Polytrauma with thoracic and/or abdominal injuries： experience in 1 540 cases

Objective:To investigate the early diagnosis and treatment of polytrauma patients with thoracic and/or abdominal injuries. Methods: The data of all polytrauma patients with thoracic and/or abdominal injuries during the past 10 years were studied retrospectively. Results: In the present study, there were 1 540 polytrauma patients, accounting for 65.0% of all 2368 trauma patients. Of these patients, 62.4% were in shock state on admission. The operative rates were 15.0% (181/1206) and 79.9% (612/766) in patients with thoracic and abdominal injury (P<0.01), 5.2% (39/758) and 31.7% ( 142/448 ) in patients with blunt and penetrating chest trauma (P<0.01). and 72.4% (359/496) and 93.7 % (253/270) in patients with blunt and penetrating abdominal injuries (P<0.01), respectively. To deal with abdominal injury, angioembolization was performed in 43 cases, with 42 cured. The overall mortality rate was 6.2%. And in the blunt and penetrating subgroups, the mortalities were 7.9% (75/950) and 3.6% (21/590), respectively (P<0.01). Most patients died from exsanguination. Conclusions: The first "golden hour" after trauma should be grasped, since the treatment in this hour can determine greatly whether the critically-injured victim could survive. Prompt diagnosis and proper treatment contribute more greatly to the survival of the victim than the severity of injury.     

Hospital management of abdominal trauma in Tehran, Iran: a review of 228 patients

Objective: Today, trauma is a major public health problem in some countries. Abdominal trauma is the source of significant mortality and morbidity with both blunt and penetrating injuries. We performed an epidemiological study of abdominal trauma (AT) in Tehran, Iran. We used all our sources to describe the epidemiology and outcome of patients with AT.Methods: This study was done in Tehran. The study population included trauma patients admitted to the emergency department of six general hospitals in Tehran during one year. The data were collected through a questionnaire that was completed by a trained physician at the trauma center. The statistical analysis was performed using the SPSS software (version 11.5 for Windows). The statistical analysis was conducted using the chi-square and P＜0.05 was accepted as being statistically significant.Results: Two hundred and twenty-eight (2.8%) out of 8 000 patients were referred to the above mentioned centers with abdominal trauma. One hundred and twenty-five (54.9%)of the patients were in their 2nd and 3rd decades of life and 189 (83%) of our patients were male. Road traffic accidents (RTA) were the leading cause of AT with 119 (52.2%) patients. Spleen was the commonly injured organ with 51 cases. Following the analysis of injury severity, 159 (69.7%) patients had mild injuries (ISS＜16) and 69 (30.3%) patients had severe injuries (ISS= 16). The overall mortality rate was 46 (20.2%).Conclusions: Blunt abdominal trauma is more common than penetrating abdominal trauma. Road traffic accidents and stab wound are the most common causes of blunt and penetrating trauma, respectively. Spleen is the most commonly injured organ in these patients. The mortality rate is higher in blunt trauma than penetrating one.     

Level I verification is associated with a decreased mortality rate after major torso vascular injuries

Major torso vascular injuries (MTVIs) are frequently fatal. Our purpose was to determine whether the American College of Surgeons' (ACS) trauma center level of verification was associated with reduced mortality rates in a rural population-based community trauma center. Patients with blunt and penetrating MTVIs were retrospectively reviewed. Mortality rates were compared between Level II and Level I verification time periods. The primary outcome measured was death from MTVIs. Two hundred seventy-four patients (blunt, 167 [61%]; penetrating, 107 [39%]) representing 1.5 per cent of all trauma admissions were studied. Mortality decreased from 41 of 80 (51%) (Level II) to 60 of 194 (31%) (Level I) (P = 0.002) for the entire group. Mortality reduction occurred primarily in the subgroup with blunt and penetrating thoracic injuries (Level II, 24 of 33 [73%] vs Level I, 25 of 82 [30%]; P < 0.001). A significant reduction was not observed in patients with major abdominal vascular injuries (Level II, 17 of 47 [36%] vs Level I, 35 of 112 [31%]; P = 0.581). Level I status was associated with an overall decreased mortality rate from MTVIs despite low patient numbers. The commitment of hospital resources that are required to achieve Level I ACS verification in a community hospital improves survival, particularly in patients with blunt and penetrating thoracic injuries.     

Clinical retrospective and comparative study on diaphragm injuries in 46 cases

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Scapular fractures and concomitant injuries

Objective: The association of scapular fractures with other life-threatening injuries including blunt thoracic aortic injury is widely recognized.Few studies have investigated this presumed association...     

