninvasive monitoring systems provided continuously monitored on-line displays of data in the early postadmission period from the ED to the operating room and to the ICU for early recognition of circulatory dysfunction in short-term emergency conditions. Survival was predicted by discriminant analysis models based on the quantitative assessment of the net cumulative deficits of CI, arterial hypoxemia, and tissue perfusion, which were significantly greater in the nonsurvivors.

Multicenter study of noninvasive monitoring systems as alternatives to invasive monitoring of acutely ill emergency patients.

BACKGROUND: Recent reports showed lack of effectiveness of pulmonary artery catheterization in critically ill medical patients and relatively late-stage surgical patients with organ failure. Since invasive monitoring requires critical care environments, the early hemodynamic patterns may have been missed. Ideally, early noninvasive hemodynamic monitoring systems, if reliable, could be used as the "front end" of invasive monitoring to supply more complete descriptions of circulatory pathophysiology. OBJECTIVES: To evaluate the accuracy and reliability of noninvasive hemodynamic monitoring consisting of a new bioimpedance method for estimating cardiac output combined with arterial BP, pulse oximetry, and transcutaneous PO2 and PCO2; we compared this system of noninvasive monitoring with simultaneous invasive measurements to evaluate circulatory deficiencies in acutely ill patients shortly after hospital admission where invasive monitoring was not readily available. We also preliminarily explored early differences in temporal hemodynamic patterns of survivors and nonsurvivors. DESIGN AND SETTING: Prospective comparison of simultaneous invasive and noninvasive measurements of circulatory function with retrospective analysis of data in university-run county hospitals, university hospitals and affiliated teaching hospitals, and a community private hospital. PATIENTS: We studied 680 patients, including 139 severely injured or hemorrhaging patients in the emergency department (ED), 129 medical (nontrauma) patients on admission to the ED, 274 high-risk surgical patients intraoperatively, and 138 patients recently admitted to the ICU. RESULTS: A new noninvasive impedance device provided cardiac output estimations under conditions in which invasive thermodilution measurements were not usually applied. There were 2,192 simultaneous bioimpedance and thermodilution cardiac index measurements; the correlation coefficient, r = 0.85, r2 = 0.73, p < 0.001. The precision and bias was -0.124+/-0.75 L/min/m2. Both invasive and noninvasive monitoring systems provide similar information and identified episodes of hypotension, low cardiac index, arterial hemoglobin desaturation, low transcutaneous O2, high transcutaneous CO2, and low oxygen consumption before and during initial resuscitation. The limitations of noninvasive systems were described. CONCLUSIONS: Noninvasive monitoring systems gave continuous displays of physiologic data that provided information allowing early recognition of low flow and poor tissue perfusion that were more pronounced in the nonsurvivors. Noninvasive systems may be acceptable alternatives where invasive monitoring is not available.

Increased dependence of leucine in posttraumatic sepsis: leucine/tyrosine clearance ratio as an indicator of hepatic impairment in septic multiple organ failure syndrome.

The body clearance of 10 plasma amino acids (AA) was determined from the rate of compared muscle-released AA and AA administered by infusion of total parenteral nutrition (TPN) compared to their estimated extracellular (ECW) pool in patients with multiple trauma with (n = 10) or without (n = 16) sepsis at 8-hour intervals. In both nonseptic and septic trauma, increasing TPN increased the mean clearance rate of all infused AA. When the individual AA clearance rates were normalized by the total AA infusion rate, regression-covariance analysis revealed that patients with sepsis had relatively impaired clearances of alanine (p less than 0.01) and methionine, proline, phenylalanine, and tyrosine p less than 0.05 for all). In contrast, the clearances of branched-chain AA (BCAA) valine and isoleucine were maintained, and the clearance of leucine was higher (p less than 0.05) in trauma patients with sepsis than in those without. At any AA infusion rate, compared with surviving patients with sepsis (p less than 0.05), patients who developed fatal multiple organ failure syndrome (MOFS) showed increased clearances of all BCAA with further impaired clearance of tyrosine. The clearance ratio of leucine/tyrosine was increased in MOFS at any AA infusion rate (p less than 0.0001), was an indicator of severity, and, if persistent, was a manifestation of a fatal outcome. Because tyrosine metabolism occurs almost entirely in the liver while leucine can be utilized by viscera and muscle, these data suggest early and progressive septic impairment of the pattern of hepatic uptake and oxidation of AA with a greater body dependence on BCAA, especially leucine, as septic MOFS develops.

