Duodenal trauma: experience of a trauma center

In the past decade 93 patients with duodenal injury were treated at a trauma center. By chart review, the age, sex, mechanism of injury, time to initial exploration (and the reason for delay), laboratory results, associated injury, extent of duodenal injury, operative repair, use of drains and tube decompression, morbidity, and cause of death were tabulated in order to improve management of these injuries. Of 87 patients surviving until the time of operative repair 73% required no repair (four) or primary closure (59). The remainder had either resection with primary anastomosis (ten), diverticulization (12), or pancreaticoduodenectomy (two). All patients with penetrating trauma were immediately explored. Patients with blunt trauma were explored on the basis of the judgment of house staff and faculty. Overall mortality was 18%. Significant morbidity occurred in 49% of survivors. This urban experience was heavily weighted toward penetrating injury. In this group early death usually resulted from associated vascular injuries. Blunt duodenal injury was less frequently associated with immediate exsanguination. Mortality associated with blunt duodenal injury was usually the result of delayed diagnosis. In blunt duodenal trauma peritoneal lavage is not diagnostic and may often be misleading; in this series 50% of lavages were false negatives. Blunt duodenal trauma, particularly when combined with pancreatic injury or delayed repair, was a lethal combination. A high index of suspicion and aggressive diagnostic evaluation (CT contrast study/amylase) in the emergency department is required in equivocal cases to avoid morbidity and mortality.     

Distal pancreatectomy for trauma: a multicenter experience.

During a 5-year period, 74 patients with pancreatic injuries were managed by distal pancreatic resection at nine referral trauma centers. Patient ages ranged from 4 to 72 years. Injury mechanism was blunt trauma in 34 (46%) patients, gunshot wound in 27 (36%), stab wound in 11 (15%), and shotgun blast in two (3%). There were 19 class II, 50 class III, and 5 class IV pancreatic injuries. The resection comprised up to 33% of the pancreas in 21 (28%) patients, from 34% to 66% in 45 (61%), and greater than 67% in eight (11%). The pancreatic resection margin was closed with staples in 44 (59%), silk sutures in 20 (27%), and polypropylene sutures in eight (11%). Of 32 patients in whom the spleen was uninjured, the spleen was left intact in 17 (53%). There were nine (12%) deaths. The cause of death was irreversible shock in three patients, multiple organ failure in five, and severe head injury in one. Pancreas-related complications occurred in 32 (45%) of 71 patients who survived the initial operation. Intra-abdominal abscess developed in 24 patients; 11 were managed by percutaneous drainage alone. Pancreatic fistula developed in 10 patients; eight closed spontaneously from 6 to 54 days. Other pancreas-related morbidity included pancreatitis (6), pseudocyst (2), and hemorrhage (2). Exocrine insufficiency was not evident in any patient and diet-controlled hyperglycemia occurred in one individual following 80% pancreatic resection.(ABSTRACT TRUNCATED AT 250 WORDS)     

Early experience with retrievable inferior vena cava filters in high-risk trauma patients

BACKGROUND: This study describes the use of retrievable IVC filters in a select group of trauma patients at high risk for deep vein thrombosis (DVT) and pulmonary embolism (PE). STUDY DESIGN: Retrievable IVC filters were placed in selected trauma patients who met high-risk criteria for deep vein thrombosis and PE according to institutional clinical management guidelines. All filters were placed percutaneously in the interventional radiology suite. Indications for filter placement were based on injury complex, weight-bearing status, and contraindications to enoxaparin or pneumatic compression devices. IVC filters were either removed or maintained. RESULTS: Retrievable IVC filters were placed in 35 patients after blunt trauma. Twenty-six patients (74%) sustained at least one orthopaedic injury; 17 patients (49%) were diagnosed with a pelvis fracture. Activity was limited to bed rest or spinal precautions in 18 patients (51%). Enoxaparin was contraindicated in 32 patients (91%) and injuries precluded the use of pneumatic compression devices in 11 (31%). IVC filters were removed in 18 patients (51%), with no reported complications. Patients with orthopaedic injuries and pelvis fractures were less likely to have their filters maintained (p = 0.040). CONCLUSIONS: Retrievable IVC filters offer a versatile option for prophylaxis in trauma patients at high risk for PE. Filter retrieval potentially spares the longterm complications of permanent filters in younger trauma patients. Retrievable filters warrant consideration in patients who meet high-risk criteria for deep vein thrombosis or PE who cannot receive effective mechanical prophylaxis and in whom contraindications to anticoagulation are expected to be temporary.     

