Surgical treatment of injuries of the large vessels

The authors present an experience with treatment of 99 patients with primary wounds of main vessels. The age of the patients was from 42 through 83 yeas. In 85 patients there were stab wounds, 9 patients had gunshot wounds, in 5 patients injuries of the main vessels were results of blunt trauma. Eleven patients were admitted in the condition of shock of I degree, 27--II degree and 46--III degree, 15 patients were in the terminal state. Wounds of the aorta were diagnosed in 10 patients, 4 patients died. Injury of the superior vena cava was found in 4 wounded patients, nobody died. Postcava was injured in 11 patients, 6 patients died. Wounds of the portal vein were diagnosed in 8 patients, 7 of them died. Operations were fulfilled on 19 patients with wounds of the neck and injuries of the large vessels. One patient died. Injuries of the large vessels of the upper and lower extremities took place in 15 patients. Nobody died.     

Gunshot injuries of chest and abdomen (author's transl)

A total of 51 patients with gunshot injuries of the chest and the abdominal cavity were treated at the Emergency Aid Institute "Pirogov" in Sofia from 1967 to 1976. The series included 45 men and 6 women, with a letality rate amounting to 21.5 per cent (11 patients). In 41 per cent it was a matter of abdominal injury where the letality was the highest (33 per cent). Chest injuries included 33 per cent with 12 per cent letality, while combined chest-abdominal injuries included 26 per cent with 14 per cent letality. Involvement of the small and large intestine showed the highest incidence of all abdominal organs (37 per cent). Traumatic-hemorrhagic shock and acute respiraotyr insufficiency prevailed. The operative tacties resorted to was strictly individual. In combined lesions of treatment of respiratory insufficiency, parenchymatous organs and major blood vessels has priority over the treatment of hollow organs.     

Blunt Thoracic and Abdominal Vascular Trauma and Organ Injury Caused by Road Traffic Accident

OBJECTIVES: To analyse the relationship between vascular trauma and associated injuries to intra-thoracic and abdominal organs caused by traffic accidents. Design retrospective study in a university hospital. MATERIALS AND METHODS: We investigated 458 consecutive patients who were admitted with blunt thoracic and/or abdominal trauma caused by road traffic accidents between 1986 and 1999. Vascular trauma was encountered in 54 patients (12%). RESULTS: The injured vessels were located in the abdomen in 45 patients and in the chest in nine patients. Mesenteric vessels were the most frequently injured vessels (33/45) in the abdomen, while the aorta and major vessels were most frequently injured (9/9) in the chest. Injury to the large/small intestine was often associated with mesenteric vessel injury (26/27). In the 190 patients with blunt abdominal organ injury, the frequency of mesenteric vessel injury was also highest, regardless of the injured organ. Vascular reconstruction was necessary only in one of 51 patients who underwent operation. CONCLUSIONS: Our results demonstrate that the mesenteric vessels are susceptible to blunt thoracic and abdominal trauma in road traffic accidents. Vascular reconstruction may be indicated for selected patients as long as the injuries to hollow organs are assessed carefully because of their strong association with vascular injury.     

Surgical tactic in the injury of neck vessels

Retrospective analysis of the surgical treatment results in 50 injured persons with the damage of the neck vessels in 1998-2003 yrs period was presented. Restorational-reconstructive operations were performed in 19 (38%) injured persons with the arteries damage, in 10 (20%)--with the veins damage, the ligature operations were done, accordingly, in 6 (12%) and in 20 (40%). Satisfactory result was noted in 41 (82%) injured persons. Neurological complications had occurred in 4 (8%) of patients. Mortality had constituted 10% (5 patients died). The principles of surgical treatment of the neck vessels damage were stated.     

Injuries of the blood vessels of the neck

The investigation of protocols of medicolegal examinations of victims of injuries of major blood vessels has shown that traumas of the neck vessels equal 8,8%. The clinical observation of 27 patients with injured vessels of the neck shows that the selection of correct methods of temporary arrest of hemorrhage at the place of the accident can save most victims, life. The main cause of death in such cases in ischemia of the brain, hemorrhagic shock, associated trauma of organs of the neck.     

Diagnosis and treatment of patients with closed injury of abdominal cavity organs in combination with craniocerebral trauma

Results of diagnosis and treatment of 114 injured persons with closed abdominal trauma, combined with craniocerebral trauma were suggested. In 34 (29.8%) observations the injury of two or more organs of peritoneal cavity was diagnosed, the parenchymatous organs trauma--in 35 (30.7%) and the hole organs trauma--in 45 (39.5%). Cerebral concussion was established in 61 (53.5%) of injured persons, cerebral contusion--in 26 (22.8%), cerebral compression on the contusion background--in 16 (14%) and subdural hematoma--in 11 (9.7%). In all the injured persons the operative intervention was performed. In 32 (28%) the blood of their own was transfused. To reduce the endogenous intoxication severity there were performed the forced diuresis, hemosorption--in 10 (8.7%), the blood ultraviolet irradiation--in 41 (35.9%), intravenous laserotherapy--in 40 (35%). After the operation 14 (12.3%) of patients died. High mortality in combined cranioabdominal trauma is caused by the injury severity, the traumatic shock and mutual burden syndrome presence.     

