Morbidity of percutaneous tube thoracostomy in trauma patients.

OBJECTIVES: This prospective study was designed to evaluate the complications of percutaneous tube thoracostomy (PTT) performed for chest trauma in our institution and to determine predictive factors. METHODS: One hundred and thirty-four primary PTTs were performed in 128 patients for blunt (83) and penetrating (45) chest traumas. Failure was defined as undrained hemothorax or pneumothorax, post-tube removal complications and empyema. Univariate and multivariate hazard analyses were used to assess the association between potential risk factors and complications. RESULTS: The overall complication rate was 25% including 30 (23%) failures and nine (7%) improper placement with iatrogenic injuries to the lung (n = 4) or subclavian vein (n = 1). Complications were managed with 18 repeat PTTs and ten early thoracotomies for clotted hemothorax (two), persistent air leak (two), fluid collection (three) or a combination (three) at a mean delay of 6.5 +/- 2.4 days. Failure of additional PTT required late decortication for empyema (three) or decortication (three) at a mean delay of 23 +/- 7 days. One patient died postoperatively, the only death directly related to PTT failure among the four (3.1%) deaths that occurred in this study. Hospital length of stay was significantly increased in patients with PTT failure (24 +/- 19 vs. 15 +/- 8 days in uncomplicated PTT, P = 0.004). By univariate analysis, polytraumatism (relative risk (RR) 2.7, P < 0.05), the need for assisted ventilation (RR 2.7, P = 0.003) and tube insertion by emergency physicians (RR 8.7, P < 0.0001) were significantly associated with increased incidence of complications in blunt trauma. Multivariate analysis identified the performance of the procedure by operators other than thoracic surgeons and residents trained in thoracic surgery as the only independent risk factor in both blunt and penetrating trauma (RR 58 and 71, respectively, P < 0.00001). CONCLUSIONS: PTT is associated with significant morbidity and extended hospitalizations, partly related to inappropriate training of all individuals dealing with trauma care. Additional training should be recommended and some conventional indications for PTT should be revised. A prospective study is currently in progress to evaluate the benefit of early videothoracoscopy in trauma and failure of primary PTT.     

Early decortication after thoracic trauma

Twenty-three patients who sustained either blunt or penetrating thoracic trauma underwent early decortication after failure of chest tube drainage. Patients were divided into two groups: (1) ten with isolated chest injuries were compared with (2) 13 with chest trauma and other associated major injuries. Group 1 patients had earlier decortication (10.3 days), rapid recovery (home in 6.1 days), and little morbidity. Group 2 patients had later decortications (19.3 days), higher incidence of infected clot, yet were home in 9.8 days after thoracotomy. Early decortication is advocated as a safe and expedient means of dealing with the complications of traumatic pneumothorax and hemothorax.     

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)     

The impact of obesity on the outcomes of 1,153 critically injured blunt trauma patients

BACKGROUND: Several small series have had mixed conclusions regarding the impact of obesity on outcomes of trauma patients. The purpose of the present study was to evaluate a large cohort of critically injured patients to better understand the influence of obesity on the outcomes of patients after severe blunt trauma. METHODS: Retrospective review using the trauma registry and intensive care unit (ICU) database of all blunt trauma patients admitted to the ICU at our urban, Level I trauma center over a 5-year period (1998-2003). Obese patients (body mass index [BMI] > or = 30 kg/m) were compared with non-obese patients (BMI < 30 kg/m). RESULTS: There were 1,153 blunt trauma patients admitted to the ICU during the study period, including 283 (25%) obese (mean BMI = 35 +/- 6 kg/m) and 870 (75%) non-obese (mean BMI = 25 +/- 3 kg/m) patients. There was no difference between groups regarding age, sex, Injury Severity Score, or admission vitals. Obese patients had fewer head injuries (42 versus 55%; p = 0.0001) but more chest (45 versus 38%; p = 0.05) and lower extremity (53 versus 38%; p < 0.0001) injuries. There was no difference in the need for laparotomy, thoracotomy, or craniotomy. Obese patients suffered more complications (42 versus 32%; p = 0.002). Although there was only a trend toward higher mortality in obese patients (22 versus 17%; p = 0.10), stepwise logistic regression revealed obesity as an independent risk factor for mortality (odds ratio, 1.6; 95% confidence interval, 1.0-2.3; p = 0.03). Among survivors, obese patients required longer stays in the hospital (24 +/- 21 versus 19 +/- 17 days; p = 0.01), the ICU (13 +/- 14 versus 10 +/- 10 days; p = 0.005), and 2 more days of mechanical ventilation (8 +/- 13 versus 6 +/- 9 days; p = 0.07). CONCLUSION: Obese patients incur different injuries after severe blunt trauma than their non-obese counterparts. Despite sustaining fewer head injuries, obese patients suffer more complications, require longer stays in the hospital, more days of mechanical ventilation, and obesity is independently associated with mortality.     

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.     

Chest injuries in childhood.

