Value of "inconclusive lavage" in abdominal trauma management.

Peritoneal lavage is an invaluable adjunct in the evaluation of abdominal trauma. Of 780 abdominal trauma patients in a prospective study, 685 underwent percutaneous peritoneal lavage. RBC counts in the effluent above 50,000/mm3 corresponded well with findings at exploration; however, two thirds of the patients having counts between 20,000--50,000/mm3 had serious injury at celiotomy. The data suggest the need for a reappraisal of lavage criteria for operation.     

Injured patients have lower mortality when treated by "full-time" trauma surgeons vs. surgeons who cover trauma "part-time"

BACKGROUND: Studies examining the effect of trauma surgeon volume on patient outcomes have had disparate results. We hypothesize that "full-time" trauma surgeons would have lower patient mortality rates than surgeons covering trauma "part-time." METHODS: Retrospective review of 14,171 patients during a span of 6.5 years (January 1998 to June 2004) from the trauma registry at an urban, university-based Level I trauma center. "Full-time" surgeons practiced primarily trauma, emergency surgery, and critical care. "Part-time" surgeons took trauma call, but mainly practiced another type of surgery (e.g., pancreatic, hepatobiliary, vascular, transplant). Chi square and multiple logistic regression compared mortality between groups. RESULTS: There were no differences in patient demographics or admission injury patterns between the two groups. On bivariate analysis, the subgroup of patients with severe head injury had lower mortality when treated by "full-time" surgeons. With ED deaths excluded, more severely injured patients (Injury Severity Score [ISS] >15) had a survival benefit in the "full-time" group. Multiple logistic regression showed a 50% increase in mortality for patients treated by "part-time" trauma surgeons when adjusting for age, sex, ISS >15, severe head injury, hypotension, nighttime admission, day of the week, and penetrating mechanism (odds ratio of death 1.45, 95% CI 1.04-2.02). Similar results are seen in only patients surviving to emergency room discharge (odds ratio of death 1.50, 95% CI 1.01-2.22). Z and W scores showed higher than expected survival for all patients with the "full-time" cohort showing a larger benefit. CONCLUSIONS: Even within an established trauma program treating many injured patients, mortality is significantly lower in patients initially treated by "full-time" trauma surgeons.     

Current application of "high-dose" steroid therapy for CNS injury. A pharmacological perspective

Although administration of glucocorticoid steroids is one of the most widely used therapeutic modalities for the clinical management of acute trauma of the central nervous system (CNS), controversy continues regarding their effectiveness. In essence, two viewpoints concerning their use exist. Some believe that despite their poor clinical record, the steroids nevertheless have a place in the treatment of human CNS trauma. In general, this group of clinical investigators uses the steroids primarily out of tradition, feeling that steroid therapy may be of some benefit. Unfortunately, confusion remains as to what constitutes an appropriate dose or regimen. In this regard, it has been suggested that the steroid dose be increased and the regimen intensified. Others believe that steroids should not be used. They contend that in view of their poor clinical record, it is unlikely that increasing the steroid dose or changing the dosing regimen will improve clinical efficacy, since steroids have already failed at what may be considered huge doses by glucocorticoid standards. Furthermore, it is contended that the side effects associated with large steroid doses reduce the margin of safety so as to make the steroids unsafe. Complicating these arguments is a body of experimental evidence that by and large strongly supports the utility of steroids for the acute treatment of CNS trauma. The intent of this article is to evaluate the current use of steroid therapy for CNS trauma from a purely pharmacological perspective, and to compare the steroids' experimental use with their clinical application.     

"Spontaneous", "delayed" and "occult" ruptures of the normal and pathologic spleen. Nosologic classification

The anatomic particularities and the diversity of the splenic pathology determine a wide spectrum of the traumatic lesions of the spleen. The classical acute rupture with consecutive hemoperitoneum and mandatory surgical indication is opposed to the controversial "spontaneous" ruptures of the normal and pathologic spleen and also to the delayed and occult ruptures the lasts of them sometimes minimal or with chronic evolution. A series of eight cases all males with ages between 40-77 years is presented in order to exemplify all these entities. There are underlined the variety of etiologic conditions, the difficulties of the diagnosis which impose an insistent anamnesis and clinical examination (searching even a "trivial" trauma) completed with ultrasonography and CT scan which are preferred to radionuclide scan of arteriography and finally peritoneal lavage after punction, laparoscopy and even laparotomy. Splenectomy--often laborious--was effective in all our patients (obviously only temporary for the cases with nonhodgkin malignant lymphoma and respectively with splenic metastasis from a renal carcinoma). In some situations--especially in children--the conservative treatment can be considered.     