Outcomes of surgical management of tracheobronchial injuries a case series from a developing country

Objective: Tracheobronchial injuries are defined as injuries involving the trachea and/or bronchi from the level of the cricoid cartilage extending up to the division of the bronchi. We present a case series with most of the tracheobronchial injuries found to be sustained after penetrating trauma.Methods: A retrospective review was performed at the Aga Khan University, Karachi, Pakistan. From January 2004to December 2009, 168 patients with thoracic trauma were treated, of whom 15 were recognized to have major tracheobronchial and pulmonary injuries.Results: The average age was 31 years with most of the patients being male (14:1). Among them,11 patients had penetrating trauma as the main cause of injury, 3 patients had blunt trauma from road traffic accidents, only 1 patient had combined trauma (blunt and penetrating trauma). Eight patients were diagnosed based on radiological findings. All the patients were treated surgically. Lobectomy was the most common intervention performed in 7 patients. The mortality rate was 7% (1 patient). Most patients survived with no sequelae (10 patients) while 5 survived with disability. We found that penetrating trauma was the leading cause of injury in our series. The severity of injury depends upon the weapon causing the trauma. Patients in our series had multiple injuries and required surgical management.Conclusions: Tracheobronchial injuries are rare but potentially life threatening. They require quick diagnosis and management. Diagnosis tends to be difficult since there are no specialised diagnostic modalities available at present.     

Review of 9 Cases of Diaphragmatic Injury Following Blunt Trauma Chest; 3 Years Experience

Diaphragmatic injuries can occur with both blunt and penetrating trauma which can be associated with herniation of abdominal viscera into the thoracic cavity. Diaphragmatic injuries can occur with blunt trauma chest in 1–7 % of patients. Retrospectively for last 3 years all cases blunt trauma chest admitted to surgery were reviewed and a study of cases of diaphragmatic rupture was done. We analysed 496 patients of blunt trauma chest retrospectively for period of three years. Nine patients have diaphragmatic injuries, all were males, six presented acutely three were chronic. In six patients laparotomy was done, four subcostal and two midline incisions were preferred. In chronic cases thoracotomy was done. Left sided injury predominates and rib fractures are most common associated finding. Diagnosis in majority of cases is made by Computerised tomography scan. Subcostal incision may be used in patients with isolated diaphragmatic injury in acute presentation while thoracotomy is preferred in late cases. Most common morbidity is pulmonary complications     

Effects of penehyclidine hydrochloride on apoptosis of lung tissues in rats with traumatic acute lung injury

Objective： To investigate the effects ofpenehyclidine hydrochloride on apoptosis of lung tissue cells and its mechanism in acute lung injury following blunt chest trauma in rats. Methods： Sprague Dawley （SD） rats （n=54） weighing （250-25） g were divided equally and randomly into three groups： normal control group （C group, n= 18）, trauma model group （T group, n= 18） and penehyclidine hydrochloride treatment group （P group, n=18）. Each group was further divided into three subgroups according to the time points of 3, 12 and 24 hours after experiment （at each time point, n=6 for each subgroup）. Rats of P group were intraperitoneally injected with penehyclidine hydrochloride for 2 mg/kg immediately after blunt chest trauma and rats in its 24 hours subgroup were once again injected with penehyclidine hy- drochloride in the same dose 12 hours after injury. Lung tissue samples were collected at every time point and cell apoptosis in lung tissues were measured by TUNEL. Apoptotic index （AI） was calculated, expressions of bax and bcl-2 were detected by immunohistochemical staining of SABC, and lung tissue sections were taken for light and electron microscopic observation. Results： As compared with C group, at every time point, AI and expressions ofbax and bcl-2 in T group were higher （P〈0.05）, and the ratio of bcl-2/bax markedly decreased （P〈0.05）, especially in the 24 hours subgroup. The ratio in T group （0.468±0.007） was lower than that in C group （1.382±0.058, t=12.5, P〈0.01）. Lung tissue injuries were significant under a light microscope, and the number of apoptotic cells increased obviously under a transmission electron microscope. As compared with T group at the same phase, AI and expression of bax decreased in P group （P〈0.05 and P〈0.01）, while the expression of bcl-2 increased significantly （P〈0.01）, and the ratio of bcl-2/bax markedly increased （P〈0.05）, especially in the 24 hours subgroup. The ratio in P group （1.012-0.070） was much higher than that in T group （0.468±0.007, t=-8.3, P〈0.01）. The injury of lung tissues was relieved, and apoptosis of cells decreased obviously under a transmission electron microscopic observation. Conclusions： Apoptosis and expressions ofbax and bcl-2 in lung tissues might be involved in the pathogenesis of lung injury induced by blunt chest trauma. Penehyclidine hydrochloride can alleviate lung injuries by inhibiting apoptosis of lung tissue cells, during which effects ofpenehyclidine hydrochloride on regulating expressions ofbax and bcl-2 may play an important role.     

