Blunt diaphragmatic and thoracic aortic rupture: an emerging injury complex.

Although both blunt diaphragmatic rupture (BDR) and thoracic aortic rupture (TAR) have been extensively discussed, the association of both injuries has been infrequently mentioned. The purpose of this study was to examine the current prevalence and clinical characteristics of combined BDR and TAR at an adult regional trauma unit. Among 3,886 trauma victims, 69 (1.8%) had a BDR and 44 (1.1%), a TAR. Seven patients (10% of all patients with a BDR) had both injuries. All 7 were victims of motor vehicle crashes and had a mean Injury Severity Score of 35. All TARs were just distal to the origin of the left subclavian artery. Five patients underwent repair of both injuries and survived, 1 patient had only the BDR repaired and survived, and 1 died during emergency thoracotomy, for a survival rate of 86%. Five patients had laparotomy and repair of the BDR in the presence of an unrepaired TAR. The TARs were repaired by the clamp-and-sew technique, three of them with primary repair and two with interposition tube grafts. Concomitant BDR and TAR appears to be an emerging injury complex with both diagnostic and therapeutic challenges. The presence of BDR demands a rigorous search for associated TAR.

Routine preoperative "one-shot" intravenous pyelography is not indicated in all patients with penetrating abdominal trauma.

BACKGROUND: To determine which patients need a "one-shot" intravenous pyelogram (IVP) before laparotomy for penetrating abdominal trauma. STUDY DESIGN: Over a 15-month period, 240 laparotomies were performed for penetrating trauma at our urban level I trauma center. Prospectively collected data included clinical suspicion of genitourinary injury, results of preoperative IVP, intraoperative findings, and operative decisions influenced by the IVP. RESULTS: Preoperative IVP was performed in 175 patients (73%). Of these, 71 (41%) had suspicion of a renal injury based on the presence of a flank wound or gross hematuria. The IVP was believed to influence operative decisions in six patients, all in this group. Each of these six patients had either a shattered kidney or a renovascular injury and had a nephrectomy performed with the knowledge that a normal functioning kidney was present on the contralateral side. No patient without a flank wound or gross hematuria had an IVP that was judged to be helpful intraoperatively. Preoperative IVP was helpful only in patients with flank wounds or gross hematuria. Nephrectomy was performed in two additional patients who did not undergo IVP, both of whom presented in shock. CONCLUSIONS: Routine preoperative IVP is not necessary in all patients undergoing laparotomy for penetrating trauma. The number of IVPs can be safely reduced by 60% if the indications are narrowed to include only those stable patients with a flank wound or gross hematuria.

Utilization of FAST (Focused Assessment with Sonography for Trauma) in 1999: results of a survey of North American trauma centers.

Although much has been written about FAST (Focused Assessment with Sonography for Trauma) in the last decade little is known about its present clinical utilization. The purpose of this study was to evaluate and characterize the contemporary utilization of FAST at trauma centers in the United States and Canada. In 1999 trauma directors or their delegates at Level I regional trauma centers in the United States and Canada were surveyed either by fax or phone regarding the present utilization and the future of FAST at their center. The overall survey response rate was 91 per cent with 96 of 105 centers completing the survey. Of the 96 centers surveyed 78 were in the United States and 18 were in Canada. Of the 78 U.S. centers surveyed 62 (79%) routinely use FAST, and it is done by surgeons in 39 per cent, surgeons and emergency departments in 21 per cent, emergency departments in 5 per cent, and radiologists in 35 per cent. Most centers (79%) thought that it sped up their workups, and 89 per cent said it was an advance in patient care. FAST is used in penetrating injury at 58 per cent of centers, and some centers use FAST to assess organ injury. The utilization of diagnostic peritoneal lavage and CT has markedly decreased at many centers. Almost all respondents thought that FAST should be a component of surgery resident training. The utilization of FAST is significantly less in Canada than in the United States (P < 0.05). Our conclusions are the following. FAST has become routinely used at the majority of the U.S. centers surveyed. FAST is performed by clinicians at 65 per cent of the trauma centers surveyed. The utilization of CT and diagnostic peritoneal lavage has changed. Many centers have broadened the scope of FAST to include the assessment of organ, pediatric, and penetrating injury.