The management of "asymptomatic" epidural hematomas. A prospective study

Standard neurosurgical management mandates prompt evacuation of all epidural hematomas to obtain a low incidence of mortality and morbidity. This dogma has recently been challenged. A number of authors have suggested that in selected cases small and moderate epidural hematomas may be managed conservatively with a normal outcome and without risk to the patient. The goal of this study was to define the clinical parameters that may aide in the management of patients with small epidural hematomas who were clinically asymptomatic at initial presentation because there was no clinical evidence of raised intracranial pressure or focal compression. A prospective study was conducted of 22 patients (17 males and five females) aged from 1 to 71 years, who had a small epidural hematoma diagnosed within 24 hours of trauma and were managed expectantly. Of these, 32% subsequently required evacuation of the epidural hematoma 1 to 10 days after the initial trauma. Analysis of the patients revealed that age, sex, Glasgow Coma Scale score, and initial size of the hematoma are not risk factors for deterioration. However, deterioration was seen in 55% of patients with a skull fracture transversing a meningeal artery, vein, or major sinus, and in 43% of those undergoing computerized tomography (CT) within 6 hours of trauma. In contrast, only 13% of patients in whom the diagnosis of a small epidural hematoma was delayed over 6 hours subsequently required evacuation of the epidural collection. Of patients with both risk factors, 71% required evacuation of the epidural hematoma. None of the patients suffered neurological sequelae attributable to this management protocol. It was concluded that patients with a small epidural hematoma, a fracture overlaying a major vessel or major sinus, and/or who are diagnosed less than 6 hours after trauma are at risk of subsequent deterioration and may require evacuation. Conversely, patients without these risk factors may be managed conservatively with repeat CT and careful neurological observation, because of the low risk of delayed deterioration.     

Futility of resuscitation criteria for the "young" old and the "old" old trauma patient: a national trauma data bank analysis

BACKGROUND: Increasing geriatric trauma is producing disproportionate use of resources. In burn victims, age and burn extent correlate with mortality, yielding the establishment of criteria for futile resuscitation. Such criteria would be useful to trauma patients and their families in making withdrawal-of-care decisions while reducing resource use. Our objective, therefore, was to identify injury and physiologic parameters that would indicate a high probability of futile resuscitation among geriatric trauma patients. METHODS: Data pertaining to patients greater than or equal to 65 years of age within the National Trauma Databank from 1994 to 2001 were analyzed. Multivariate logistic regression-with mortality as the outcome variable and head, chest, and/or abdominal injury; base deficit; gender; comorbidities; and admission systolic blood pressure (SBP) as covariates-was performed to develop a stratification scheme providing criteria indicative of a high probability of futile resuscitation. RESULTS: There were 76,304 patients with a mean age of 79.4 years. Head, thoracic, and abdominal injury; age; gender; comorbidities; admission SBP; and base deficit were associated with mortality. Patients with severe chest and/or abdominal injury, moderate to severe head injury, admission SBP less than 90 mm Hg, and significant base deficit had mortalities approaching 100%. Older patients with modest shock and mild to moderate head injury admitted with severe chest and/or abdominal injury had a less than 5% chance of survival. CONCLUSION: Geriatric trauma patients with severe chest and/or abdominal trauma with moderate shock and mild to moderate head injury have an exceedingly low probability of survival. These data support early withdrawal of care in these individuals.     

Families' perception of the value of timed daily "family rounds" in a trauma ICU

Daily communications between the ICU trauma patients' families and the trauma team are often limited due to the unpredictable nature of subsequent patient admissions and operative procedures. In order to improve the lines of family-physician communication and educate residents regarding family communication, our level I trauma center instituted daily "Family Rounds" (FR). FR occur at the same time every day, in the patient's ICU room. The purpose of this study was to determine whether families valued the scheduled daily FR, to establish whether FR improved the family-physician relationship, and to delineate strengths and weaknesses of the present structure of our FR. We mailed surveys to family members of trauma patients hospitalized in the trauma ICU for > or = 3 days. A total of 55 (22%) families responded. Combining "excellent" and "good" responses, 86.5 per cent of families looked forward to having a specific time of day to meet with the trauma team, and 90 per cent liked having rounds in the ICU room with the patient. However, 36 per cent did not like having only scheduled time for FR. The majority, 75 per cent, believed that all concerns were addressed during FR, and 84.9 per cent rated their overall experience as either excellent or good. Scheduled FR appear to improve communication between trauma surgeons and patients' families, enhance the family-physician relationship, and strengthen our surgical residency teaching program.     