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.     

Management of penetrating and blunt diaphragmatic injury

The past 5 years' experience with diaphragmatic injuries at the University of Texas Health Science Center in San Antonio was reviewed to refine the clinical signs and appropriate treatment. During this period 102 patients were treated. Ninety-three patients incurred penetrating trauma to the diaphragm and nine patients suffered blunt trauma. Chest X-rays were normal in 40 patients, a hemo- and/or pneumothorax was present in 57, herniated abdominal viscera in four, and free air in one. Peritoneal lavage was positive in six of seven patients with blunt diaphragmatic injury, but was falsely negative in two of five patients (20%) with penetrating diaphragmatic injury. Eighty-nine patients (87%) experienced 137 associated injuries (excluding hemo- and/or pneumothorax). Nine patients (8.8%) had an isolated diaphragmatic injury. Four patients (4%) had a diaphragmatic injury associated with only a hemo- and/or pneumothorax. All patients, except for three with injuries recognized late, were operated upon immediately. Two patients had a missed diaphragmatic injury at initial laparotomy. There was one death in the series from a consumption coagulopathy. It was concluded that injuries to the diaphragm should be suspected in all patients with severe blunt torso trauma or with penetrating injuries near the diaphragm. Because of the nonspecificity of X-rays and the 20% false negative rate for peritoneal lavage, we believe that missed injuries and morbidity can be minimized by immediate laparotomy for all patients with abdominal and low thoracic penetrating injuries. Care must be taken not to overlook associated injuries.     

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.     

Correlation of abdominal trauma index and injury severity score with abdominal septic complications in penetrating and blunt trauma.

The Abdominal Trauma Index (ATI) was designed to stratify patients with penetrating injuries, and has been used to classify patients with blunt trauma. The Injury Severity Score (ISS) was originally designed to stratify victims of blunt trauma, and it has also been used for victims of penetrating trauma. We attempted to validate the use of ISS and ATI for both penetrating and blunt trauma. A total of 592 penetrating and 334 blunt trauma patients who underwent laparotomy over a 5-year period were evaluated. The overall rate of abdominal sepsis was 7.5% for blunt trauma and 7.6% for penetrating trauma. Mortality (excluding deaths within 48 hours) was 7% for blunt trauma and 1% for penetrating trauma. In the penetrating injury population, an ATI value greater than 15 and an ATI value greater than 25 were significantly associated with abdominal septic complications (ASCs) (p less than 0.001, both comparisons). An ISS greater than or equal to 16 was also associated with ASCs (p less than 0.001). The ASC rate for gunshots was higher than that for stab wounds (11% vs. 2%; p less than 0.001). In the blunt group, an ATI value greater than 15 and an ATI value greater than 25 were associated with ASCs (p less than 0.01 and p less than 0.001, respectively). The association of ASCs and ISS was linear with increasing ISS in patients with blunt abdominal trauma.(ABSTRACT TRUNCATED AT 250 WORDS)     

Thoracotomy for blunt trauma: traditional indications may not apply

The indications for performing as urgent thoractomy after trauma are based on the criteria used for penetrating injuries. However, few data are available on the use of these indications for patients with blunt injuries. In a retrospective study (June 1996 to July 2001), we compared the indications of urgent thoracotomy after blunt injury and penetrating injury in patients who underwent thoracotomy within 24 hours of hospital admission at our institution. Patients with blunt aortic injuries or emergency department thoracotomies were excluded from evaluation. Fifty-nine patients were identified (37 penetrating injuries, 22 blunt injuries). Blunt trauma victims had a higher mortality rate than penetrating trauma victims (73% vs. 22%). Chest tube output was the indication for nontherapuetic thoracotomy in 5 patients with blunt injuries whereas this occurred in only 1 penetrating injury victim (P = 0.04). All 5 blunt injury patients underwent a prior procedure and were coagulopathic when thoracotomy was performed. In conclusion, thoracotomy following blunt trauma is associated with a high rate of mortality. The rate of nontherapeutic exploration is increased when chest tube output is the indication for thoracotomy after blunt trauma. Since the majority of such patients have multicavitary injuries that require prior operation and are commonly coagulopathic, caution should be exercised when deciding whether to proceed with thoracotomy based solely on chest tube output.     