Abbreviated laparotomy for damage control: a case report.

During the initial operation on victims of multisystem trauma, life-threatening hypothermia, metabolic acidosis and coagulopathy occasionally develop. Without the immediate control of active bleeding and correction of these abnormalities, the intraoperative death rate is high. A patient with severe abdominal trauma was successfully managed with staged laparotomies. The patient's initial surgery was abbreviated to allow the aggressive correction of hypothermia and coagulopathy before definitive reconstruction of bowel injuries. Abbreviated laparotomy for damage control should be a part of the surgical armamentarium in the management of severe abdominal trauma.

Surgical management of abdominal wall disruption after blunt trauma.

Abdominal wall disruption following blunt trauma is a rare but challenging injury, both in the acute and convalescent phases. The present report describes the recent experience with this injury at a single adult trauma center. In a 22-month period, nine patients with traumatic abdominal wall disruption were managed. Flank and anteroinferior abdominal wall defects were most common. Associated injuries included 6 patients with a pelvic fracture and 4 patients with rectosigmoid injuries. Immediate primary repair of the defect was attempted in seven cases at the time of trauma laparotomy, but was difficult and often unsuccessful because of the related tissue destruction. Delayed abdominal wall repair was performed in patients with symptomatic disability (n = 5) and, if required, restoration of intestinal continuity was performed at a separate operation before abdominal wall repair. Delayed repair with autogenous tissue included the use of tensor fascia lata, rectus femoris muscle, rectus abdominis fascia, and latissimus dorsi muscle. Reconstruction with prosthetic mesh was required in two patients. One early and one late recurrence occurred, resulting in reoperation. In conclusion, traumatic abdominal wall disruption represents a complex challenge for both general and plastic surgeons. The key to successful surgical management seems to be a delayed staged repair with autogenous tissue when feasible.

Thoracic trauma and early intramedullary nailing of femur fractures: are we doing harm?

INTRODUCTION: It has been reported that early intramedullary nailing (IMN) of a femur fracture in the presence of thoracic injury increases morbidity and mortality. The purpose of the present study was to determine if IMN < or = 24 hours after multisystem injury (Injury Severity Score (ISS) > 16) is associated with a poor hospital outcome in the presence of blunt thoracic trauma (Abbreviated Injury Scale (AIS) thorax score > or = 2). METHODS: Retrospective cohort study at a single adult trauma center. RESULTS: In a 6-year period, 149 blunt trauma patients had both an ISS > 16 and a femur fracture managed by IMN. These 149 patients were divided into four groups based on thoracic injury (T = AIS thorax score > or = 2; N = AIS thorax score < 2) and the timing of IMN (E = < or = 24 hours; L = > 24 hours). There were 68 TE, 57 NE, 15 TL, and 9 NL patients. The TE and NE groups were similar in age and ISS. TE and NE groups had similar durations of ventilation, critical care, hospital stay, and mortality. Furthermore, TE patients were no more likely to be intubated after IMN than NE patients. TE patients were matched with similar patients without a femur fracture and found to have similar hospital outcomes. CONCLUSIONS: This study has not demonstrated an increased morbidity or mortality associated with early IMN in the presence of thoracic trauma.

Chylothorax after blunt chest trauma: a report of 2 cases.

Chylothorax is a rare complication of blunt chest trauma and is associated with fracture-dislocation of the thoracic spine in only 20% of these cases. Two cases of chylothorax after blunt chest injury are described in this paper; 1 was related to a fracture of the third thoracic vertebra. Closed chest drainage and total parenteral nutrition led to resolution of the condition within 3 weeks in both cases. In general, traumatic chylothorax should be managed conservatively for at least 4 weeks before surgical intervention is considered.

Advances in fluid resuscitation of hemorrhagic shock.

The optimal fluid for resuscitation in hemorrhagic shock would combine the volume expansion and oxygen-carrying capacity of blood without the need for cross-matching or the risk of disease transmission. Although the ideal fluid has yet to be discovered, current options are discussed in this review, including crystalloids, colloids, blood and blood substitutes. The future role of blood substitutes is not yet defined, but the potential advantages in trauma or elective surgery may prove to be enormous.