The impact of a dedicated trauma program on outcome in severely injured patients.

BACKGROUND: In recent years, many trauma centers have been closing or scaling down their operations because of financial losses and lack of commitment by the relevant authorities. OBJECTIVE: To investigate the effect of commitment to trauma and the establishment of a dedicated trauma program on injury outcome. DESIGN: In 1992, a well-funded dedicated trauma program was implemented at the Los Angeles County--University of Southern California Medical Center, Los Angeles. We analyzed the outcome in severely injured patients (Injury Severity Score [ISS] > 15) before and after implementation of the program (1991 and 1993). SETTING: Large, urban, level 1 trauma center. PATIENTS: Patients with trauma and an ISS higher than 15. RESULTS: There were 737 patients with an ISS higher than 15 in 1991 and 812 patients with an ISS higher than 15 in 1993. The overall mortality rate was 30% in 1991 and 24.5% in 1993 (P = .018), which is a reduction by 18.3%. In patients with blunt trauma and an ISS higher than 15, mortality was reduced by 33% (mortality rate of 31.1% in 1991 vs 20.8% in 1993) (P < .002). Mortality in patients with penetrating trauma and an ISS higher than 30 was reduced by 42.7% (mortality rate of 59.3% in 1991 vs 34% in 1993) (P = .019). There was also a trend toward lower permanent disabilities among survivors with an ISS higher than 15 (14.7% in 1991 vs 11.3% in 1993). CONCLUSION: Commitment of financial and human resources for the establishment of a dedicated trauma program is a sound investment in terms of improved survival and fewer permanent disabilities in critically injured patients.

Paramedic vs private transportation of trauma patients. Effect on outcome.

BACKGROUND: Prehospital emergency medical services (EMS) play a major role in any trauma system. However, there is very little information regarding the role of prehospital emergency care in trauma. To investigate this issue, we compared the outcome of severely injured patients transported by paramedics (EMS group) with the outcome of those transported by friends, relatives, bystanders, or police (non-EMS group). DESIGN: We compared 4856 EMS patients with 926 non-EMS patients. General linear model analysis was performed to test the hypothesis that hospital mortality is the same in EMS and non-EMS cases, controlling for the following confounding factors, which are not affected by mode of transportation: age, gender, mechanism of injury, cause of injury, Injury Severity Score (ISS), and severe head injury. Crude, specific, and adjusted mortality rates and relative risks were also derived for the EMS and non-EMS groups. SETTING: Large, urban, academic level I trauma center. PATIENTS: All patients meeting the criteria for major trauma. RESULTS: The two groups were similar with regard to mechanism of injury and the need for surgery or intensive care unit admission. The crude mortality rate was 9.3% in the EMS group and 4.0% in the non-EMS group (relative risk, 2.32; P < .001). After adjustment for ISS, the relative risk was 1.60 (P = .002). Subgroup analysis showed that among patients with ISS greater than 15, those in the EMS group had a mortality rate twice that of those in the non-EMS group (28.8% vs 14.1%). After controlling for confounding factors, the adjusted mortality among patients with ISS greater than 15 was 28.2% for the EMS group and 17.9% for the non-EMS group (P < .001). CONCLUSIONS: Patients with severe trauma transported by private means in this setting have better survival than those transported via the EMS system. Large prospective studies are needed to identify the factors responsible for this difference.

The role of thyroid hormone administration in potential organ donors.