Early experience with the retrievable OptEase vena cava filter in high-risk trauma patients.

OBJECTIVES: Prophylactic vena cava filters (VCF) are efficient in preventing pulmonary embolism. Filter retrieval avoids the potential long-term complications of permanent VCF. Clinical evaluation was focused on filter-related complications and feasibility of retrieval in high-risk trauma patients. METHODS: Analysis of single-institution consecutive case series of patients who received a prophylactic OptEase VCF after multiple trauma between 08/2003 and 12/2004. Data were collected prospectively. RESULTS: A total of 37 OptEase filters were inserted prophylactically after multiple trauma (median patient age 35 years, range, 17-73 years, median ISS 41, range, 17-59). All patients had contraindications for pharmacological prophylaxis for thromboembolic events. 32 filters (86%) were retrieved after 16 days (range, 7-25 days). 12 of 33 filters (36%) demonstrated trapped clots/thrombosis within the filter structure on pre-retrieval cavography. Two patients received anticoagulation before filter retrieval due to filter thrombosis (6%). Symptomatic PE was observed in 1 patient (3%) 5 days after VCF retrieval. Minor caudal filter migration was observed in 1 patient (3%). Overall mortality was 3%. CONCLUSIONS: Retrieval of the OptEase filter is safe and feasible. Temporary filter placement avoids possible long-term complications of permanent VCF. It is an efficient form of PE prophylaxis when temporary contraindications to anticoagulation are present.     

Finnish Trauma Audit 2004: current state of trauma management in Finnish hospitals

There is great variation in the organisation of trauma care in European countries. The state of trauma care in Finnish hospitals has not been appropriately reviewed in the past. The aim of the present study conducted by the Finnish Trauma Association (FTA) was to assess the number of Finnish hospitals admitting severe trauma patients, and to evaluate the organisation and training of trauma care in those hospitals. In 2004, a telephone survey to all the Finnish hospitals was conducted, and information on the number of severe trauma patients treated per month, the organisation of acute trauma care, and the existence of multidisciplinary trauma care training was collected. Thirty-six Finnish hospitals admitted trauma patients. The range of estimated number of severely injured trauma patients treated in individual hospitals per month varied from 0.5 to 12, resulting in an estimated number of 1000-1300 patients with severe trauma treated in Finland every year (19-25/100.000 inhabitants). About 20% of the hospitals had a trauma team, and 25% had a systematic trauma education program. Only one hospital had established multidisciplinary and systematic trauma team training. The case load of severe trauma patients is low in most Finnish hospitals making it difficult to obtain and maintain sufficient experience. Too many hospitals admit too few patients, and only a few hospitals have been working on updating their trauma management protocols and education. There is an obvious need for leadership, discussion, legislation and initiatives by the professional organisations and the government to establish a modern trauma system in Finland.     

Major trauma: a district general hospital experience

A retrospective review of all patients with major trauma admitted to a busy suburban district hospital was conducted over a 1-year period. Outcome for each patient was assessed using the TRISS system which calculates the probability of survival based on anatomical extent of injury and degree of physiological disturbance at the time of admission. Thirty-nine patients were admitted following major trauma, of whom nine died. Seven of the deaths were in patients with a greater than 50 per cent chance of survival according to the TRISS system. In contrast, four patients survived who had a greater than 50 per cent chance of death. Details of these 11 cases are given. The numbers of patients who were referred to neurosurgeons and cardiothoracic surgeons in regional specialist centres were recorded, as was the relative contribution of general and orthopaedic surgeons in our own hospital. We conclude that, in the absence of specialized trauma centres, a reasonable standard of care for patients who have sustained major trauma can be delivered in a district general hospital.     

Liver trauma: a 10-year experience.

The management of 73 patients with liver trauma (58 male, 15 female; mean age 30 (range 6-68) years) presenting from January 1980 to August 1990 is reviewed. There were 29 cases of penetrating injury and 44 of blunt trauma. Seven patients were successfully managed without operation (five with blunt injury) and were discharged after a mean hospital stay of 8 days. Fifty-one cases were classified as simple injuries (grade I or II) and were managed by suture (with or without drainage) or required no intervention, with three deaths. Fifteen cases were classified as complex injuries (grade III or IV) and underwent one or more of the following: perihepatic packing, resectional debridement, hemihepatectomy and hepatotomy with direct suture ligation. Six of these patients died from uncontrolled haemorrhage. The continued use of suture for simple injuries and of resectional debridement and/or packing for complex injuries is supported. Judicious clinical assessment and radiological monitoring may reduce the number of unnecessary laparotomies.     

