Optimal limb salvage in penetrating civilian vascular trauma

To evaluate current treatment of peripheral vascular trauma, we reviewed our recent experience with noniatrogenic penetrating vascular injuries of the extremities. Between 1979 and 1984, 139 patients sustained 204 vascular injuries inflicted by single gunshots (64%), stabbings (24%), and shotguns (12%). Eighty-four percent of patients underwent preoperative arteriography, which revealed occult arterial injury in 13 patients (9%). Compartmental hypertension necessitated fasciotomy in 19% of patients and was required more often after combined arterial and venous injuries (29%) than after isolated arterial injury (14%). Arterial continuity was restored by interposition grafting with reversed saphenous vein (62%), end-to-end anastomosis (19%), vein patch angioplasty (8%), or primary repair (4%). After arterial repair, completion angiography detected the need for revision in 8% of patients. Arterial ligation was performed in 7% of injuries and was only used in the treatment of tibial and distal profunda femoris injuries. Forty-five percent of patients sustained concomitant venous injury; 64% of all venous injuries and 90% of femoropopliteal venous injuries were repaired. No deaths occurred, and a single patient required amputation. We conclude that a protocol of preoperative arteriography, liberal. use of fasciotomy, frequent use of autologous interposition grafts, repair of major venous injuries, and routine use of completion arteriography can result in limb salvage rates that approach 100% after penetrating vascular trauma to the extremities.     

Tracheobronchial injuries from blunt trauma

Tracheobronchial injuries from trauma can be life threatening. We present a case report of a 23-year-old man who suffered a left main bronchus transection after a motorbike accident. The diagnostic and management issues surrounding tracheobronchial injuries are reviewed. Early diagnosis and treatment lead to the best outcome, with almost complete return of pulmonary function.     

Esophageal disruption from blunt and penetrating external trauma.

Eleven patients suffered esophageal perforations from external trauma. This series includes the first report of esophageal perforation that resulted from a cervical flexion-hyperextension injury. The other ten patient had penetrating trauma. Early signs were subtle. Small amounts of mediastinal and cervical air tended to be overlooked or erroneously attributed to other causes, such as associated pneumothorax. Once suspected, the possibility of esophageal disruption was not always pursued with optimum vigor. There was undue reliance on contrast media radiography. There were two patients with falsely normal esophagograms. All patients healed well when treated witreatment of choice.     

Advances in the management of acute popliteal vascular blunt injuries

This report evaluates critical points in the management of 30 consecutive blunt traumatic popliteal vascular injuries. All arterial injuries were diagnosed both clinically and by Doppler and PVR examinations. Twenty-eight of the 30 arterial reconstructions required interposition bypass grafts, nine of which were PTFE and the remainder were autogenous saphenous veins. In 19 patients the distal anastomosis was made to the distal popliteal artery and in nine patients to the tibial-peroneal arteries. In ten patients in whom limb survival was threatened, the ischemic time was shortened by the use of temporary Silastic shunt for rapid restoration of arterial flow. Nine patients had associated venous injuries which were repaired. Nine of the first 14 patients required fasciotomy but the last 16 patients were treated with hypertonic mannitol and only two of them required fasciotomy. There were no amputations, but in four limbs there were functional losses. In spite of the more extensive damage of blunt trauma, prompt and aggressive management aided by vascular laboratory tests, indwelling shunt, and hypertonic mannitol is rewarded with preservation of limbs following acute popliteal vascular injuries.     