HYPOTHESIS: Levothyroxine sodium therapy should be used in brain-dead potential organ donors to reverse hemodynamic instability and to prevent cardiovascular collapse, leading to more available organs for transplantation. DESIGN: Prospective, before and after clinical study. SETTING: A surgical intensive care unit of an academic county hospital. PATIENTS: During a 12-month period (September 1, 1999, through August 31, 2000), we evaluated 19 hemodynamically unstable patients with traumatic and nontraumatic intracranial lesions, who were candidates for organ donation following brain death declaration. INTERVENTIONS: All patients were resuscitated aggressively for organ preservation by fluids, inotropic agents, and vasopressors. If, despite all measures, the patients remained hemodynamically unstable, a bolus of 1 ampule of 50% dextrose, 2 g of methylprednisolone sodium succinate, 20 U of insulin, and 20 microg of levothyroxine sodium was administered, followed by a continuous levothyroxine sodium infusion at 10 microg/h. RESULTS: There was a significant reduction in the total vasopressor requirement after levothyroxine therapy (mean +/- SD, 11.1 +/- 0.9 microg/kg per minute vs 6.4 +/- 1.4 microg/kg per minute, P =.02). Ten patients (53%) had complete discontinuation of vasopressors. There were no failures to reach organ donation due to cardiopulmonary arrest. CONCLUSIONS: Levothyroxine therapy plays an important role in the management of hemodynamically unstable potential organ donors by decreasing vasopressor requirements and preventing cardiovascular collapse. This may result in an increase in the quantity and quality of organs available for transplantation.

Selective nonoperative management of gunshot wounds of the anterior abdomen.

OBJECTIVE: To investigate the role of selective nonoperative management of gunshot wounds to the abdomen. DESIGN: A prospective, protocol-guided study including all gunshot wounds of the anterior abdomen. PATIENTS AND METHODS: The patients were assessed and managed according to a written protocol. Patients with hemodynamic instability or peritonitis or associated spinal cord or head injury or requiring a general anesthetic for an extra-abdominal injury were managed by laparotomy. The test of the patients were selected for initial nonoperative management with serial physical examinations. RESULTS: During a 16-month period, 309 patients with gunshot wounds of the anterior abdomen were treated. Eighteen patients in extremis (5.8%) underwent an emergency department-performed thoracotomy. Another 185 patients (59.9%) met the criteria for operation and underwent a laparotomy. The incidence of nontherapeutic operations was 2.2%, and that of negative operations was 8.6%. One hundred six patients (34.3%) were selected for observation. Fourteen of the initially observed patients underwent a late operation, but it was therapeutic in only 5. Overall, 92 patients (29.8%) were successfully managed nonoperatively. The overall sensitivity of the initial physical examination was 97.1%. The estimated bullet trajectory was not reliable in identifying the need for operation because of 224 patients with likely peritoneal penetration only 169 (75.4%) had significant injuries requiring surgical repair. CONCLUSION: In the appropriate environment, many civilian abdominal gunshot wounds can be managed non-operatively.

Reprioritization of hepatic plasma protein release in trauma and sepsis.

We studied the temporal pattern of seven hepatic synthesized plasma proteins in 26 severely injured patients beginning in the immediate posttrauma period. Clinical sepsis developed in ten patients between three and eight days after injury, and 16 patients had nonseptic courses. In the initial five days after injury, except for albumin, all acute-phase protein levels rose. However, if sepsis developed, C-reactive protein, fibrinogen, ceruloplasmin, and alpha 1-antitrypsin levels continued to be elevated after the initial five posttrauma days, while transferrin, albumin, and alpha 2-macroglobulin levels fell. This differential response became more extreme as sepsis progressed. Covariance analysis of the regression of the five true acute-phase hepatic proteins on C-reactive protein showed that, when sepsis occurred after major traumatic injury, the C-reactive protein rise was associated with a significant reprioritization of hepatic acute-phase plasma protein release. This reprioritization response seems to be both a predictor of sepsis as well as a measure of the adequacy of the host response to trauma and sepsis.