The abdominal compartment syndrome.

The abdominal compartment syndrome refers to the alterations in respiratory mechanics, hemodynamic parameters and renal function that occur as a result of a sustained increase in intra-abdominal pressure. The syndrome may follow a diverse series of insults, including laparotomy for severe abdominal trauma, ruptured abdominal aortic aneurysm and intra-abdominal infection. Diagnosis depends on recognizing the clinical picture in patients at risk, followed by an objective measurement of intra-abdominal pressure. Successful management may require abdominal decompression with temporary abdominal closure. Despite urgent decompression, the death rate is high because of the severity of the patients' underlying illness.

Long-term outcomes in open pelvic fractures.

BACKGROUND: Open pelvic fractures represent one of the most devastating injuries in orthopedic trauma. The purpose of this study was to document the injury characteristics, complications, mortality, and long-term, health-related quality of life outcomes in patients with open pelvic fractures. METHODS: The trauma registry at an adult trauma center was used to identify all multiple system blunt trauma patients with a pelvic fracture from January of 1987 to August of 1995 (n = 1,179). Demographic data, mechanism of injury, and fracture type were determined from hospital records. Short-term outcome measures included infectious complications, mortality, and length of stay in hospital. Long-term outcomes of survivors were obtained by telephone interview using the SF-36 Health Survey and the Functional Independence Measure. RESULTS: Open pelvic fractures were uncommon, occurring in 44 patients (4%). Patients with open fractures were about 9 years younger, on average, than patients with closed fractures (30 vs. 39, p < 0.001). Similarly, patients with open fractures were more likely to be male (75 vs. 57%, p < 0.02), more likely to have been involved in a motorcycle crash (27 vs. 6%, p < 0.001), and more likely to have an unstable pelvic ring disruption (45 vs. 25%, p < 0.001). Open pelvic fracture patients required more blood than closed pelvic fracture patients, both in the first day (16 vs. 4 units, p < 0.001) and during the total hospital admission (29 vs. 9 units, p < 0.001). Five patients with perineal wounds did not receive a diverting colostomy; in turn, these individuals had a total of six pelvic infectious complications (one abscess, two with osteomyelitis, and three perineal wound infections). Overall, 11 patients died, six patients were lost to follow-up, and 27 were long-term survivors (mean duration of 4 years). Chronic disability was common after a pelvic fracture, with problems related to physical role performance and physical functioning, and was particularly severe after an open pelvic fracture (p < 0.05 for both as measured by the SF-36). CONCLUSIONS: Patients with open pelvic fractures often survive, need to be treated with massive blood transfusions, and often require a colostomy. They are frequently left with chronic pain and residual disabilities in physical functioning and physical roles, and many remain unemployed years after injury.

Is clinical examination an accurate indicator of raised intra-abdominal pressure in critically injured patients?

OBJECTIVES: To determine the rate of elevated intra-abdominal pressure (IAP) and to evaluate the accuracy of clinical abdominal examination in the assessment of IAP in the critically injured trauma patient. DESIGN: A prospective blinded study. SETTING: The medical-surgical critical care unit of a university-affiliated regional adult trauma centre. PATIENTS: Forty-two adult blunt trauma victims, who had a mean injury severity score of 36. INTERVENTIONS: Urinary bladder pressure was measured daily and classified as normal (10 mm Hg or less), elevated (more than 10 mm Hg) or significantly elevated (more than 15 mm Hg). A blinded clinical assessment of abdominal pressure was concurrently performed and recorded as elevated or normal. MAIN OUTCOME MEASURES: The sensitivity, specificity and accuracy and the positive and negative predictive values of the 2 interventions in identifying elevated IAP. RESULTS: Twenty-one patients (50%) had an elevated IAP at some point during the study. Of the 147 bladder pressure measurements done in these 42 patients, 47 (32%) were more than 10 mm Hg and 16 (11%) were more than 15 mm Hg. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of clinical abdominal examination for identifying elevated IAP were 40%, 94%, 76%, 77% and 77%, respectively. Clinical abdominal examination had a sensitivity, specificity, positive predictive value, negative predictive value and accuracy of 56%, 87%, 35%, 94% and 84% respectively, for significantly elevated IAP. CONCLUSIONS: Urinary bladder pressure was commonly elevated among our population of critically injured adults. Compared with bladder pressure measurements, clinical abdominal assessment showed poor sensitivity and accuracy for elevated IAP. These findings suggest that more routine measurements of bladder pressure in patients at risk for intra-abdominal hypertension should be performed.

