A multi-institutional study of factors associated with fetal death in injured pregnant patients.

HYPOTHESIS: Factors associated with fetal death in injured pregnant patients are related to increasing injury severity and abnormal maternal physiologic profile. DESIGN: A multi-institutional retrospective study of 13 level I and level II trauma centers from 1992 to 1996. MAIN OUTCOME MEASURE: Fetal survival. RESULTS: Of 27,715 female admissions, there were 372 injured pregnant patients (1.3%); 84% had blunt injuries and 16% had penetrating injuries. There were 14 maternal deaths (3.8%) and 35 fetal deaths (9.4%). The population suffering fetal death had higher injury severity scores (P<.001), lower Glascow Coma Scale scores (P<.001), and lower admitting maternal pH (P = .002). Most women who lost their fetus arrived in shock (P = .005) or had a fetal heart rate of less than 110 beats/min at some time during their hospitalization (P<.001). An Injury Severity Score greater than 25 was associated with a 50% incidence of fetal death. Placental abruption was the most frequent complication, occurring in 3.5% of patients and associated with 54% mortality. Cardiotrophic monitoring to detect potentially threatening fetal heart rates was performed on only 61% of pregnant women in their third trimester. Of these patients, 7 had abnormalities on cardiotrophic monitoring and underwent successful cesarean delivery. CONCLUSIONS: Fetal death was more likely with greater severity of injury. Cardiotrophic monitoring is underused in injured pregnant patients in their third trimester even after admission to major trauma centers. Increased use of cardiotrophic monitoring may decrease the mortality caused by placental abruption.

Two-dimensional echocardiography in the evaluation of penetrating intrapericardial injuries.

Patients with penetrating pericardial trauma whose vital signs stabilize after fluid administration may present a therapeutic dilemma. Two-dimensional echocardiography has emerged as a diagnostic technique to help determine whether surgical intervention may be required. We present 5 patients with penetrating pericardial trauma whose vital signs stabilized after fluid administration and who had minimal clinical findings. In 3 of these patients, a small effusion was seen; in 2 others, no abnormalities were noted. All 5 underwent surgical exploration and had major intrapericardial injuries. We conclude that a normal echocardiographic study does not rule out major intrapericardial injury in patients with penetrating chest trauma. Furthermore, small areas of effusion seen on echocardiography in these patients represent indications for surgical exploration.

Bilateral neck exploration for primary hyperparathyroidism.

Controversy about the operative approach for primary hyperparathyroidism has prompted a review of our operative experience since 1980. We treated 73 patients with primary hyperparathyroidism during this 10-year period, all of whom underwent bilateral neck exploration in which the surgeons attempted to locate all parathyroid tissue. Thirty-eight patients (52%) were found to have a solitary adenoma, while 35 (48%) patients had multiple gland pathology. There were two cases of persistent hypercalcemia because of a synchronous parathyroid hormone-secreting malignancy in one patient and aberrant fifth gland adenoma in the other patient. Without bilateral neck exploration, about one-half of the patients in our series would not have been cured of primary hyperparathyroidism. Because of the high incidence of multiple parathyroid gland involvement, we conclude that thorough bilateral neck exploration must be considered the goal for surgical treatment of primary hyperparathyroidism.

Lower extremity amputation for peripheral vascular disease. A low-risk operation.

Two hundred fifty-three consecutive major amputations of the lower extremity for peripheral vascular insufficiency were performed over a 3-year period. Operative mortality was 0.9 per cent for 113 below-knee and 2.8 per cent for 140 above-knee amputations. Although lower extremity amputation has a reputation for high mortality and morbidity, this is unwarranted; adherence to a protocol of aggressive medical management with timely surgical intervention allows a mortality that is appropriate to the age and general debility of this patient population.

Splenic salvage techniques in the management of pseudocysts of the spleen.

Nonparasitic splenic pseudocysts are an uncommon late sequela of splenic trauma. These cysts presumably develop from previously unrecognized subcapsular splenic hematomas. Classical therapy for splenic pseudocysts has been splenectomy. However, the recent recognition of the postsplenectomy sepsis syndrome has led to methods of surgical management that salvage the remainder of the spleen.

Analysis of septic morbidity following gunshot wounds to the colon: the missile is an adjuvant for abscess.