Emergency medical services (EMS) vs non-EMS transport of critically injured patients: a prospective evaluation.

BACKGROUND: A previous report of 5,782 trauma patients demonstrated higher mortality among those transported by emergency medical services (EMS) than among their non-EMS-transported counterparts. HYPOTHESIS: Trauma patients who are transported by EMS and those who are not differ in the injury-to-hospital arrival time interval. DESIGN: Prospective cohort-matched observation study. SETTING: Level I trauma center, multidisciplinary study group. PATIENTS: All non-EMS patients were matched with the next appropriate EMS patient by an investigator who was unaware of the outcome and mode of transport. Every 10th EMS patient with an Injury Severity Score (ISS) of 13 or greater was also randomly enrolled. Matching characteristics included age, ISS, mechanism of injury, head Abbreviated Injury Score, and presence of hypotension. An interview protocol was developed to determine the time of injury. Interview responses from patients, witnesses, and friends were combined with data obtained from police, sheriff, and medical examiner reports. MAIN OUTCOME MEASURES: Time to the hospital, mortality, morbidity, and length of stay. RESULTS: A total of 103 patients were enrolled (38 non-EMS, 38 EMS matched, 27 random EMS). Injury time was estimated using all available data made on 100 patients (97%). Independent raters agreed in 81% of cases. Deaths, complications, and length of hospital stay were similar between the EMS- and non-EMS-transported groups. Although time intervals were similar among the groups overall, more critically injured non-EMS patients (ISS > or = 13) got themselves to the trauma center in less time than their EMS counterparts (15 minutes vs 28 minutes; P<.05). CONCLUSIONS: A multidisciplinary approach can be utilized, and an interview protocol created to determine actual time of injury. Critically injured non-EMS-transported patients (ISS > or =13) arrived at the hospital earlier after their injuries.

Occult injuries to the diaphragm: prospective evaluation of laparoscopy in penetrating injuries to the left lower chest.

BACKGROUND: To evaluate the incidence of occult diaphragmatic injuries and investigate the role of laparoscopy in patients with penetrating trauma to the left lower chest who lack indications for exploratory celiotomy other than the potential for a diaphragm injury. STUDY DESIGN: Patients with penetrating injuries to the left lower chest who were hemodynamically stable and without indications for a celiotomy were prospectively evaluated with diagnostic laparoscopy to determine the presence of an injury to the left hemidiaphragm. Diagnostic laparoscopy was performed in the operating room under general anesthesia. RESULTS: One-hundred-ten patients (94 stab wounds, 16 gunshot wounds) were evaluated with laparoscopy. Twenty-six (24%) diaphragmatic injuries were identified (26% for stab wounds and 13% for gunshot wounds). Comparison of patients with diaphragmatic injuries with those without diaphragmatic injuries demonstrated a slightly greater incidence of hemo/pneumothoraces (35% versus 24%, NS). The incidence of diaphragmatic injuries in patients with a normal chest x-ray was 21% versus 31% for patients with a hemo/pneumothorax. An elevated left hemidiaphragm was associated with a diaphragmatic injuries in only 1 of 7 patients (14%). The incidence of diaphragmatic injuries was similar for anterior, lateral, and posterior injuries (22%, 27%, and 22% respectively). CONCLUSIONS: The incidence of occult diaphragmatic injuries in penetrating trauma to the left lower chest is high, 24%. These injuries are associated with a lack of clinical and radiographic findings, and would have been missed had laparoscopy not been performed. Patients with penetrating trauma to the left lower chest who do not have any other indication for a celiotomy should undergo videoscopic evaluation of the left hemidiaphragm to exclude an occult injury.

Inability of an aggressive policy of thromboprophylaxis to prevent deep venous thrombosis (DVT) in critically injured patients: are current methods of DVT prophylaxis insufficient?