Measuring injury severity: time for a change?

BACKGROUND: The Injury Severity Score (ISS) does not take into account multiple injuries in the same body region, whereas a New ISS (NISS) may provide a more accurate measure of trauma severity by considering the patient's three greatest injuries regardless of body region. The purpose of this study was to evaluate the ISS and NISS in patients with blunt trauma. METHODS: Consecutive individuals treated from January of 1992 to September of 1996 at one institution were included if they had sustained blunt trauma and satisfied triage standards (n = 2,328). For each patient, we computed the ISS and the NISS to determine how often the two scores were identical or discrepant. Discrepant cases were then further analyzed using receiver operating characteristic curves to determine which score better predicted short-term mortality. RESULTS: The mean ISS was 25 +/- 13, and the mean NISS was 33 +/- 18. The two predictive scores were identical in 32% of patients and discrepant in 68% of patients. Patients with identical scores had a lower mortality rate than patients with discrepant scores (10% vs. 13%; p < 0.02). In patients with discrepant scores, the area under the receiver operating characteristic curves was greater for the NISS than the ISS (0.852 vs. 0.799; p < 0.001), and greater amounts of discrepancy were associated with increasing rates of mortality (p < 0.001). CONCLUSIONS: The NISS often increases the apparent severity of injury and provides a more accurate prediction of short-term mortality. The benefit associated with using the NISS rather than the ISS must be weighed against the disadvantages of changing a scoring system and the potential for still greater improvements.

Classification of liver trauma.

The classification of liver injuries is important for clinical practice, clinical research and quality assurance activities. The Organ Injury Scaling (OIS) Committee of the American Association for the Surgery of Trauma proposed the OIS for liver trauma in 1989. The purpose of the present study was to apply this scale to a cohort of liver trauma patients managed at a single Canadian trauma centre from January 1987 to June 1992. 170 study patients were identified and reviewed. The mean age was 30, with 69% male and a mean ISS of 33. 90% had a blunt mechanism of injury. The 170 patients were categorized into the 6 OIS grades of liver injury. The number of units of blood transfused, the magnitude of the operative treatment required, the liver-related complications and the liver-related mortality correlated well with the OIS grade. The OIS grade was unable to predict the need for laparotomy or the length of stay in hospital. We conclude that the OIS is a useful, practical and important tool for the categorization of liver injuries, and it may prove to be the universally accepted classification scheme in liver trauma.

Prospective evidence of the superiority of a sonography-based algorithm in the assessment of blunt abdominal injury.

BACKGROUND: Although the routine use of FAST (focused assessment with sonography for trauma) in the evaluation of trauma victims is increasing, to our knowledge, a prospective comparison of contemporary adult trauma victims managed with and without FAST has not been reported in North America. METHODS: Adult victims of blunt trauma for whom there was a suspicion of abdominal injury were managed with one of two diagnostic algorithms, FAST or no-FAST. The two algorithms were compared for diagnostic accuracy, cost, time, and delayed diagnoses. RESULTS: Among 706 patients (mean Injury Severity Score, 23), 460 were managed with FAST and 246 with no-FAST. The two groups were similar with respect to age, Injury Severity Score, prehospital time, and mortality (p = not significant). There were 3 of 460 (0.7%) delayed diagnoses in the FAST group and 4 of 246 (1.6%) in the no-FAST group (p = not significant). The diagnostic accuracy for the FAST and no-FAST algorithms was 99% and 98%, respectfully. The FAST and no-FAST algorithms led to similar rates of laparotomy, 13% and 14%, respectfully, but nonoperative management was more common in the no-FAST group (p < 0.01). The mean diagnostic cost for the FAST algorithm was $156, compared with $540 with the no-FAST algorithm (p < 0.0001) and the mean time required for diagnostic work-up was 53 minutes with the FAST algorithm, compared with 151 minutes with the no-FAST algorithm (p < 0.0001). CONCLUSION: This study has provided prospective evidence that a FAST-based algorithm for blunt abdominal injury was more rapid, less expensive, and as accurate as an algorithm that used computed tomography or diagnostic peritoneal lavage only. Trauma centers are encouraged to incorporate a FAST-based algorithm into their initial management of blunt trauma victims.