Hemodynamic patterns of blunt and penetrating injuries

BACKGROUND: The aims of this prospective observational study were to describe early hemodynamic patterns of blunt and penetrating truncal injury and to evaluate outcomes prediction using noninvasive hemodynamic monitoring with a mathematical model tested against actual in-hospital outcomes. The hypothesis was that traumatic shock is a circulatory disorder that can be monitored by noninvasive hemodynamic parameters that reflect cardiac, pulmonary, and tissue perfusion functions. STUDY DESIGN: The cardiac index (CI), heart rate (HR), mean arterial pressure (MAP), pulse oximetry (SapO(2)), transcutaneous oxygen tension indexed to FiO(2) (PtcO(2)/FiO(2)), and carbon dioxide (PtcCO(2)) tensions were monitored beginning shortly after emergency department admission in 657 emergency patients with severe blunt and penetrating chest, abdominal, and extremity trauma. Of these, 113 patients had associated head injury, and these patients also were analyzed separately. A search and display mathematical model, with a decision support program, was based on continuous online, real-time, noninvasive hemodynamic monitoring. RESULTS: There were similar patterns in the blunt and penetrating injuries; the cardiac index, mean arterial pressure, pulse oximetry, transcutaneous oxygen tension indexed to FiO(2), and survival probability values of the survivors were significantly higher (p < 0.01) than the corresponding values of those who died, although heart rate and carbon dioxide tension were higher in the nonsurvivors during the first 24 hours after their emergency department admission. These patterns occurred more rapidly in patients with penetrating injuries. After initial resuscitation in the emergency department, results were correlated with actual outcomes at hospital discharge and found to be 88% correct. CONCLUSIONS: Early noninvasive hemodynamic monitoring with a computerized information system provided a feasible pattern recognition program for outcomes prediction and therapeutic decision support.     

Complications following blunt and penetrating injuries in 216 victims of chest trauma requiring tube thoracostomy

Tube thoracostomy (TT) is required in the treatment of many blunt and penetrating injuries of the chest. In addition to complications from the injuries, TT may contribute to morbidity by introducing microorganisms into the pleural space or by incomplete lung expansion and evacuation of pleural blood. We have attempted to assess the impact of TT following penetrating and blunt thoracic trauma by examining a consecutive series of 216 patients seen at two urban trauma centers with such injuries who required TT over a 30-month period. Ninety-four patients suffered blunt chest trauma; 122 patients were victims of penetrating wounds. Patients with blunt injuries had longer ventilator requirements (12.6 +/- 14 days vs. 3.7 +/- 7.1 days, p = 0.003), longer intensive care stays (12.2 +/- 12.5 days vs. 4.1 +/- 7.5 days, p = 0.001), and longer periods of TT, (6.5 +/- 4.9 days vs. 5.2 +/- 4.5 days, p = 0.018). Empyema occurred in six patients (3%). Residual hemothorax was found in 39 patients (18%), seven of whom required decortication. Recurrent pneumothorax developed in 51 patients (24%) and ten required repeat TT. Complications occurred in 78 patients (36%). Patients with blunt trauma experienced more complications (44%) than those with penetrating wounds (30%) (p = 0.04). However, only seven of 13 patients developing empyema or requiring decortication had blunt trauma. Despite longer requirements for mechanical ventilation, intensive care, and intubation, victims of blunt trauma seemed to have effective drainage of their pleural space by TT without increased risk of infectious complications.     

Use of laparoscopy in evaluation and treatment of penetrating and blunt abdominal injuries

Use of laparoscopy in penetrating trauma has been well established; however, its application in blunt trauma is evolving. The authors hypothesized that laparoscopy is safe and feasible as a diagnostic and therapeutic modality in both the patients with penetrating and blunt trauma. Trauma registry data and medical records of consecutive patients who underwent laparoscopy for abdominal trauma were reviewed. Over a 4-year period, 43 patients (18 blunt trauma / 25 penetrating trauma) underwent a diagnostic laparoscopy. Conversion to laparotomy occurred in 9 (50%) blunt trauma and 9 (36%) penetrating trauma patients. Diagnostic laparoscopy was negative in 33% of blunt trauma and 52% of penetrating trauma patients. Sensitivity/specificity of laparoscopy in patients with blunt and penetrating trauma was 92%/100% and 90%/100%, respectively. Overall, laparotomy was avoided in 25 (58%) patients. Use of laparoscopy in selected patients with blunt and penetrating abdominal trauma is safe, minimizes nontherapeutic laparotomies, and allows for minimal invasive management of selected intra-abdominal injuries.     