The diagnosis and treatment of injuries of the upper respiratory tract in wounds and traumas of the neck

The authors made an analysis of results of treatment of 339 patients with wounds and closed injuries of the neck. Laryngotracheal injuries were found in 27 (7.9%) patients, in 15 patients the injuries being of combined character. Active surgical strategy including the necessary thorough revision of the penetrating wounds of the neck during operation under general narcosis anesthesia, by instrumental methods of examination. Such strategy allowed timely detection and adequate elimination of injuries of the organs and vessels of the neck and improvement of the results of treatment of such patients.     

Complications of endovideosurgical repair of inguinal and femoral hernias

On the basis of an experience with 1800 operations of endovideosurgical hernioplasty in patients with inguinal and femoral hernias, the authors analyze the frequency and character of complications after such operations. Complications were noted in 37 (2.05%) patients. The most frequent complication was injury of the vessels. It could be liquidated in all the cases using laparoscopic technology. In three cases hollow organs were injured. In these cases laparotomy was used. The laparoscopic hernioplasty, if all details are fulfilled thoroughly, is a minimally invasive and effective method of treatment of inguinal and femoral hernias. The frequency of recurrences after these interventions is considerably less than that after traditional operations.     

Treatment and diagnostic policy in gunshot wounds of the pancreas

Results of treatment of 71 patients with gun-shot wounds of the pancreas were analyzed. Features and structure of gun-shot abdominal penetrating wounds with injury of the pancreas, potential of up-to-date diagnostic methods were studied. Surgical policy in combined injuries of hollow organs and pancreas was developed. Variants and sequence of surgeries were determined depending on location and types of pancreatic injuries. Proposed treatment and diagnostic policy permitted to reduce rate of purulent and septic complications by 11.1% and lethality by 5.3%.     

Penetrating zone II neck injury by broken windshield

All penetrating neck wounds are potentially dangerous and require emergency treatment because there are important vessels, nerves and organs in the neck. We present the case of a patient who had an unusual penetrating neck injury caused by a broken windshield, noticed accidentally. Because fragments of windshield glass consist of sharp material, and the neck contains vital structures, such penetrating neck injury may cause life-threatening complications. Radiological examinations should be offered before the management of all neck wounds. The risk of retained foreign bodies and related complications can be prevented by using fluoroscopy during surgical exploration of the neck.     

Injuries of the duodenum

During 10 years there were 94 patients aged 16-68 years with injuries of the duodenum. Their case histories were studied in order to establish the causes of complications and lethality. Among them there were 48 patients with knife wounds, 5 patients with gunshot wounds, closed trauma of the abdomen was diagnosed in 40 patients, 1 patient had a iatrogenic wound of the duodenum. There were 17 isolated injuries of the gut and 77 combined and multiple injuries. Patients with traumatic perforations in the duodenum made up 89.4%, 31% of them died. In 70 patients suture of the duodenum was put during operation, 10 patients had sutures and intubation of the duodenum, in 6 patients the injured gut was excluded, in 1 patient resection of the duodenum was made and primary anastomosis was formed. 28 patients (29.8%) died. Among the causes of the deaths were non-compensated blood loss resulting from hemorrhage from the vessels of the liver and other organs, combined and multiple injuries. Pyo-septic complications led to death of 12 patients, duodenal fistula was found in 4 patients. An analysis of the material has shown that most patients with traumas of the duodenum could be cured by suturing the incised or lacerated wound of the duodenum. Exclusion of the duodenum is thought to be a helpful addition to operation on the injured duodenum, especially on large wounds. Pancreatoduodenectomy is necessary but seldom in surgery of such traumas.     

The “Innsbruck Emergency Algorithm” avoids the underdiagnosis of blunt cervical vascular injuries

Objectives

Blunt cervical vascular injuries (BCVI) from alpine sports accidents bear an increased risk for being underdiagnosed during initial radiological evaluation. At our hospital, the “Innsbruck Emergency Algorithm”, which includes assessment of the neck as a computed tomography (CT) angiography during initial whole-body CT, has been introduced to avoid misdiagnoses and optimizes emergency radiology management.