Dynamics of indicators of the "skin window" and change in body reactivity upon trauma

The dynamics of indicators of the "skin window" was studied in 118 patients with fractures of the bones. The dynamics of changes of the indicators was found to correspond to severity of the trauma. The picture of dermocytograms in patients with complications was different as compared with that of patients without complications. The method can be used for the estimation of reactivity of the organism in clinical practice.     

"Avoidable" deaths in two areas of Sweden - analysis of deaths in hospital after injury.

OBJECTIVE: To describe causes of death and other characteristics of "avoidable" deaths in patients admitted to hospital after trauma, and estimate and analyse changes in the avoidable death rate during the years studied. DESIGN: Retrospective analysis of medico legal autopsy material. SETTING: One northern and one western area in Sweden 1988-1996. SUBJECTS: 335 cases who died in hospital after trauma. MAIN OUTCOME MEASURES: Avoidable death, defined as an Injury Severity Score (ISS) of 35 or less and Abbreviated Injury Scale (AIS) head of 4 or less and cause of death. RESULTS: We found 70 avoidable deaths (21%). Among these, 15 (21%) died of head injuries, 17 (24%) of thoracic, abdominal, or pelvic injuries, and 38 (54%) of medical complications. The number of deaths after trauma decreased considerably from 1988-90 to 1994-96, but the proportion who died in hospital remained almost constant. The proportion of avoidable deaths decreased from 22% to 17%, mainly because the proportion of deaths from medical complications was halved. CONCLUSION: The standard of Swedish in-hospital trauma care has improved, particularly with a reduction in post-traumatic complications. However, there is still room for improvement in the treatment of complications among elderly people.     

Resuscitative thoracotomy performed in the operating room.

The efficacy of resuscitative thoracotomy in the trauma patient has been questioned. Survival rates are variable, but a review of resuscitative thoracotomy in the emergency department of our institution documented an overall survival rate of only 1.8%. Higher survival rates may be anticipated in patients initially presenting with signs of life who can be transported directly to the operating room prior to the need for resuscitative thoracotomy. To test this hypothesis, the clinical course of all injured patients undergoing urgent or exigent thoracotomy in the operating room between July 1983 and June 1989 was reviewed. There were 34 patients undergoing exigent/resuscitative thoracotomy, 8 with penetrating injuries, 25 with blunt trauma to multiple systems, and 1 with isolated blunt chest trauma. Eight median sternotomies were performed and 26 left or bilateral thoracotomies. Twenty-six patients underwent concurrent exploratory celiotomy. The overall survival rate was 9% (3 of 34). The survival rate for patients with penetrating injuries was 37.5% (3 of 8) and 0% (0 of 26) for those with blunt trauma. Fifty-four patients underwent urgent/nonresuscitative thoracotomy with an overall survival rate of 74% (40 of 54). Combined group survival rates were 49% overall, 77% for patients with penetrating wounds, and 22% for patients with blunt trauma. These data underscore the futility of resuscitative thoracotomy in patients with blunt trauma who have deteriorated to the point of being in extremis. The relatively high salvage rates in patients with penetrating injuries support continued use of resuscitative thoracotomy when vital signs are lost, particularly if the injury is to the thorax. Variability in reported survival rates may be primarily due to the mix of patients with blunt trauma and penetrating injuries and disagreement as to what constitutes a resuscitative thoracotomy.     

Outcomes after ruptured abdominal aortic aneurysms: the "halo effect" of trauma center designation

BACKGROUND: Trauma centers have an array of services available around the clock that help reduce mortality in injured patients. Having such services available can benefit patients other than those who are injured. We set out to determine whether patients hospitalized with ruptured abdominal aortic aneurysms experience lower morbidity and mortality at regional trauma centers than at other acute care hospitals. STUDY DESIGN: We conducted a retrospective cohort study with the exposure being care at a trauma center and outcomes either mortality or organ failure. We evaluated all patients 40 to 84 years of age with a diagnosis of a ruptured abdominal aortic aneurysm who underwent operation during 2001 in 20 US states with organized systems of trauma care. We determined the relative risk of either death or organ failure at regional trauma centers compared with nondesignated centers. RESULTS: Of 2,450 patients hospitalized for ruptured abdominal aortic aneurysm, 867 (35%) hospitalizations occurred at regional trauma centers. At trauma centers, 41.4% of patients died before hospital discharge, compared with 45.2% of patients at nondesignated hospitals (odds ratio [OR], 0.85; 95% CI, 0.71-1.02). After adjusting for payor, hospital beds, annual hospital admissions, annual inpatient operations, affiliation with a vascular surgery fellowship, and comorbid illnesses, the likelihood of death or organ failure was lower at trauma centers (OR, 0.72; 95% CI, 0.55-0.93). CONCLUSIONS: Care at regional trauma centers after operative repair of ruptured abdominal aortic aneurysm is associated with improved outcomes. We postulate that these benefits reflect the ability of both vascular and general surgeons to immediately mobilize resources for care of the patient requiring urgent operative intervention. The beneficial effects of trauma center designation might extend beyond caring for the critically injured.     