Emergency pneumonectomy for penetrating and blunt trauma

Emergency pneumonectomy for penetrating and blunt trauma has an attendant high mortality. Patients with major lung injuries presenting with prolonged shock followed by control of bleeding, resuscitation with or without aortic cross-clamping and pneumonectomy have had uniformly unsatisfactory results. From 1972 to 1982, eight patients at the University of Louisville Hospital underwent emergency pneumonectomy. All patients underwent expeditious evaluation, resuscitation, and thoracotomy with pneumonectomy. Three patients died of exsanguination (2 patients had major associated intra-abdominal injuries). Three other patients died due to pulmonary edema and right ventricular failure 2 to 3 hours after hemorrhage had been controlled and intravascular volume restored. Aortic cross-clamping was employed in four patients due to persistent hypovolemia with 100 per cent mortality. Of the two surviving patients, one presented with stable blood pressure and had pneumonectomy for tracheobronchial disruption, while the other had pneumonectomy for tangential laceration of the lung at the hilum. Pulmonary edema and right ventricular failure were responsible for mortality following emergency pneumonectomy and control of hemorrhage and restoration of blood volume. The addition of aortic cross-clamping did not seem to alter survival and may, indeed, hinder therapy due to increased vascular afterload and increased heart failure and pulmonary edema.     

Management of blunt and penetrating colon injuries.

The records of 28 patients with traumatic colon injuries (TCI) were retrospectively reviewed. Sixteen patients (57%) with 17 TCI had blunt trauma, whereas 8 patients (29%) experienced penetrating trauma. Four TCI were from intraluminal injury. Blunt trauma commonly involved the left colon, whereas penetrating trauma usually involved the right or transverse colon. Fifty-nine percent of the blunt TCI were treated with primary repair, including resection and primary anastomosis, as were 88% of the penetrating TCI. Shock, transfusion requirement of more than 4 units, contamination, and associated injuries did not necessarily preclude primary repair. One of 16 patients (6%) who underwent primary repair developed morbidity related to the colon injury. The morbidity rate for the colostomy group was 13% (1 of 8). The mortality rate was 13% in the patients who experienced external trauma (3 of 24). Two of these deaths were related to severe head injury and chest injury, respectively. These data represent a much higher proportion of blunt injuries to the colon than is reported in the literature. The low rate of morbidity for all patients treated by primary repair tends to support the more liberal trend toward this technique for both blunt and penetrating TCI.     

Management of blunt and penetrating external esophageal trauma

The records of 26 patients with external blunt or penetrating esophageal trauma were reviewed to determine clinical features and results of therapy. Twenty-one injuries (four blunt, 17 penetrating) were to the cervical esophagus, and five to the thoracic esophagus. Major physical signs included subcutaneous air, neck hematoma, and blood in the nasogastric tube. Helpful roentgenographic findings were cervical and/or mediastinal air, mediastinal widening, pleural effusion, and pneumothorax (15%). Nine of 12 (75%) contrast studies and five of six (83%) esophagoscopies were positive. Twenty-four patients had associated injuries, the most common of which was tracheal (14 patients) (64%). All patients were managed by prompt surgical exploration, primary closure, and drainage. There were three early deaths. Thirteen patients had postoperative complications, four of which were esophageal leaks. Two of the leaks caused mediastinitis, pleural sepsis, and led to death. They were not treated by early esophageal exclusion or excision. There were no significant strictures or esophageal sequelae in the other patients. It is concluded that early primary closure and drainage results in a relatively high incidence of survival. If a thoracic esophageal leak occurs, aggressive management of prompt esophageal exclusion or excision is necessary to control sepsis and improve survival.     

Isolated jejunal injuries arising from blunt abdominal trauma

Examples of isolated jejunal injuries due to blunt abdominal trauma are presented. The mechanisms of injury and management are discussed, together with a brief review of the literature.     

