Penetrating cardiac trauma. Quantifying the severity of anatomic and physiologic injury.

A method of quantifying the anatomic extent of injury to the heart, Penetrating Cardiac Trauma Index, (PCTI) and other thoracic organs has been proposed. The total extent of thoracic injury, Penetrating Thoracic Trauma Index (PTTI), was measured. When associated abdominal injury was present, it was assessed by the Penetrating Abdominal Trauma Index (PATI) of Moore et al. The severity of total injury sustained by the patient, represented by the Penetrating Trauma Index (PTI), was determined by the sum total of these scores. The extent of physiologic abnormality induced by cardiac penetration, (Physiologic Index or PI), was graded on a scale of increasing severity from 5-20 based on the vital signs of patients on admission. Analysis of 112 patients with penetrating cardiac injuries (1973-1983) revealed that the indices, PCTI and PI, showed an excellent correlation with survival (R2 = 0.827 and 0.928, respectively) as did the total extent of trauma (PTI). A composite prognostic score of the sum of PI and PTI demonstrated a significant separation of survivors from nonsurvivors (p less than 0.001). It is concluded that these anatomic (PCTI and PTI) and physiologic (PI) indices are valid and, with additional confirmation, may provide an objective method of evaluating penetrating cardiac injuries.     

Perioperative optimisation of fluid management improves outcome

Mortality from high-risk surgery is close to 10% (20% with emergency). Poor outcome is linked to tissue hypoperfusion. Optimising fluid therapy has a good pathophysiological basis related to microvascular flow to the tissues and the risk of multiple organ failure. Metaanalysis showed the higher the risk of surgery the greater the benefit of fluid and flow optimisation. A direct technique (blood pressure is indirect) to manage fluid therapy measuring tissues perfusions has not yet fulfilled criteria (easiness, accuracy, less invasiveness). At present pulmonary artery catheter with continuous output measurement is the choice. The aim of the study is to assess the impact of fluid management to increase blood flow in high-risk surgical patient.     

Prehospital ultrasound imaging improves management of abdominal trauma

BACKGROUND: Blunt abdominal trauma with intra-abdominal bleeding is often underdiagnosed or even overlooked at trauma scenes. The purpose of this prospective, multicentre study was to compare the accuracy of physical examination and prehospital focused abdominal sonography for trauma (PFAST) to detect abdominal bleeding. METHODS: Six rescue centres took part in the study from December 2002 to December 2003, including 230 patients with suspected abdominal injury. The accuracy of physical examination at the scene and PFAST were compared. Later examinations in the emergency department (ultrasonography and/or computed tomography) were used as the reference standard. RESULTS: The complete protocol and follow-up was obtained in 202 patients. The sensitivity, specificity and accuracy of PFAST were 93 per cent, 99 per cent and 99 per cent, respectively, compared with 93 per cent, 52 per cent and 57 per cent for physical examination at the scene. Scanning with PFAST occurred a mean(s.d.) 35(13) min earlier than ultrasound in the emergency department. Abdominal bleeding was detected in 14 per cent of patients. Using PFAST led to a change in either prehospital therapy or management in 30 per cent of patients, and a change to admitting hospital in 22 per cent. CONCLUSION: In this study, PFAST was a useful and reliable diagnostic tool when used as part of surgical triage at the trauma scene.     

The management of penetrating rectal and anal trauma: A systematic review

IntroductionTraumatic injuries to the lower gastrointestinal tract (rectum and anus) have been largely reported in the military setting with sparse publications from the civilian setting. Additionally, there remains a lack of international consensus regarding definitive treatment pathways. This systematic review aimed to assess the current literature and propose a standardised treatment algorithm to aid management in the civilian setting.MethodsA systematic review of available literature from 1999 to 2016 that was performed. Primary endpoints were the assessment and surgical management of reported rectal and anal trauma.ResultsSeven studies were included in this review, reporting on 1255 patients. 96.3% had rectal trauma and 3.7% had anal trauma. Gunshot wounds are the most common mechanism of injury (46.9%). The overwhelming majority of injuries occurred in males (>85%) and were associated with other pelvic injuries. Surgical management has substantially evolved over the last five decades, with no clear consensus on best management strategies.ConclusionThere remains significant international discrepancy regarding the management of penetrating trauma to the rectum. Key management principals include the varying use of the direct primary closure, faecal diversion, pre-sacral drainage and/or distal rectal washout (rarely used). To date, there is sparse evidence regarding the management of penetrating anal trauma.     

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.     

Penetrating cardiac trauma: management strategy based on 129 surgical emergencies over 2 years.

Between 1986 and 1988, 129 patients with stab wounds to the heart were referred from the emergency room of our institution for a thoracic surgical procedure. Multiple entrance wounds of the heart were present in 12 patients, and through-and-through stab wounds were encountered in another 10. The overall hospital mortality rate was 8.5% (11/129), which includes a 54% mortality rate for the 13 patients undergoing emergency room thoracotomy. These patients were pulseless and unconscious either on arrival (n = 8) or soon thereafter (n = 5). Cardiopulmonary bypass was not used during the primary operation, although 7 patients underwent subsequent intracardiac repair with bypass without hospital mortality. Important aspects of our preoperative management strategy include: (1) aggressive transfusion to improve the central venous pressure/intrapericardial pressure gradient; (2) rapid drainage of the pleural and pericardial spaces to reduce intrapericardial pressure; (3) empirical partial correction of metabolic acidosis with sodium bicarbonate; and (4) emergency operation without unnecessary cardiac imaging. Patients suspected of having penetrating cardiac trauma and cardiac tamponade are best managed by aggressive primary intervention and immediate operation.     