Damage control surgery for severe thoracic and abdominal injuries

OBJECTIVE: To investigate the application of damage control surgery in treatment of patients with severe thoracic and abdominal injuries. METHODS: A retrospective study was done on 37 patients with severe thoracic and abdominal injuries who underwent damage control surgery from January 2000 to October 2006 in our department. There were 8 cases of polytrauma (with thoracic injury most commonly seen), 21 of polytrauma (with abdominal injury most commonly seen) and 8 of single abdominal trauma. Main organ damage included smashed hepatic injuries in 17 cases, posterior hepatic veins injuries in 8,pancreaticoduodenal injuries in 7, epidural or subdural hemorrhage in 4, contusion and laceration of brain in 5, severe lung and bronchus injuries in 4, pelvis and one smashed lower limb wound in 3 and pelvic fractures and retroperitoneal hemorrhage in 6. Injury severity score (ISS) was 28-45 scores (38.4 scores on average), abbreviated injury scale (AIS) > or = 4.13. The patients underwent arteriography and arterial embolization including arteria hepatica embolization in 4 patients, arteria renalis embolization in 2 and pelvic arteria retroperitoneal embolization in 7. Once abbreviated operation finished, the patients were sent to ICU for resuscitation. Twenty-four cases underwent definitive operation within 48 hours after initial operation, 5 underwent definitive operation within 72 hours after initial operation, 2 cases underwent definitive operation postponed to 96 hours after initial operation for secondary operation to control bleeding because of abdominal cavity hemorrhea. Two cases underwent urgent laparotomy and decompression because of abdominal compartment syndrome and 2 cases underwent secondary operation because of intestinal fistulae (1 case of small intestinal fistula and 1 colon fistula) and gangrene of gallbladder. RESULTS: A total of 28 patients survived, with a survival rate of 75.68%, and 9 died (4 died within 24 hours and 5 died 3-9 days after injury). The trauma deaths at the early stage were caused by severe primary injuries resulting in failure of respiration and circulation, while mortality at the later stage was caused by multiple organ failure. CONCLUSIONS: Damage control surgery is important for the treatment against severe thoracic and abdominal injuries. It is suggested that the surgeon should select the reasonable auxiliary examination before operation, and take the proper time to perform damage control and definitive surgery.     

Outcomes of surgical and endovascular treatment of acute traumatic thoracic aortic injury

BACKGROUND: Acute thoracic aortic injury resulting from blunt trauma is a life-threatening condition. Endovascular therapy is a less invasive treatment modality that may potentially improve patient outcomes. We reviewed our experience with patients who sustained blunt thoracic aortic injuries distal to the left subclavian artery and presented for open surgical or endovascular repair. METHODS: Between August 1993 and August 2006, 62 patients sustained blunt thoracic aortic injuries distal to the origin of the left subclavian artery and proceeded to undergo open surgical (n = 48, 77%), or endovascular repair (n = 14, 23%). Revised trauma score (RTS), injury severity score (ISS), new injury severity score (NISS), individual associated traumatic injuries, as well as operative and postoperative outcomes were compared between open surgical and endovascular groups. RESULTS: Age, gender, race, and mechanism of injury did not differ between open surgical and endovascular groups. Additionally, RTS, ISS, and NISS values were not significantly different. The proportion of patients with sternal fractures (14% vs 0%), or unstable spinal fractures (36% vs 10%) was significantly greater in the endovascular group. Of the patients who received endografts, 93% (n = 13) were evaluated by a cardiothoracic surgeon and assessed to be prohibitive to operative intervention. Endografts utilized included commercially manufactured thoracic endografts (n = 6; 43%) and abdominal aortic endograft components (n = 8; 57%). Forty-one interposition grafts were placed in the open surgical group. Renal complications (32% vs 7%), and urinary tract infections (35% vs 7%) approached significance between surgical and endovascular groups (P = .082 and P = .077, respectively). Intraoperative mortality for the surgical and endovascular groups was 23% and 0%, respectively (P = .056). Endovascular repair was associated with significant reductions in operative time (118 vs 209 minutes), estimated blood loss (77 vs 3180 ml), and intraoperative blood transfusions (0.9 vs 6.1 units). No endoleaks were detected during a mean follow-up of 9.4 months in the endovascular group. CONCLUSION: Endovascular repair of blunt descending thoracic aortic injuries utilizing thoracic or abdominal endographs is a technically feasible modality that is at least equivalent to open therapy in the short term and associated with a lower intraoperative mortality (P = .056). Endovascular therapy has advantages in operative time, operative blood loss, and intraoperative blood transfusions.     