Outcomes research in surgery.

The phrase "outcomes studies" is usually used to describe those studies where outcome is assessed in large cohorts of patients, often using data from administrative databases. They are used to determine the role and impact of variations in the structure and process of health care delivery play in routine practice. Optimally, outcome should be assessed in terms of measures that are important to patients (e.g., quality of life). More often, clinically relevant outcome measures are lacking, and outcome is measured in terms of mortality, morbidity, and length of hospital stay. Although the outcomes movement continues to expand and much valuable information can be learned from this type of study, there are limitations. These studies are essentially observational and most often are performed using databases set up for other purposes. Thus data may be incomplete and incorrect. Moreover, they cannot assess the impact of patient preferences on outcome. The term outcomes studies has also been applied to small area variation and volume outcome studies.

Prospective evaluation of the potential role of teleradiology in acute interhospital trauma referrals.

BACKGROUND: Teleradiology is one form of telemedicine that would allow the transmission of radiographs before the transfer of acutely traumatized patients between referring and receiving hospitals. The purpose of this study was to evaluate the potential impact of a prehospital teleradiology system on trauma patient management and transfer. METHODS: Forty-four injured adults referred to a trauma center were included. The history, physical examination, and radiographic findings reported by the referring physician to the receiving physician were documented. The plain radiographs of the chest, pelvis, and cervical spine taken at the referring hospital were obtained after patient transfer. For each case, two reviewers blinded to the case (surgeon [S] and emergency department physician [E]) and one reviewer not blinded to the case were individually presented with the referring physician's report and the radiographs. The reviewers were surveyed as to the implications of viewing the plain radiographs taken at the referring hospital before patient transfer. RESULTS: Overall, the blinded reviewers felt that viewing the radiographs before transfer would have influenced care in 40% and 38% of cases as judged by (S) and (E), respectively, with a crude agreement of 67.5% (kappa level, 0.32). The blinded reviewers (S and E) commonly noted the following four changes in management as a result of viewing the referred radiographs: requested further clinical history (S, 18%; E, 23%), suggested further pretransfer interventions (S, 38%; E, 30%), suggested further pretransfer diagnostic tests (S, 25%; E, 13%), and emphasized precautions during transfer (S, 28%; E, 30%). The nonblinded reviewer suggested potential influence in the management of at least 65% of the cases. CONCLUSION: This study suggests that viewing the radiographs of acutely injured trauma patients has the potential to influence many aspects of the management of interhospital transfer.

Injury pattern and severity in lateral motor vehicle collisions: a Canadian experience.

OBJECTIVE: To determine the pattern and severity of injury and the outcome of front seat motor vehicle occupants after lateral impact crashes. DESIGN: Retrospective review undertaken in a Regional Trauma Unit (Sunnybrook Health Science Centre). MATERIALS AND METHODS: Review of seriously injured front seat motor vehicle occupants admitted to a Regional Trauma Unit over a 46-month period (September 15, 1989, to July 15, 1993) for whom vehicle crash information and occupant seat belt use were known. MEASUREMENTS AND MAIN RESULTS: Three hundred forty-eight front seat vehicle occupants were available for study; one hundred forty-one (41%) were involved in a lateral impact motor vehicle crash. Driver side lateral crashes (57%) were more common than passenger side impacts. Victims of lateral impact crashes had a significantly higher mean Injury Severity Score (25 compared with 20 for nonlateral crashes: p < 0.05), and the direction of impact was strongly associated with injury severity (p < 0.05). Lateral impact crashes resulted in substantially more significant chest (p < 0.01) and intra-abdominal (p < 0.0001) injuries. Type of injury was significantly different between the lateral and nonlateral impact groups for facial, chest, abdominal, and musculoskeletal injuries. CONCLUSIONS: The direction of impact in motor vehicle crashes is strongly associated with the pattern and severity of organ injuries. Further attention to automobile safety design is necessary to better protect occupants involved in lateral impact crashes.