Hepatic trauma management and outcome; Our experience

Background  

Injuries to the liver have been reported in 35–45% of patients with significant blunt abdominal trauma. Since the introduction of ultrasonography and computerized tomography in the evaluation of these patients, there has been an increase in number of hepatic injuries diagnosed that previously would not have been apparent.     

Complex bronchial ruptures in blunt thoracic trauma: management and outcome

Complex bronchial ruptures are rare. Primary surgical repair is the preferred procedure. The aim of this retrospective case series was to study the clinical presentation of these complex bronchial injuries and their management and outcomes. Patients with injuries to the trachea or those who had simple single bronchial rupture and isolated lobar and segmental injuries were excluded. Twenty-one patients were operated for bronchial rupture due to blunt chest trauma. Seven patients had complex bronchial injuries and had right bronchial tree injury (n = 3), left bronchial tree injury (n = 3), and rupture of both right and left main bronchi (n = 1). Fibreoptic bronchoscopy established the diagnosis in all patients. Postoperative complications included atelectasis in four patients (57%) and left recurrent laryngeal nerve paralysis (n = 1; 14.3%), and one patient required tracheostomy (14.3%). All patients had follow-up bronchoscopy 2 months later, which showed no stenosis or scar formation in any of the patients. We concluded that primary repair of complex bronchial injuries, with preservation of the normal functioning lung, is the preferred option as it carries favorable immediate- and long-term results.     

Renovascular trauma: risk assessment, surgical management, and outcome

In an effort to define better the indications for renovascular repair, risk factors for renal loss, and eventual patient outcome, records of 36 patients with 37 renovascular injuries were reviewed. The renal artery alone was injured in nine kidneys, the renal vein alone in 12, and both the main renal vein and artery in six. Segmental vessel injuries alone were noted in ten kidneys. Two patients died before repair could be attempted. Eleven nephrectomies were performed. Vascular repair was attempted in the remaining 24 renal units either as isolated procedures or combined with renal parenchymal repair. Compared to 78 patients with only parenchymal injuries, those with renovascular injuries were more severely injured as assessed by nephrectomy rate, Injury Severity Score, transfusion requirement, number of major complications, and death. Fifteen patients sustained main renal artery injuries of whom six underwent immediate nephrectomy. Nine attempts at repair were performed. Six patients had either persistent thrombosis or preservation of only marginal function. One patient died in the immediate postoperative period of associated injuries. Complete renal preservation was achieved in only two kidneys (14%). Nephrectomy was required for the management of three of 12 main renal vein injuries, but in none of ten patients with segmental vascular injuries.     

Penetrating neck trauma: hidden injuries-oesophagospinal traumatic fistula

Injuries to the eosophagus are notoriously difficult to diagnose pre-operatively. Patients with such injuries usually will not have pre-operative signs and symptoms to suggest the presence of this type of injury. These injuries require a high index of suspicion, appreciation of the presence of injuries to adjacent structures, and an understanding that the clinical and radiological findings may evolve over a period of time. We describe a child with a rare presentation of an acute traumatic esophageal spinal fistula due to a bullet wound. This complicated injury required a variety of diagnostic modalities, including contrast radiography, multiple computerised tomography (CT) scans and operative assessments to make the definitive diagnosis.     

Audience response system technology improves accuracy and reliability of trauma outcome judgments

BACKGROUND: Peer-review judgments are necessary for effective trauma performance improvement (PI), but may be influenced by peer pressure and the tendency to vote with the majority. Incorporation of Audience Response System (ARS) technology into trauma PI should result in improved outcome assessments. METHODS: We compared 30 months of nonanonymous trauma care judgments with 30 months of anonymous judgments obtained with the use of a keypad-based ARS. Statistical methods included the chi2 test and the Wilcoxon rank sum test. RESULTS: Use of the ARS resulted in a 28% reduction in deaths judged nonpreventable and a 24% reduction in trauma care judged to be appropriate (p < 0.0001). Unanimous outcome judgments were also significantly reduced (p < 0.0001). CONCLUSIONS: Outcome judgments obtained anonymously were significantly more divergent and less positive than those obtained nonanonymously. Anonymously derived outcome judgments may provide a better opportunity to identify adverse outcomes and thereby potentially improve trauma PI and trauma care.     

A thoracostomy tube guideline improves management efficiency in trauma patients

BACKGROUND: Thoracostomy tube (TT) placement constitutes primary treatment for traumatic hemopneumothorax. Practice patterns vary widely, and criteria for management and removal remain poorly defined. In this cohort study, we examined the impact of implementation of a practice guideline (PG) on improving management efficiency of thoracostomy tube. METHODS: We developed a PG aimed at standardizing the management of TTs in critically ill patients admitted to a Level I trauma center. During the 9-month period before (Pre-PG) and 3 months after (Post-PG) implementation, practice parameters including prophylactic antibiotics, duration of TT therapy, preremoval chest radiographs with associated charges, and complications were evaluated. Differences between groups were assessed by Mann-Whitney rank sum and chi(2) with Yates correction. RESULTS: There were 61 patients, 14 in the Pre-PG group and 47 in the Post-PG group. The groups were matched in age and Injury Severity Scores. The Post-PG cohort averaged 3 fewer days of TT therapy. After implementation of the PG, 21 patients did not have preremoval chest radiography, representing a $3000 reduction in radiology fees. Complication rates (retained pneumothorax, hemothorax, and empyema) were not different between the two groups. CONCLUSION: Implementation of a thoracostomy tube practice guideline was associated with improved management efficiency in trauma patients.