Methods

Critically injured patients who were admitted for emergency CT after trauma from alpine skiing and mountain-biking accidents and who were reported with BCVI were included in this retrospective study.

Results

During 2003–2009, 36 victims were eligible for inclusion. They presented with a mean (SD) of 4.6 (2.1) diagnoses per patient, of which 3.5 (2.3) were perceptible on radiology examinations only. The “Innsbruck Emergency Algorithm” was performed in 15 individuals while 21 underwent another CT protocol including a native scan of the neck or during a parenchymatous contrast-medium phase only. In addition to BCVI, most patients (71%) were diagnosed with fractures followed by unspecific contusion/s (54%), head injuries (43%), and injuries of parenchymatous organs (19%). In five (14%), BCVI was underdiagnosed during the initial radiological examination. All of the latter had CT during a parenchymatous contrast-medium phase and not according to the “Innsbruck Emergency Algorithm”. Four of those patients died during their hospital stay. In 11, cerebral follow-up examinations showed cerebral pathologies considered as results from BCVI.

Conclusions

The “Innsbruck Emergency Algorithm” in patients with clinically unapparent BCVI after skiing and mountain-biking accidents avoided overlooking vascular injuries, which significantly improved their long-term outcome.     

Surgical management of vertebral artery injuries

The authors describe problems of giving urgent surgical care to patients with wounds of the vertebral arteries in different areas of the neck and propose a simple and reliable method of hemostasis for wounds of the vertebral artery in the bony canal. An analysis of results of the surgical treatment of 16 patients with injured vertebral artery is presented.     

Abdominal vascular trauma: a review of 106 injuries.

A retrospective analysis of acute abdominal vascular injuries was performed to review outcome variables and treatment principles. The authors review their most recent 5-year experience with 106 major abdominal vascular injuries in 64 patients treated at a combined Army and Air Force urban medical center. The majority of the patients were young men who sustained penetrating injuries. There were 41 (64%) gunshot wounds, 17 (27%) stab wounds, and 6 (9%) sustained blunt trauma. Forty-five patients (71%) came to the hospital in shock. The inferior vena cava in 26 patients (41%) and the aorta in 11 patients (17%) were injured most frequently. Suture repair was possible in 53 (50%) injuries. Ligation was performed in 41 (39%). Overall mortality for the series was 39 per cent. Hemorrhagic shock was the cause of death in 23 patients (92%) with only two late deaths. Transfusion requirement, presence of shock, and number of vessels injured all affected outcome. Immediate stabilization in the emergency department includes appropriate crystalloid and blood product resuscitation with minimal delay for diagnostic studies. Prompt abdominal exploration to control hemorrhage and particular attention to factors associated with coagulopathy remain the key elements in saving the lives of these severely injured patients.     

Injuries of cervical great vessels

Results of surgical treatment of 156 patients with cervical vessels injuries over 10-year period were analyzed. The majority of the wounds (82.7%) located in zone II of the neck. There were 143 (91.7%) stab-knife and 12 (7.7%) shotgun wounds. Combination of vascular traumas with injuries of deep cervical structures was in 16 (10%) patients. Detailed physical examination permits to avoid special device examinations before surgery in the majority of cases. When injuries of the esophagus or respiratory tract were suspected, the patients underwent diagnostic esophago- and bronchoscopy before and during surgery. Diagnostic and therapeutic policies in these kinds of injuries are systematized.     

Factors which influence the risk of wound infection in trauma patients

Surgical wound infections following traumatic injury remain a source of morbidity and mortality. A simple system for estimating the risk of infectious complications was evaluated in 949 trauma patients requiring operative therapy. The majority of cases were caused by penetrating trauma (784). Truncal, neck, and extremity procedures were included. The overall wound infection rate was 7%. Infection rates were related to amount of bacterial contamination and mechanism of injury. Age, type of antibiotics, and delay time from injury to operation were not risk factors for any injury type. Wound classification, shock, blood loss, number of organs injured, and operative time were significant risk factors, but had different effects on infection rate related to injury type. Multivariate analysis revealed no significant infectious risk factors for stabwounds. Significant factors were wound class (p = 0.02) and shock (p = 0.001) for gunshot wounds, wound class (p = 0.03) and number of organs injured (p = 0.01) for blunt trauma, and blood loss (p = 0.01) for shotgun wounds. This classification system can be used to review outcome and compare trauma patient populations for infectious morbidity in a more uniform fashion.     