Clinical importance of the "seat belt sign" in blunt trauma to the neck

Currently a carotid duplex scan is the initial screening modality routinely used to evaluate occult extracranial carotid artery injuries secondary to blunt neck trauma. The objective of this study was to investigate the role of carotid artery duplex scanning in patients who suffered blunt trauma to the neck with a "seat belt sign." The medical records of 131 consecutive patients who sustained blunt trauma to the neck from a motor vehicle accident were reviewed. Patients with the cervical seat belt sign underwent a complete physical examination and carotid duplex scan in an accredited vascular laboratory. An intimal flap with severe carotid artery stenosis was found in one of 131 patients (0.76%). This patient has multiple injuries to the face, head, chest, lateralizing neurological signs, and a Glasgow Coma Scale score of 8. In an era of cost containment, resource consumption should target appropriate populations. A cervical seat belt sign should not serve as a sole indicator for evaluation of the carotid artery in the absence of other pertinent signs or symptoms.     

The "crushed open pelvis" in children

A retrospective analysis was performed in order to review the outcome of open pelvic fractures in children. Medical records, radiographs and CT scans of 15 children with open pelvic fractures admitted to our trauma centre between 1983 and 1995 were reviewed. The minimal follow-up on the survivors was two years. Out of 15 open pelvic fractures ten were vertically unstable. The mechanism of injury was auto-pedestrian collision in 93% (n = 14) of the cases. 86% (n = 13) of the fractures were a result of a "run-over" mechanism, 40% (n = 6) were caused by heavy duty vehicles. All children had injuries in the proximity of the pelvis. Despite the severity of trauma, we found mortality to be 20% (n = 3). Sepsis and deep infection originating from anorectal and genitourinary excretions were found to be the most frequent complications. The improvement in surgical techniques of the pelvis influenced the orthopaedic treatment in these 15 children. External fixation of the pelvis is not always sufficient and to achieve better stabilization of the pelvis, open reduction and internal fixation should be considered. In order to minimize complications, aggressive intervention is needed including irrigation, debridement, intravenous antibiotics, diverging colostomies and cystostomies and fracture fixation. The coordination between trauma teams of different disciplines throughout all stages of the treatment is crucial to achieving better results.     

Injury and violence in Los Angeles. Impact on access to health care and surgical education.

The Los Angeles County (California) Trauma Hospital System was designed to ensure that all patients requiring specialized trauma care would be transported directly to a trauma center using established trauma triage criteria. The designation and implementation of all level 1, 2, and 3 (rural) trauma centers were completed between October 1983 and July 1985. However, by February 1, 1985, one level 2 trauma center withdrew, and nine other level 2 and 3 trauma centers followed suit over the next few months and years. The reasons for closure of these 10 trauma centers were almost exclusively related to economic factors. The major impact of trauma center closure on surgical educational programs at the Drew University of Medicine and Science and the Martin Luther King, Jr/Charles R. Drew Medical Center have been additive and cumulative. The high volume of patients with trauma has been cited, sometimes correctly and sometimes incorrectly, as the primary reason for a lack of access to health care for patients without trauma. We have developed a blueprint for survival that, when fully implemented, will improve access to health care for all residents in our catchment area and optimize surgical education. While the Los Angeles County Trauma Hospital System has had many difficulties during the last 9 years, the population it serves is greater than that in 42 states in the United States. The experiences gained in Los Angeles County may be beneficial to statewide systems in the United States and in countries of comparable size.     

"Osteoporosis and orthopods" incidences of osteoporosis in distal radius fracture from low energy trauma

Fracture of the distal radius from low energy trauma is a common presentation to orthopaedic trauma services. This fragility type fracture is associated with underlying osteoporosis. Osteoporosis is a 'silent disease' where fragility fracture is a common presentation. Orthopaedic surgeons may be the only physician that these patients encounter. We found a high percentage of female patients who sustained a fragility fracture of the distal radius have an underlying osteoporosis. Further management of osteoporosis is important to prevent future fragility fractures.     