BACKGROUND: Deep venous thrombosis (DVT) in severely injured patients is a life-threatening complication. Effective and safe thromboprophylaxis is highly desirable to prevent DVT. Low-dose heparin (LDH) and sequential compression device (SCDs) are the most frequently used methods. Inappropriate use of these methods because of the nature or site of critical injuries (eg, brain lesion, solid visceral or retroperitoneal hematoma, extremity fractures) may lead to failure of DVT prophylaxis. STUDY DESIGN: A prospective study was performed to evaluate the efficacy of a policy of aggressive use of LDH and SCDs in patients who are at very high risk for DVT. From January 1996 to August 1997, 200 critically injured patients were followed by weekly Doppler examinations to detect DVT at the proximal lower extremities. Only 3 patients did not receive any thromboprophylaxis. SCDs were applied in 97.5% and LDH was administered to 46% of the patients; 45% had both. RESULTS: DVT was found in 26 patients (13%). The majority (58%) developed DVT within the first 2 weeks, but new cases were found as late as 12 weeks after admission. The incidence of DVT was the same among patients who had SCDs only or a combination of LDH and SCDs. Mechanism of injury, type and number of operations, site of injury, Injury Severity Score, and the incidence of femoral lines were not different between patients with and without DVT. Differences were found in the severity of injury to the chest and the extremities and the need for high-level respiratory support. Patients with DVT had prolonged ICU and hospital stays (on average, 34 and 49 days, respectively) and a high mortality rate (31%). CONCLUSIONS: The incidence of DVT remains high among severely injured patients despite aggressive thromboprophylaxis. A combination of LDH and an SCD showed no advantage over SCD alone in decreasing DVT rates. Risk factors in this group of patients who are already at very high risk are hard to detect; Doppler examinations are justified for surveillance in all critically injured patients. Current methods of thromboprophylaxis seem to offer limited efficacy, and the search for more effective methods should continue.

Lethal abdominal gunshot wounds at a level I trauma center: analysis of TRISS (Revised Trauma Score and Injury Severity Score) fallouts.

BACKGROUND: The TRISS methodology (composite index of the Revised Trauma Score and the Injury Severity Score) has become widely used by trauma centers to assess quality of care. The American College of Surgeons recommends including negative TRISS fallouts (fatally injured patients predicted to survive by the TRISS methodology) as a filter to select patients for peer review. The purpose of this study was to analyze the TRISS fallouts among patients with lethal abdominal gunshot wounds admitted to a level I trauma center. STUDY DESIGN: All patients categorized as TRISS fallouts admitted from January 1995 through December 1996 were analyzed. RESULTS: During the study period, 848 patients with abdominal gunshot wounds were admitted. Of the 108 patients with any sign of life on admission who subsequently died, 39 (36%) were TRISS fallouts. The patients were largely young (mean age, 29 years) and male (87%), received rapid transport (mean scene time, 11 minutes), and had an attending-led trauma-team response (<5 minutes, 87%). Major vascular (80%) and multiple intraabdominal injuries (90%) predominated. The mean Penetrating Abdominal Trauma Index was 40.3. The mean TRISS probability of survival was 89%. The peer-review process deemed the deaths to be nonpreventable in 38 patients (97%) and potentially preventable in one patient (3%). CONCLUSIONS: "TRISS fallouts" were predominantly patients who died despite receiving rapid prehospital transport, rapid senior-level trauma-team response, and surgical intervention for a serious complex of injuries. We conclude that without regional adjustment of coefficients used to predict the probability of survival, the TRISS methodology is of limited use in patients with abdominal gunshot wounds.

Duration of antibiotic prophylaxis in high-risk patients with penetrating abdominal trauma: a prospective randomized trial.