Fifteen years' experience with penetrating trauma to the head and neck in children

To determine the extent and consequences of penetrating trauma to the head and neck in children, as well as the safety and efficacy of selective management of penetrating wounds of the face and neck, we reviewed our experience with these injuries since 1970. During this interval, 45 children aged 2 to 17 years were admitted for treatment of 37 missile wounds (MW) and eight stab wounds (SW). Most patients reached the hospital within 30 minutes of injury. The greatest single number of these injuries were due to accidents; violent crimes accounted for the remainder of injuries in which a motive for attack was known. Craniotomy was performed in neurologically viable patients only; neck exploration was reserved for those patients who presented with profuse hemorrhage, an expanding or pulsatile hematoma, respiratory distress, or violation of the esophagus, trachea, or great vessels seen on fluoroscopy, endoscopy, or angiography. Overall survival was 87% (MW 84%, SW 100%). Three of the nonsurvivors presented in extremis with gunshot (GSW) wounds to the head, and died shortly thereafter, while two who presented with similar injuries survived craniotomy but died subsequently from irreversible brain damage; one presented in shock due to massive hemorrhage (internal jugular vein transection flush with the base of the skull) and exsanguinated during attempted repair. Among the 39 survivors, 15 sustained multiple wounds, but only two presented in shock, due in both instances to tension pneumothorax. Soft tissue injuries of the scalp, face, and neck accounted for 36 of the 39 nonfatal wounds; five of these involved major cervical structures, but only four required immediate exploration.(ABSTRACT TRUNCATED AT 250 WORDS)     

Abdominal trauma with injuries of the major vessels

Treatment results in 87 patients (mean age 30.1 years) with traumatic injuries of major abdominal vessels were analyzed. 73 patients had stab-incised wounds, 9--blunt trauma, 5--gunshot wounds. Hemodynamics of the majority of hospitalized patients (66 from 87) was unstable. Inferior cava vein injury was revealed in 29 patients, aorta injury--in 21, iliac vessels injury--in 22, visceral vessels injury--in 15. One vascular wall was injured in 58 cases, two walls--in 27 cases, complete transection or separation of vessel was revealed in 6 cases. Major vessel injuries were associated with abdominal visceral trauma in 97% cases. Vascular operations (side suture--in 49 patients, circular suture--in 11, vein ligation--in 5, prosthesis--in 3) were performed in 17 (25%) patients by general surgeons, in the rest (75%)--by vascular surgeons. General mortality (including hospitalized but non-operated patients, and patients who died during the operation and in postoperative period) was 46%. It is necessary to teach vascular surgery to general surgeons for high-quality and timely care in patients with abdominal trauma complicated by major vessels injuries.     

Penetrating trauma to the carotid vessels

Over a 13 year period extending between April 1975 and June 1988, 510 neck injuries were treated at the American University of Beirut Medical Center; the carotid vessels were involved in 48 patients, resulting in 53 carotid injuries. The mean age of the patients was 25.3 years and shrapnel injuries were the commonest (45.8%), followed by bullet wounds (33%). Thirty-nine patients had a laceration and five had complete disruption of the carotid vessels and only three presented in coma. Shock was present in 14 patients, of whom five had a neurological deficit. In six the injured vessels were ligated, three of them were external carotid arteries. Nine patients were not initially operated on. Six of them had a chronic arterio-venous fistula and three were in coma. The remainder underwent surgical repair. Nine patients died, giving an overall mortality rate of 18.8%. Four of these died because of multisystem failure, thus giving a 10.4% mortality rate for the isolated carotid injury. There was definite improvement in the repaired group, but the haemodynamic status seemed to significantly affect the mortality rate (P less than 0.01). Follow-up of surviving patients has revealed five with persistent neurological deficits in the repaired group (33 patients), and four patients with a chronic arterio-venous fistula. Two patients had a false aneurysm. Carotid artery injury seems to have a good prognosis if repaired promptly within 3 h.     

Trauma in the Afghan guerrilla war: effects of lack of access to care

Little or no acute medical care or evacuation capability was available to resistance forces in the Afghanistan War. We examined the effects of these constraints through a review of 1373 patients admitted to a Pakistani border hospital from 1985 to 1987. Most wounds were to the extremities (92%). Serious complications from injuries were found in 41% of cases, of which the leading causes were soft-tissue infections (36%), chronic osteomyelitis (25%), and marked restriction of joint movement (18%). For 201 patients with known cause of injury, the distribution of responsible weapons was similar to the wars in Korea, Vietnam, and the Falkland Islands. The ratio of critical-area wounds (trunk, head and neck)/extremity wounds was low (0.07) compared with most other wars (about 0.50), indicating that the most seriously injured patients died before treatment was obtained. These early deaths and the many complications from injuries reflect the lack of appropriate surgical attention and evacuation facilities in the field. It is proposed that the ratio of wounds in critical areas to wounds in the extremities might be useful in monitoring the efficiency of evacuation in similar conflicts. Early surgical management and evacuation of battle casualties could have greatly reduced mortality from the war and subsequent disabilities.