Survival after emergency department thoracotomy: review of published data from the past 25 years

BACKGROUND: Emergency department thoracotomy (EDT) has become standard therapy for patients who acutely arrest after injury. Patient selection is vitally important to achieve optimal outcomes without wasting valuable resources. The aim of this study was to determine the main factors that most influence survival after EDT. STUDY DESIGN: Twenty-four studies that included 4,620 cases from institutions that reported EDT for both blunt and penetrating trauma during the past 25 years were reviewed. The primary outcomes analyzed were in-hospital survival rates. RESULTS: EDT had an overall survival rate of 7.4%. Normal neurologic outcomes were noted in 92.4% of surviving patients. Factors reported as influencing outcomes were the mechanism of injury (MOI), location of major injury (LOMI), and signs of life (SOL). Survival rates for MOI were 8.8% for penetrating injuries and 1.4% for blunt injuries. When penetrating injuries were further separated, the survival rates were 16.8% for stab wounds and 4.3% for gunshot wounds. For the LOMI, survival rates were 10.7% for thoracic injuries, 4.5% for abdominal injuries, and 0.7% for multiple injuries. If the LOMI was the heart, the survival rate was the highest at 19.4%. The third factor influencing outcomes was SOL. If SOL were present on arrival at the hospital, survival rate was 11.5% in contrast to 2.6% if none were present. SOL present during transport resulted in a survival rate of 8.9%. Absence of SOL in the field yielded a survival rate of 1.2%. There was no clear single independent preoperative factor that could uniformly predict death. CONCLUSIONS: The best survival results are seen in patients who undergo EDT for thoracic stab injuries and who arrive with SOL in the emergency department. All three factors-MOI, LOMI, and SOL-should be taken into account when deciding whether to perform EDT. Uniform reporting guidelines are needed to further elucidate the role of EDT taking into account the combination of MOI, LOMI, and SOL.     

Outcomes of surgical management of tracheobronchial injuries---a case series from a developing country

Objective

Tracheobronchial injuries are defined as injuries involving the trachea and/or bronchi from the level of the cricoid cartilage extending up to the division of the bronchi. We present a case series with most of the tracheobronchial injuries found to be sustained after penetrating trauma.

Methods

A retrospective review was performed at the Aga Khan University, Karachi, Pakistan. From January 2004 to December 2009, 168 patients with thoracic trauma were treated, of whom 15 were recognized to have major tracheobronchial and pulmonary injuries.

Results

The average age was 31 years with most of the patients being male (14:1). Among them, 11 patients had penetrating trauma as the main cause of injury, 3 patients had blunt trauma from road traffic accidents, only 1 patient had combined trauma (blunt and penetrating trauma). Eight patients were diagnosed based on radiological findings. All the patients were treated surgically. Lobectomy was the most common intervention performed in 7 patients. The mortality rate was 7% (1 patient). Most patients survived with no sequelae (10 patients) while 5 survived with disability. We found that penetrating trauma was the leading cause of injury in our series. The severity of injury depends upon the weapon causing the trauma. Patients in our series had multiple injuries and required surgical management.

Conclusions

Tracheobronchial injuries are rare but potentially life threatening. They require quick diagnosis and management. Diagnosis tends to be difficult since there are no specialised diagnostic modalities available at present.     

Outcome of lung trauma.