Diaphragmatic injuries following blunt trauma

Over the last 10 years, 26 patients have undergone repair of blunt traumatic diaphragmatic injury. Motor vehicle accidents were the cause in 77 per cent of these cases. The diagnosis was made immediately by chest x-ray in eight of 26 cases, and in ten cases, the diagnosis was made at celiotomy because of other suspected intraabdominal injury. The other eight cases fell into two categories; delayed (diagnosis made within same hospitalization) and late (diagnosis made at subsequent presentation). In many cases in which diaphragmatic injuries were missed or delays in diagnosis occurred, radiologic evidence for possible injury was present on the initial chest x-ray, but the diagnosis was not suspected. Seventy-seven per cent of patients (20 of 26) had associated major injuries (spleen, chest, extremities). The left hemidiaphragm was involved in 19 patients and right diaphragmatic injuries in seven patients. Repair was accomplished in 23 cases transabdominally with a thoracoabdominal extension required in three patients because of severe liver trauma. The three cases in which the diagnosis was delayed had diaphragmatic defects repaired by a transthoracic approach.     

Videothoracospy in thoracic trauma and penetrating injuries

Videothoracoscopy represents a valid and useful approach in some patients with blunt chest trauma or penetrating thoracic injury. This technique has been validated for the treatment of clotted hemothorax or posttraumatic empyema, traumatic chylothorax, traumatic pneumothorax, in patients with hemodynamic stability. Moreover, it is probably the most reliable technique for the diagnosis of diaphragmatic injury. It is also useful for the extraction of intrathoracic projectiles and foreign bodies. This technique might be useful in hemodynamically stable patients with continued bleeding or for the exploration of patients with penetrating injury in the cardiac area, although straightforward data are lacking to confirm those indications. Thoracotomy or median sternotomy remain indicated in patients with hemodynamic instability or those that cannot tolerate lateral decubitus position or one-lung ventilation. Performing video-surgery in the trauma setting require expertise in both video-assisted thoracic surgery and chest trauma management. The contra-indications to videothoracoscopy and indications for converting the procedure to an open thoracotomy should be perfectly known by surgeons performing video-assisted thoracic surgery in the trauma setting. Conversion to thoracotomy or median sternotomy should be performed without delay whenever needed to avoid blood loss and achieve an adequate procedure.     

Rupture of the airways from blunt trauma: treatment of complex injuries.

Tracheobronchial rupture from blunt trauma is usually single and transverse but may be longitudinal or complex, a combination of various sites and forms of rupture. From 1970 to 1990, 183 cases of rupture of the airways were reported in the literature: 136 (74%) transverse, 33 (18%) longitudinal, and 14 (8%) complex. During the same 20 years at Grady Memorial Hospital, 6 patients with such injuries were treated. One had complex injury consisting of rupture of the distal trachea and both main bronchi, 1 had a longitudinal tracheal rupture and rupture of the innominate artery, and 4 had a transverse rupture, 1 of whom also had a traumatic false aneurysm of the left pulmonary artery. Cardiopulmonary bypass was used only for the repair of the complex injury, whereas the repair of the left main bronchial rupture associated with a false aneurysm of the left pulmonary artery was done with standby cardiopulmonary bypass. All 6 patients had satisfactory results from the correction of their lesions except 1 child in whom stenosis developed at the rupture site. This study suggests that complex injuries are rarely seen, and their repair is often quite involved. In some of these cases, the use of cardiopulmonary bypass increases the margin of safety during operation and may encourage repair rather than resection of the affected lung.     