To evaluate the effect of varying durations of antibiotic prophylaxis in trauma patients with multiple risk factors for postoperative septic complications, a prospective randomized trial was undertaken at an urban level I trauma center. The inclusion criteria were full-thickness colon injury and one of the following: (1) Penetrating Abdominal Trauma Index > 25, (2) transfusion of 6 units or more of packed red blood cells, or (3) more than 4 hours from injury to operation. Patients were randomly assigned to a short course (24 hours) or a long course (5 days) of antibiotic therapy. All patients received 2 g cefoxitin en route to the operating room and 2 g intravenously piggyback every 6 hours for a total of 1 day vs. 5 days. Sixty-three patients were equally divided into short-course (n = 31) and long-course (n = 32) therapy. This was a high-risk patient population, as assessed by the mean Penetrating Abdominal Trauma Index (33), number of patients with multiple blood transfusions (51 of 63; 81%), number of patients with an Injury Severity Score greater than 15 (37 of 63; 59%), number of patients with destructive colon wounds requiring resection (27 of 63; 43%), and number of patients requiring postoperative critical care (37 of 63; 59%). Differences in intra-abdominal (1-day, 19%; 5-days, 38%) and extra-abdominal (1-day, 45%; 5-days, 25%) infection rates did not achieve statistical significance. There continues to be no evidence that extending antibiotic prophylaxis beyond 24 hours is of benefit, even among the highest risk patients with penetrating abdominal trauma. A large, multi-institutional trial will be necessary to condemn this common practice with statistical validity.

Hemodynamic parameters in patients with acute cervical cord trauma: description, intervention, and prediction of outcome.

The cardiovascular response of the patient with acute spinal cord injury (SCI) is known to be altered secondary to the cord injury. Our current protocol of managing the acute phase of patients with SCI includes invasive hemodynamic monitoring (with arterial line and Swan-Ganz catheter) and support with fluids and dopamine and/or dobutamine, titrated to maintain a hemodynamic profile with adequate cardiac output (to be determined by oxygen consumption and delivery) and a mean blood pressure of > 90 mm Hg. We feel that this protocol provides two benefits: 1) maintaining the mean blood pressure improves the morbidity of these patients by deterring ischemia and accompanying secondary insults; 2) aggressive monitoring and hemodynamic intervention help stabilize the hemodynamic status of these patients and make it possible to consider early surgery in selected cases. Our hypothesis is that the pulmonary vascular bed is more sensitive to the sympathectomized effect of acute complete cervical SCI. We analyzed the demographic, neurologic, and hemodynamic data of 50 consecutive patients during their first week postinjury. All had signs of myelopathy; 31 (62%) were considered clinically complete. Of the 50 patients, 9 (18%) died, 20 did not improve functionally, and 21 improved. The mean heart rate (82.1 +/- 13.3), blood pressure (94.4 +/- 9.4), pulmonary artery pressure (22 +/- 5) and wedge (12.7 +/- 3.4), cardiac index (4.5 +/- 0.9), systemic vascular resistance index (SVRI) (1637 +/- 399), pulmonary vascular resistance index (PVRI) (181 +/- 80), and oxygen transport (694 +/- 156) showed good response to the treatment. Because the measurements were obtained during treatment, they differ from the expected "classic sympathectomized" response, but they provide a database for further analysis of hemodynamic manipulation in SCI. An analysis of the hemodynamic parameters did not differentiate between complete and incomplete lesions or between patients with functional improvement. We determined, on the basis of the initial hemodynamic measurements, that no patient with a clinically complete motor deficit (Frankel Grade A+B) improved of the 10 who had measurements compatible with either: 1) PVRI < 100 with SVRI < 1200; or 2) PVRI < 115 with SVRI < 1300 or PVR/SVR ratio of < 0.08 when SVRI was < 1600. These patients could not have other measurements that showed low SVRI < 1350 with PVRI > 139. At odds with this unique group, 13 of 29 patients with the same clinical picture and without the above physiological criteria of severe hemodynamic deficit eventually improved (P < 0.05).(ABSTRACT TRUNCATED AT 400 WORDS)

The rapid infusion system: a superior method for the resuscitation of hypovolemic trauma patients.