An evaluation of the "quoad vitam" prognosis in the elderly patient with medial fracture of the femoral neck.

The authors analyzed 425 consecutive cases of medial fracture of the femoral neck with the purpose of establishing a simple and practical system, and one which is easy to use, in order to evaluate this type of lesion and to compare different series of cases. Based on these criteria the death rate occurring intra-hospital and 6 months after trauma, the influence of the age factor, the type of anesthesia used and the type of treatment carried out, were evaluated. The results were as follows: The classification devised by the American Society of Anesthesiology continues to be an effective system for the evaluation of vital risk. The death rate was always directly related to age, and it was not influenced by either the type of anesthesia or the type of surgery used; however, it doubled when non-surgical treatment was used.     

Natural history of scaphoid non-union, with special reference to "asymptomatic" cases.

33 patients with non-union of the carpal scaphoid were diagnosed by X-ray examination two to 37 years following the original trauma. All of the patients could be contacted and summoned for a re-examination ten to 17 years later. X-rays revealed a 100% incidence of progressive radio-carpal osteoarthritis. It is concluded that freedom of pain is not a reliable prognostic indicator, and that all patients with non-union of the carpal scaphoid are likely to benefit from surgical treatment of the pseudarthrosis. The only exception to this rule might be the patient in whom the radio-carpal joint is already deteriorated by an advanced degenerative arthritis.     

Fenestrated felt facilitates anastomotic stability and safety in "off-pump" coronary bypass.

Metal stabilizing devices used in beating heart surgery, although largely effective, occasionally slip or cause lacerations of epicardial veins or myocardium, resulting in blood loss that requires time-consuming corrective maneuvers. The use of a fenestrated felt as a cushion in conjunction with the stabilizers eliminates slipping and/or trauma, thus facilitating coronary anastomoses on the beating heart.     

Childhood trauma. Now and in the new millennium

Given the magnitude of childhood injuries that occur yearly in the United States, physicians need integrated echelons of care that include regional pediatric trauma centers, trauma centers with pediatric commitment, and EDs appropriate for children. Head injury is the most significant cause of morbidity and mortality among children, but physicians are far from effectively evaluating the dynamics of cerebral metabolism and oxygen delivery in the acute resuscitation of injured children. Critically injured children must be kept normothermic, and attention to the signs of hypovolemic shock must be monitored. Secondary brain ischemia frequently occurs because the details of resuscitation are not carefully monitored. A "leader" must be designated, and this should be someone experienced in childhood trauma. The younger the child and the more severe the injury, the more important is the notion of "experience." The ultimate goal, now and in the new millennium, should not be who, where, or when to administer care to critically ill or injured children but rather the quality of the treatment of these children.     

"Insignificant" mechanism of injury: not to be taken lightly

BACKGROUND: Trauma resources should be spent rationally. The mechanism of trauma is used extensively to triage patients to appropriate levels of care. We examine the hypothesis that patients with "insignificant" mechanism of trauma may have major injuries that require expert trauma care. STUDY DESIGN: Over 9 months at a high-volume Level I trauma center, a prospective study was done on patients who sustained ground-level falls (GLF), low-level falls (LLF) from less than 10 feet, or were found down (FD) with no external evidence of significant trauma, and required evaluation by the trauma team. Of 301 patients included, 110 (37%) had GLF, 95 (31%) LLF, and 96 (32%) FD. Our main outcomes measure was significant injuries, defined as visceral or intracranial injuries, long-bone, pelvic, facial, or spinal fractures. RESULTS: One hundred ten patients (37%) had significant injuries, 20 (7%) were admitted to the ICU, 14 (5%) required an operation, and 4 (1%) died. The most common injuries were intracranial and skeletal. Almost all patients were evaluated by CT (95%), but only one-quarter had abnormal findings on it. LLF, age more than 55 years, and the absence of severe intoxication (blood alcohol level of less than 200 mg/dL) were independent risk factors for significant injuries. A statistical prediction model showed that, when all risk factors are present, the probability of significant injuries is 73%; when all risk factors are absent, there is still a 16% chance for significant injuries. Patients with significant injuries had more operations, longer hospital stays, and higher hospitalization costs compared with patients without significant injuries. CONCLUSIONS: Low-energy trauma may produce significant injuries, predominantly intracranial and skeletal. Trauma care providers should be cautious about dismissing such patients based on the trivial mechanism of injury. Patients with LLF who are older than 55 years and not severely intoxicated have a high likelihood for significant injuries. Resources should be spent rationally for patients who do not have these characteristics, because the probability of significant injuries among them is low, but not zero.