Lateral impact motor vehicle collisions: significant cause of blunt traumatic rupture of the thoracic aorta.

BACKGROUND: This study was undertaken to determine the relationship between traumatic rupture of the thoracic aorta (TRA) and the direction of impact at the time of motor vehicle crash. METHODS: Retrospective review of TRA patients from two different databases over a 4.5-year period (January 1, 1991 to June 30, 1995): (1) Ontario Coroner's Office records of motor vehicle deaths from Metropolitan Toronto, and (2) the trauma registries of Sunnybrook Health Science Centre and St. Michael's Hospital in Metropolitan Toronto. RESULTS: Ninety-seven patients (81 from the coroner's database and 16 from the adult trauma unit registries) sustained traumatic rupture of the thoracic aorta. Forty-eight cases (49.5%) were a result of lateral impact crashes. Twenty-eight drivers (22 ipsilateral and six contralateral) and 20 passengers (16 ipsilateral and four contralateral) sustained TRA from lateral impact crashes. Ninety-one TRAs (94%) occurred at the peri-isthmic region. CONCLUSION: Lateral impact crashes are a significant cause of TRA. Traumatic rupture of the aorta should be considered with a high index of suspicion after serious lateral impact crashes, just as physicians now consider patients at high risk of TRA after serious frontal impact crashes.

Long-term outcomes in blunt trauma: who goes back to work?

BACKGROUND: Trauma patients continue to improve after discharge from the trauma center, but the completeness of this recovery remains uncertain. The purpose of this study was to compare the characteristics of patients who do and who do not return to work after blunt trauma. METHODS: Consecutive survivors of blunt trauma discharged from a regional trauma center over a 1-year interval (July of 1994 to June of 1995) were included in the study. Patients completed the SF-36 Health Survey and some additional questions related to employment status both at discharge and again after 1 year. Our principal analysis compared patients who were employed and unemployed at 1-year follow-up. RESULTS: Complete data were available for 195 patients. The typical patient was a young man who had been in a motor vehicle collision and had an injury severity score of 25. At 1-year follow-up, 101 patients had returned to work and 94 remained unemployed. Employed individuals were younger (31 vs. 44 years, p < 0.0001), less severely injured (mean injury severity score 23 vs. 27, p < 0.001), and more likely to hold professional jobs (50 vs. 16%, p < 0.0001). Patterns of injury and operative procedures were similar for employed and unemployed patients. However, the average employed patient had fewer days in the intensive care unit (2 vs. 5 days, p < 0.001), a shorter total hospitalization (19 vs. 28 days, p < 0.01), and was more likely to be discharged to home (62 vs. 39%, p < 0.01). At discharge, those who went on to employment had marginally better SF-36 Health Survey scores on seven of the eight scales (all except general health). During the year after discharge, both groups improved significantly, although employed individuals to a greater extent on all scales of the SF-36 Health Survey. CONCLUSIONS: Almost one half of the multiple system blunt trauma patients remain unemployed 1 year after hospital discharge. Those patients who return to work are usually young professionals with a lower severity of injury. Functional status at discharge predicts future employment status, but underestimates the extent of long-term recovery.

Major trauma in elderly adults receiving lipid-lowering medications.

BACKGROUND: Some clinical trials, laboratory experiments, and in vitro studies suggest that lipid-lowering medications predispose a person to traumatic injury. METHODS: We used population-based administrative database analysis to study adults age 65 years or more over a 5-year interval (n = 1,348,259). RESULTS: About 12% of the cohort received a prescription for a lipid-lowering medication and about 88% did not. The two groups had similar distributions of age, gender, and income. Overall, 2,557 (0.2%) were hospitalized for major trauma. Those who received a lipid-lowering medication were 39% less likely to sustain a major trauma than those who did not receive such medication (95% confidence interval, 29 to 47). Similar results were observed after adjustment for age, gender, and income; cardiac and neurologic medications; and lethality. No other cardiac or neurologic medication was associated with an apparent safety advantage. CONCLUSION: Lipid-lowering medications do not lead to a clinically important increase in the absolute risk of major trauma for elderly patients in the community.