The rapid infusion system (RIS), which can deliver fluids/blood products rapidly at precise rates and normothermic conditions, was compared with conventional fluid administration (CFA) in a randomized study of 36 hypovolemic trauma patients. Admission stratification criteria of the groups were similar relative to age, Glasgow Coma Score (GCS), Injury Severity Score (ISS) and plasma lactate. Despite the lack of difference in blood loss between the 24-h survivors of the two groups, the CFA group required greater total fluids (23.6/20.21), red blood cells (5.5/4.61), fresh frozen plasma (FFP) (2.8/1.91), platelets (523/204 ml), and crystalloids (12.9/10.61). Lactate levels were lower in the RIS group at virtually all times from hours 1 to 24 (4.3/5.3 mM/l, t-value = 3.3, DF = 279, P = 0.001). Post-admission hypothermia was greater in the CFA group at all times during the first 24 h (35.2/36.4 degrees C, t-value = 5.6, DF = 250, P = 0.001). The mean partial thromboplastin time was significantly higher in the CFA group (47.3/35.1 s, t-value = 3.1, DF = 279, P = 0.002). The PTT and PT were related to the degree of lactic acidosis (P = 0.0001) and hypothermia (P = 0.001) but not to the amount of FFP given (P = 0.14). The hospital costs, days in the ICU, and days on the ventilator were greater for the CFA group, as was the incidence of pneumonia (0/11 vs. 6/17; P = 0.03). Hypovolemic trauma patients resuscitated with the RIS needed fewer fluid/blood products and had less coagulopathy; more rapid resolution of hypoperfusion acidosis; better temperature preservation; and fewer hospital complications than those resuscitated with conventional methods of fluid/blood product administration.

A selective approach to the management of gunshot wounds to the back.

BACKGROUND: Gunshot wounds to the back with retroperitoneal trajectories have been traditionally managed under the same guidelines as anterior gunshot wounds. Recent work has suggested that selective nonoperative management of anterior abdominal gunshot wounds is safe. The role of this policy in gunshot wounds to the back, where retroperitoneal organ injuries may be more difficult to detect clinically, has not been investigated. OBJECTIVE: To examine if selective nonoperative management based on clinical assessment is a safe alternative to mandatory exploration for gunshot wounds to the back. DESIGN: Prospective study. SETTING: Large-volume level-1 university affiliated trauma center. PATIENTS AND METHODS: Two hundred and three consecutive patients with gunshot wounds to the back were managed according to a protocol during a 12-month period. Patients with hemodynamic instability or peritonitis underwent urgent operation. The rest of the patients were observed with careful serial clinical examinations. RESULTS: Eleven patients underwent an emergency room thoracotomy and were excluded. Four more patients were operated upon, despite the absence of abdominal findings, because of associated spinal cord injuries (2 patients), inability to observe due to need for repair of an associated peripheral vascular injury (1 patient), and participation in another protocol of aggressive evaluation of asymptomatic patients with suspected diaphragmatic injuries (1 patient). Of the remaining 188 patients, 58 (31%) underwent laparotomy (56 therapeutic, 2 negative) and 130 (69%) were initially observed owing to negative clinical examination. Following the development of increasing abdominal tenderness, 4 of these 130 (3%) underwent delayed explorations, which were all nontherapeutic. The sensitivity and specificity of initial clinical examination in detecting significant intraabdominal injuries were 100% and 95%, respectively. CONCLUSIONS: Mandatory laparotomy is not necessary for gunshot wounds of the back. Clinical examination is a safe method of selecting patients for nonoperative management. An observation period of 24 hours is adequate for patients with no abdominal symptoms.

A unified approach to the surgical exposure of pancreatic and duodenal injuries.

One of the greatest challenges to any surgeon is the intraoperative detection and surgical management of duodenal and pancreatic injuries. A uniform approach to the surgical exposure of all suspected pancreatic and duodenal injuries will decrease their morbidity and mortality by identifying all injuries. Proper intraoperative assessment and grading will help with procedure selection from the broad surgical armamentarium available to manage these injuries.