Over a 7-year period, 151 patients with gunshot wounds to the colon surviving beyond 24 hours were managed. The bullet was retained in the body in 66% and exited in 34%. Thirty-four (23%) developed major septic complications (diffuse peritonitis, 21%; intraperitoneal abscesses 24%; and extraperitoneal abdominal abscesses, 56%). The septic complication rate was 26% in the bullet-present group compared with 16% in the remainder (p less than 0.15). The increased septic rate in those with bullets present was the result of abscesses developing around the retained missile. That group with missile abscesses had a lesser degree of injury as measured by the abdominal trauma index compared with the other patients with septic complications (p less than 0.001). Fifteen (79%) of the 19 patients with missile and missile track abscesses had them develop in the psoas muscle. These abscesses occur by fecal contamination of the muscle following inoculation by the bullet, which passes through the large bowel. Computed tomography-guided and operative drainage tend to fail if the foreign body is not removed. Computed tomography-guided or operative drainage should be successful in draining missile track abscesses when the bullet has exited the patient.

Post-traumatic sinusitis.

Septic complications following traumatic injury continue to be a contributing factor to morbidity and mortality. Paranasal sinusitis is being recognized as an often occult etiology of fever and sepsis in multiply injured patients. Our series of 11 patients who developed clinically important maxillary sinusitis is presented. Common features of the patients include: 1) nasal instrumentation; 2) craniofacial trauma; 3) concomitant use of steroids; and 4) severe multisystem injury (mean I.S.S., 45.5; T.S., 10.6). A high index of suspicion in patients with nasal tubes who develop unexplained fever or signs of systemic sepsis should prompt appropriate investigation of the paranasal sinuses. Removal of the tubes, antral puncture for irrigation and aspiration for microbiologic culture, topical nasal decongestants, systemic antibiotics based on sensitivity studies, and occasionally, formal surgical sinus drainage contribute to effective therapy.

Complications of nonoperative management of blunt hepatic injuries.

Few, if any, complications have been reported with the nonoperative management of selected hepatic injuries diagnosed by computed tomographic (CT) scan in hemodynamically stable patients. This retrospective study was designed to evaluate complications associated with this form of management. Twenty-six patients (21%) of 128 patients with blunt hepatic injuries were treated nonoperatively over a 3-year period. All patients were hemodynamically stable at the time of admission and had hepatic injuries identified by CT scans of the abdomen. Five patients (19%) developed complications associated with nonoperative therapy. Of these, two patients had minor hepatic injuries (grades 1-2) and three had major (grades 3-5) hepatic injuries. Two patients (one with minor and one with major hepatic injury), developed free intraperitoneal biliary leaks and required operative repair. Three patients (one with minor and two with major hepatic injuries) developed large subcapsular bilomas with resultant hepatic dysfunction. These patients were successfully managed with percutaneous CT-guided drainage. There were no deaths in our study population with nonoperative therapy. The complications of hepatic injuries initially managed by expectant observation were treated operatively or by percutaneous CT-guided drainage. Repeated CT evaluation to follow the progress of liver fracture and the occasional use of hepatobiliary scans for the identification of biliary leaks have proven useful in our experience.

Noninvasive diagnosis of vascular trauma by duplex ultrasonography.

Duplex ultrasonography was used prospectively in the initial evaluation of 198 patients with 319 potential vascular injuries of the neck and extremities. Patients who were unstable or who had obvious arterial trauma were excluded. Injury was caused by gunshot in 104 (53%), blunt trauma in 42 (21%), stab wound in 34 (17%), and shotgun in 18 (9%). Duplex ultrasonography correctly characterized and localized vascular injuries in 23 patients: arterial disruptions (13), intimal flaps (4), acute pseudoaneurysms (3), arteriovenous fistulas (2), and shotgun pellet arteriopuncture (1). Nineteen other patients had vasospasm (13) or external compression (6) without evidence of intrinsic vessel injury, these 42 studies had true-positive results. Twenty patients underwent arterial repair (13 on the basis of duplex ultrasonography alone), one had primary amputation, three required fasciotomy, and 18 were observed. Two patients with false-negative results had minor shotgun pellet arteriopunctures that were missed by duplex ultrasonography, but neither needed repair. One hundred fifty-three patients had true-negative results on duplex ultrasonography: all clinically had only proximity injuries and easily palpable distal pulses. The result of one duplex ultrasonography study was found to be false-positive on arteriography. The sensitivity of duplex ultrasonography was 95%, the specificity was 99%, and the overall accuracy was 98%. These results closely approximate those reported with the use of exclusion arteriography in the evaluation of similar vascular trauma patients. Furthermore, duplex ultrasonography has no interventional risks and is more cost-effective for screening such injuries than arteriography or exploration. Duplex ultrasonography is a reliable method of diagnosis in patients with potential peripheral vascular injuries.