OBJECTIVE: To find out whether we could manage critical pulmonary haemorrhages in penetrating injuries, and to report our experience with blunt trauma of the lung. DESIGN: Retrospective study. SETTING: Teaching hospital, Sweden. SUBJECTS: 81 patients who presented with pulmonary injuries during the period January 1988-December 1997; 6 were penetrating and 75 blunt. RESULTS: There was only one patient with an isolated lung contusion. The remaining was divided into 2 groups: those with pulmonary contusion and thoracic lesions (n = 32), and those with pulmonary contusion and extrathoracic lesions (n = 42). Four patients in the penetrating group were shocked and required urgent operations; emergency room thoracotomy (n = 1), urgent thoracotomy (n = 2), and urgent thoracoabdominal exploration (n = 1) were done successfully. We correlated grade of lung injury [American Association for the Surgery of Trauma-Abbreviated Injury Scale (AIS)] with mortality. All patients with penetrating injuries survived without serious consequences. There were a mean (SD), of 6 (2) injuries/patient in those with extrathoracic injuries compared with 3 (1) injuries/patient in the group with thoracic lesions (p < 0.001). The corresponding hospital mortality was 6/42 (19%) mainly as a result of the central nervous system lesions (4/6) compared with 0/32. The mean (SD) Injury Severity Score (ISS) was 9.3 (4.8) in patients with thoracic lesions compared with 24.1 (14.7) in patients with extrathoracic lesions (p < 0.0001), and 14.9 (9.5) in all survivors compared with 49.9 (13.6) among those who died (p < 0.0001). CONCLUSIONS: An excellent outcome can be achieved managing penetrating injuries of the lung by an aggressive approach and urgent surgical intervention even when emergency room thoracotomy is essential. Pulmonary contusion is considered to be a relatively benign lesion that does not add to the morbidity or mortality in patients with blunt chest trauma. These data may help to decrease the obsession with pulmonary contusion in patients with chest trauma, with or without extrathoracic lesions, and avoid many unnecessary computed tomograms of the chest.     

Predictive factors of operative or nonoperative management of blunt hepatic trauma

AIM: Nonoperative management (NOM) has revolutionized the care of blunt hepatic trauma patients. The aim of the present study was to identify and evaluate the predictors of NOM of these patients. METHODS: The Trauma Registry data of 55 consecutive adult patients admitted with blunt hepatic trauma over a 4-year period was reviewed. Patients were divided into immediately operated (OP-group) and selected for NOM (NOM-group). Factors analyzed were: demographics, injury mechanism, initial vital signs, liver injury grade, concomitant injuries, and total injury severity scoring systems. RESULTS: Concomitant abdominal trauma, high Injury Severity Score (ISS), low International Classification of Diseases 9(th) revision Injury Severity Score (ICISS), and low probability of survival (Ps) were predictors for operative management. Compared to NOM-patients (66%, N=36), OP-patients (34%, N=19) suffered more frequently concomitant abdominal injuries (84.2% vs 47.2%, P=0.004) and were more severely totally injured as expressed by higher ISS (25 vs 20, P=0.01), lower ICISS (0.51 vs 0.74, P=0.003), and lower Ps (0.81 vs 0.98, P=0.005). NOM resulted in lower intensive care unit admission and mortality rates (47.2% vs 78.9%, P=0.002 and 2.7% vs 15.8%, P=0.03, respectively). NOM-success rate was 92%. CONCLUSION: NOM of blunt hepatic trauma is safe and efficient. Concomitant abdominal trauma, ISS, ICISS, and Ps are predictors for operative or nonoperative management.     

Management and outcome of traumatic aortic injuries

BACKGROUND AND AIMS: Aortic injuries are rare and associated with high early mortality challenging the surgical services both from a technical as well as organisational point of view, especially in countries with low incidence of trauma. A Finnish experience in the management of aortic injuries is reported with special emphasis on outcome after early involvement of cardiothoracic surgeons. MATERIAL AND METHODS: Retrospective analysis of hospital records identified 36 consecutive patients with aortic injuries arriving alive to the hospital during a 32-year period of 1967-98. RESULTS: Of the 19 thoracic aortic injuries, 17 (89%) were caused by blunt trauma, 8 (42%) of the patients arrived in shock, 7 (37%) died before repair could be attempted, 11 (58%) underwent repair with prosthesis and one (5%) with sutures, with an overall mortality rate of 9/19 (47%). Of the 17 patients with abdominal aortic injuries (15 penetrating), 13 (76%) arrived in shock, 3 (18%) died before repair, 13 (76%) were repaired with sutures and one (6%) with prosthesis, with an overall mortality rate of 8/17 (47%). Fourteen (82%) of the 17 non-survivors died within 24 hours from the injury, 13 from exsanguination and one from associated brain injury. CONCLUSIONS: Abdominal aortic injuries are usually penetrating, diagnosed intraoperatively and amenable to suture repair with good results indicating that stable and unstable patients with potential aortic injuries after penetrating abdominal trauma can safely be managed in hospitals with experienced general surgeons on call. In contrast, stable patients with suspected thoracic aortic injuries could benefit from early transfer to a hospital with cardiothoracic surgical facilities and personnel.