Military penetrating spine injuries compared with blunt

Background contextThe nature of blunt and penetrating injuries to the spine and spinal column in a military combat setting has been poorly documented in the literature. To date, no study has attempted to characterize and compare blunt and penetrating spine injuries sustained by American servicemembers.PurposeThe purpose of this study was to compare the military penetrating spine injuries with blunt spine injuries in the current military conflicts.Study design/settingRetrospective study.Patient sampleAll American military servicemembers who have been injured while deployed in Iraq (Operation Iraqi Freedom) and Afghanistan (Operation Enduring Freedom) whose medical data have been entered into the Joint Theater Trauma Registry (JTTR).MethodsThe JTTR was queried for all American servicemembers sustaining an injury to the spinal column or spinal cord while deployed in Iraq or Afghanistan. These data were manually reviewed for relevant information regarding demographics, mechanism of injury, surgical intervention, and neurologic injury.ResultsA total of 598 servicemembers sustained injuries to the spine or spinal cord. Isolated blunt injuries were recorded in 396 (66%) servicemembers and 165 (28%) sustained isolating penetrating injuries. Thirty servicemembers (5%) sustained combined blunt and penetrating injuries to the spine. The most commonly documented injuries were transverse process fractures, compression fractures, and burst fractures in the blunt-injured servicemembers versus transverse process fractures, lamina fractures, and spinous process fractures in those injured with a penetrating injury. One hundred four (17%) servicemembers sustained spinal cord injuries, comprising 10% of blunt injuries and 38% of penetrating injuries (p<.0001). Twenty-eight percent (28%) of blunt-injured servicemembers underwent a surgical procedure compared with 41% of those injured by penetrating mechanisms (p=.4). Sixty percent (n=12/20) of blunt-injured servicemembers experienced a neurologic improvement after surgical intervention at follow-up compared with 43% of servicemembers (n=10/23) who underwent a surgical intervention after a penetrating trauma (p=.28). Explosions accounted for 58% of blunt injuries and 47% of penetrating injuries, whereas motor vehicle collisions accounted for 40% of blunt injuries and 2% of penetrating injuries. Concomitant injuries to the abdomen, chest, and head were common in both groups.ConclusionsBlunt and penetrating injuries to the spinal column and spinal cord occur frequently in the current conflicts in Iraq and Afghanistan. Penetrating injuries result in significantly higher rates of spinal cord injury and trend toward increased rates of operative interventions and decreased neurologic improvement at follow-up.     

Splenic preservation in adults after blunt and penetrating trauma

This study was carried out to evaluate the possibility and safety of splenic preservation in adults subjected to both blunt and penetrating trauma. In an 18 month period there were a total of 36 splenic injuries studied (in 36 patients): 18 due to blunt trauma, 11 due to gunshot wounds, and 7 due to stab wounds. A total of 18 spleens were repaired: 8 (45 percent) in the blunt trauma group, 4 (36 percent) in the gunshot group, and 6 (85 percent) in the stab wound group. There were no deaths in the entire group nor were there any complications associated with splenic salvage. Splenic preservation after both blunt and penetrating trauma is both safe and feasible in the adult population, except in those instances specified herein.     

Delayed presentation and treatment of tracheobronchial injuries due to blunt trauma

BACKGROUND: Blunt thoracic trauma that results in tracheobronchial injury is difficult to diagnose. Many injuries are catastrophic and result in early mortality. Others are not immediately life threatening and are missed at initial presentation. Some of those injuries will later become symptomatic and will require medical attention. Ideal treatment in that situation is not yet clearly defined. OBJECTIVES: The objective is to review the current literature of delayed diagnoses of traumatic tracheobronchial injuries, their management, and the results of the most common repair methods. An interesting case report from this institution is presented as well. DESIGN: A Medline search of the English literature of delayed presentation of tracheobronchial injuries over the past 10 years was performed. Delayed diagnosis was defined as injuries not identified during the initial hospitalization. RESULTS: The median time from initial presentation to diagnosis was 6 months. Dyspnea (56%) and pneumonia (39%) were the most common complaints. No difference in complications was observed between parenchymal sparing procedures and resections. CONCLUSIONS: Despite delays in presentation and the radiographic appearance of destroyed distal lung, proximal injuries can often be repaired without sacrifice of distal lung parenchyma. Bronchial sleeve resections or end-to-end anastomosis can be performed safely in most situations.