Liberalized screening for blunt carotid and vertebral artery injuries is justified.

BACKGROUND: Current literature suggests that blunt carotid injuries (BCIs) and vertebral artery injuries (BVIs) are more common than once appreciated. Screening criteria have been suggested, but only one previous study has attempted to identify factors that predict the presence of BCI/BVI. This current study was conducted for two reasons. First, we wanted to determine the incidence of BCI/BVI in our institution. Second, we wanted to determine the incidence of abnormal four-vessel cerebral angiograms ordered for injuries and signs believed to be associated with BCI/BVI and thus to determine whether the screening protocol developed was appropriate. METHODS: From August 1998, we used liberalized screening criteria for patients who were prospectively identified and suspected to be at high risk for BCI/BVI if any of the following were present: anisocoria, unexplained mono-/hemiparesis, unexplained neurologic exam, basilar skull fracture through or near the carotid canal, fracture through the foramen transversarium, cerebrovascular accident or transient ischemic attack, massive epistaxis, severe flexion or extension cervical spine fracture, massive facial fractures, or neck hematoma. Four-vessel cerebral angiograms were used for screening for BCI/BVI. RESULTS: Over the 18-month study period, 48 patients were angiographically screened, with 21 patients (44%) being identified as having a total of 19 BCIs and 10 BVIs. Nine patients had unilateral carotid artery injuries and three patients had bilateral carotid artery injuries. Vertebral artery injuries were unilateral in six patients. One patient had bilateral carotid artery injuries and a unilateral vertebral artery injury. One patient had a unilateral carotid artery injury and a unilateral vertebral artery injury, and one patient had a unilateral carotid artery injury and bilateral vertebral artery injuries. During the same study period, 2,331 trauma patients were admitted, with 1,941 (83%) secondary to blunt trauma. The overall incidence of BCI/BVI was 1.1%. The frequency of abnormal angiograms ordered for cerebrovascular accident or transient ischemic attack, massive epistaxis, or severe cervical spine fractures was 100%. The frequency of abnormal angiograms ordered for the other indications was as follows: fracture through foramen transversarium, 60%; unexplained mono- or hemiparesis, 44%; basilar skull fracture, 42%; unexplained neurologic examination, 38%; anisocoria, 33%; and severe facial fractures, 0%. CONCLUSION: The liberalized screening criteria used in this study were appropriate to identify patients with BCI/BVI. This study suggests BCI/BVI to be more common than previously believed and justifies that screening should be liberalized.

Prospective study of blunt aortic injury: Multicenter Trial of the American Association for the Surgery of Trauma.

BACKGROUND: Blunt aortic injury is a major cause of death from blunt trauma. Evolution of diagnostic techniques and methods of operative repair have altered the management and posed new questions in recent years. METHODS: This study was a prospectively conducted multi-center trial involving 50 trauma centers in North America under the direction of the Multi-institutional Trial Committee of the American Association for the Surgery of Trauma. RESULTS: There were 274 blunt aortic injury cases studied over 2.5 years, of which 81% were caused by automobile crashes. Chest computed tomography and transesophageal echocardiography were applied in 88 and 30 cases, respectively, and were 75 and 80% diagnostic, respectively. Two hundred seven stable patients underwent planned thoracotomy and repair. Clamp and sew technique was used in 73 (35%) and bypass techniques in 134 (65%). Overall mortality was 31%, with 63% of deaths being attributable to aortic rupture; mortality was not affected by method of repair. Paraplegia occurred postoperatively in 8.7%. Logistic regression analysis demonstrated clamp and sew (p = 0.002) and aortic cross clamp time of > or = 30 minutes (p = 0.01) to be associated with development of postoperative paraplegia. CONCLUSIONS: Rupture after hospital admission remains a major problem. Although newer diagnostic techniques are being applied, at this time aortography remains the diagnostic standard. Aortic cross clamp time beyond 30 minutes was associated with paraplegia; bypass techniques, which provide distal aortic perfusion, produced significantly lower paraplegia rates than the clamp and sew approach.