Penetrating chest trauma: a 20-year experience

From 1965 to 1985, 76 patients were admitted to Sacré-Coeur Hospital, Montreal, with a diagnosis of penetrating chest trauma (PCT). The majority were under the age of 30 years and almost two thirds suffered gunshot wounds. Sixty-seven (88.1%) sustained a lateral or thoracic (T) injury and in nine (11.8%) the lesion was central or mediastinal (M). In the first group (T), 53.7% were treated surgically with thoracotomy, laparotomy, and chest tube (CT) insertion or both; 46.2% were managed conservatively. In the second group (M) the pericardium or the heart was involved, eight patients (88.8%) were managed surgically without the use of extracorporeal circulation and one patient was observed only. Eight (11.9%) died in the thoracic group; all survived in the mediastinal group, for an overall mortality of 10.5%. Shock was associated with increased morbidity and mortality in the thoracic group (T) and infection was the most frequent complication for the entire group of patients under study. There has been a steady increase in the total number of PCT at our hospital during the last two decades suggesting an increase in crime and violence in our urban surroundings.     

Endoscopic investigation for gastric cancer in a high-risk group.

Early gastric cancer (EGC) was diagnosed in only a small percentage (less than 1%) of gastric cancer cases seen at Tygerberg Hospital over a 10-year period (1976-1985). This study, aimed at increasing the yield of EGC, was conducted in some high-incidence areas for gastric cancer. Coloured men, who are at high risk for gastric cancer, were identified by their medical practitioners and investigated. A total of 272 coloured males with nonspecific foregut symptoms underwent upper gastro-intestinal endoscopy and multiple biopsy specimens were obtained from all localised mucosal lesions. Twelve gastric cancers were histologically verified, of which 11 were diagnosed in males over 40 years of age. Two EGCs were diagnosed in older males, resulting in a markedly higher proportion of EGC in this subgroup (18.2%) than the proportion of EGC in inpatients at our institution (0.9%). Twenty-two per cent of males over 40 years of age had gastric ulcers compared with 9.2% of younger males. Chronic atrophic gastritis was present in 56.2% of older males but in only 24.6% of younger males. Those over 40 years of age emerged as a subgroup with a high prevalence of gastric cancer and EGC, and concomitant conditions.     

Intrapericardial trauma: surgical experience

From 1975 to 1987, 19 patients (pts) were operated on for a traumatic lesion of the heart or of the ascending aorta. There were 15 males and four females with a mean age of 42 years. Twelve lesions (Group I) were penetrating and seven (Group II) blunt. Group I: Nine patients were in shock upon admission, including six with cardiac tamponade. Six pts were stabbed, three sustained a gunshot wound, and two were accidental victims of a pneumatic gun. In the last pt, with previous lung surgery and mediastinal shift, a chest tube lacerated the right ventricle; this pt died in the operating room (OR), for a mortality rate of 8.3% (1/12). Associated intrathoracic and intra-abdominal lesions were present, but did not influence the outcome. Group II: All pts were involved in motor vehicle accidents. Five pts were in shock, including two with cardiac tamponade. Three pts required extracorporeal circulation (ECC) for aortic valve replacement, tricuspid valve reconstruction, and replacement of the ascending aorta. In one case, a lacerated right ventricle could be repaired without ECC, but the pt died from low cardiac output. Three pts with a ruptured left ventricle were managed in the OR, and two pts exsanguinated for a mortality rate of 43% (3/7). Associated lesions were present and death was related to ventricular rupture. Intrapericardial lesions are relatively rare in our Canadian experience. High survival can be obtained in penetrating injuries, while blunt injuries are more complex and remain highly lethal. ECC should be available for definitive treatment.     

Intrahepatic gas at postmortem computed tomography: forensic experience as a potential guide for in vivo trauma imaging

BACKGROUND: Until August 2004 there were 106 forensic cases examined with postmortem multislice computed tomography (MSCT) and magnetic resonance (MR) imaging before traditional autopsy within the Virtopsy project. Intrahepatic gas (IHG) was a frequent finding in postmortem MSCT examinations. The aim of this study was to investigate its cause and significance. METHODS: There were 84 virtopsy cases retrospectively investigated concerning the occurrence, location, and volume of IHG in postmortem MSCT imaging (1.25 mm collimation, 1.25 mm thickness). We assessed and noted the occurrence of intestinal distention, putrefaction, and systemic gas embolisms and the cause of death, possible open trauma, possible artificial respiration, and the postmortem interval. We investigated the relations between the findings using the contingency table (chi2 test) and the comparison of the postmortem intervals in both groups was performed using the t test in 79 nonputrefied corpses. RESULTS: IHG was found in 47 cases (59.5%). In five of the cases, the IHG was caused or influenced by putrefaction. Gas distribution within the liver of the remaining 42 cases was as follows: hepatic arteries in 21 cases, hepatic veins in 35 cases, and portal vein branches in 13 cases; among which combinations also occurred in 20 cases. The presence of IHG was strongly related to open trauma with systemic gas. Pulmonary barotrauma as occurring under artificial respiration or in drowning also caused IHG. Putrefaction did not seem to influence the occurrence of IHG until macroscopic signs of putrefaction were noticeable. CONCLUSIONS: IHG is a frequent finding in traumatic causes of death and requires a systemic gas embolism. Exceptions are putrefied or burned corpses. Common clinical causes such as necrotic bowel diseases appear rarely as a cause of IHG in our forensic case material.     

The consequences of high-risk behaviors: trauma during pregnancy

BACKGROUND: Trauma during pregnancy places two lives at risk. Knowledge of risk factors for trauma during pregnancy may improve outcomes. METHODS: We reviewed the charts of 188 such patients admitted to a Level I trauma center from 1996 to 2004. A comparison was made of injury severity and outcome from a cohort of nonpregnant female trauma patients selected with a similar temporal occurrence and age range. RESULTS: Motor vehicle collisions comprised 160 cases, 67 using a restraint device. Of 84 patients tested, 45 tested positive for intoxicants, 16 positive for 2 or more intoxicants. A significant trend toward less testing through the study period was observed (p = 0.0002). Injury severity was assessed by Revised Trauma Score (RTS). RTS <11 or admission to operating room or intensive care units (OR/ICU) classified patients as severely injured. The six maternal fatalities had an RTS <11 or OR/ICU disposition. Fetal outcomes included 155 live in utero, 18 live births, and 15 fatalities correlating with injury severity by either criteria (p < 0.0001). Of the fetal fatalities, 7 occurred with RTS = 12, but only 3 fatalities occurred in the 147 cases not admitted to OR/ICU. Gestational age correlated (p < 0.0001) with fetal outcomes. The 18 live births had mean gestational ages of 35 +/- 4 weeks as compared with fetal fatalities at 20 +/- 9 weeks, and fetuses alive in utero at 22 +/- 9 weeks gestation. Coagulation tests prothrombin time (PT), international normalized ratio (INR) (both p < 0.008), and partial thromboplastin time (PTT) (p < 0.0001) correlated with maternal outcome. A matched cohort of nonpregnancy trauma cases during the same time frame indicated that, despite a significantly higher percentage of severely injured patients, fewer fatalities occurred. This might reflect a greater risk for the pregnant trauma patient. CONCLUSIONS: This study of trauma in pregnancy cases revealed a high percentage with risk behaviors. There was a significant trend toward less intoxicant testing in recent years. Coagulation tests were the most predictive of outcomes. Lower gestational age correlated with fetal demise.     

Snowmobile trauma: an eleven-year experience

Records of 88 patients with snowmobile injuries from 1977 to 1987 were reviewed to identify the types of trauma. Data collected included age, sex, method and degree of injury, use of safety attire, and risk factors. There were 77 males and 11 females. Seventeen (19.3%) were children under the age of 16. Poor driving judgment involved in the hitting of obstacles led to the majority of injuries. There were 106 fractures in 71 patients. Eighteen patients (25%) had more than one fracture. Eleven patients had loss of consciousness. Eighty-eight other injuries resulted for a total of 205 injuries. There were three fatalities. Results indicate that inexperience, prior use of alcohol, driver carelessness, excessive speed, and poor adherence to manufacturer recommendations were the leading contributors to the accidents.     

Management of splenic trauma: the Durban experience

In a retrospective survey of splenic trauma managed at a teaching hospital, the data of 127 patients during a 2 year period have been analysed. Splenic conservation was achieved in 47 laparotomies (38.8 per cent). Six patients with blunt abdominal trauma (4.7 per cent of all patients) were managed non-operatively. Splenic conservation by suture with or without packing with omentum or oxidized cellulose was successful in 27 out of 37 attempts. Failure of this technique was easily recognized during laparotomy and no patient required re-operation for continued splenic bleeding after splenorrhaphy. There was no significant difference between successful conservation of the spleen at laparotomy of patients below the median age (28 years) and older patients. Wound sepsis was increased after splenectomy (P less than 0.05). Splenic conservation is not appropriate for all types of splenic injury. Where conservation is not possible splenectomy and re-implantation is recommended.