Differences in anatomy and mechanisms of injury are believed to contribute to the unique response of children to thoracic trauma. To characterize the scope and consequences of childhood chest injury, we reviewed the records of 105 children (ages 1 month to 17 years, mean 7.6 years) with chest injuries admitted to a level I pediatric trauma center from 1981 to 1988. Nearly all injuries (97.1%) were due to blunt trauma, and more than 50% were traffic related. Rib fractures, commonly multiple, and pulmonary contusions occurred with nearly equal frequency (49.5% and 53.3%, respectively), followed by pneumothorax (37.1%) and hemothorax (13.3%). One fourth of all pneumothoraces were under tension. Significant intrathoracic injuries occurred without rib fractures in 52% of cases with blunt trauma. Associated head, abdominal, and orthopedic injuries were present in 68.6% of children reviewed. One in five received endotracheal intubation and ventilatory support for 1 to 109 days. Presence or absence of head injury neither increased the need for respiratory support (29.4% vs. 17.2%, respectively; p = 0.24) nor affected the duration of support for those who were ventilated (6.8 +/- 8.9 days vs. 3.3 +/- 2.6 days, excluding one ventilator-dependent head-injured patient and five early deaths). The presence of associated injuries, intubation, and pneumothorax or hemothorax all resulted in significantly longer hospitalizations and more severe injury as measured by Injury Severity Score (ISS). Age, rib fracture, and contusion had no effect. Rarely encountered were ruptured diaphragm (2 cases), transection of the aorta (1), major tracheobronchial tears (3), flail chest (1), and cardiac contusion (2). Only two of the three children with penetrating injuries and three of the 83 (3.6%) with blunt injuries underwent chest operations. Six children (7%) died, one from a penetrating injury and five from blunt mechanisms. Chest Abbreviated Injury Scale (AIS) and ISS correlated significantly with mortality; age and head AIS did not. Rib fractures, lung contusions, and associated head, abdominal, and skeletal injuries are common because of the predominance of blunt-injury mechanisms. Nearly one half of chest injuries occurred without rib fractures. The need for ventilatory support is uncommon; when required, its duration is generally brief. Aortic transection, flail chest, and penetrating injuries more frequently encountered in adults and are uncommon in children. Thoracotomy generally is not required.(ABSTRACT TRUNCATED AT 400 WORDS)     

The clinical significance of myocardial contusion.

In an attempt to identify a group of blunt trauma victims with asymptomatic myocardial contusion (MC) who do not benefit from intensive cardiac monitoring, we prospectively divided 336 patients admitted to the SICU with possible MC following blunt trauma in the 6 years prior to January 1990 into three groups: Group 1 (n = 155, age 30.5 +/- 9 years) consisted of those patients admitted for mechanism of injury, J-point elevation, with or without minor chest injury. None developed arrhythmias. Their SICU length of stay (LOS) was 2.41 +/- 0.77 days. Group 2 (n = 43, age 31.5 +/- 10 years) patients had the same admission criteria as the patients in group 1 plus an abnormal emergency department ECG, i.e., arrhythmia, heart block, ischemia. None had cardiac complications. Their SICU LOS was 2.47 +/- 0.94 days. Group 3 (n = 138, age 40 +/- 20 years) patients had four or more rib fxs, a pulmonary contusion, a flail chest, or extra-thoracic injuries or were greater than 60 years of age. All required SICU admission for their non-cardiac injuries. Nineteen patients had cardiac complications requiring treatment. None had a cardiac death. Their SICU LOS was 10 +/- 22 days. We conclude that young patients with minor blunt thoracic trauma and a normal or minimally abnormal ECG do not benefit from cardiac monitoring.     

Penetrating trauma in patients older than 55 years: a case-control study

BACKGROUND: Multiple studies have compared young and elderly blunt trauma patients, and concluded that, because elderly patients have outcomes similar to young patients, aggressive resuscitation should be offered regardless of age. Similar data on penetrating trauma patients are limited. STUDY DESIGN: In a retrospective review, 79 patients with penetrating injuries and age > or =55 were blindly matched for Injury Severity Score (ISS) and Abbreviated Injury Scores (AIS) with 79 penetrating trauma patients aged 15-35 years, who were admitted to the hospital over the same 4 year period (June 1994-June 1998). Mortality rates and length of stay in the intensive care unit (ICU) and the hospital were compared between the two groups. RESULTS: The average ISS for all patients was 12 (range 1-75) and identical for both groups. Both groups had similar injuries and were evaluated by an equal number and type of diagnostic studies. The mean ISS was not different between severely injured older and younger patients who required ICU admission or died. Among 32 nonsurvivors (18 older and 14 younger), older patients were more likely than younger patients to present with normal vital signs, although the comparison did not reach statistical significance (50% vs. 13%, P=0.25). There was a clinically significant trend for longer ICU (15+/-30 vs. 3+/-2 days, P=0.096) and hospital stay (10+/-18 vs. 6+/-8 days, P=0.08) among older patients, but mortality rates were similar (23% in older vs. 18% in younger, P=NS). Furthermore, these outcome parameters showed no difference when both groups were classified according to severity of injury or physiologic response. CONCLUSIONS: Following penetrating trauma, older patients arriving alive and admitted to the hospital are as likely to survive as younger patients who have injuries of similar severity, but at the expense of longer ICU and hospital stays.     

CT as a first-line modality in elderly patients with stable blunt chest trauma

Purpose: Blunt thoracic injuries are common among elderly patients and may be a common cause of morbidity and death from blunt trauma injuries. We aimed to examine the impact of chest CT on the diagnosis and change of management plan in elderly patients with stable blunt chest trauma. We hypothesized that chest CT may play an important role in providing optimal management to this subgroup of trauma patients. Methods: A retrospective analysis was performed on all the admitted adult blunt trauma patients between January 2014 and December 2018. Stable blunt chest trauma patients with abbreviated injury severity (AIS) < 3 for extra-thoracic injuries confirmed with chest X-ray (CXR) and chest CT on admission or during hospitalization were included in the study. The AIS is an international scale for grading the severity of anatomic injury following blunt trauma. Primary outcome variables were occult injuries, change in management, need for surgical procedures, missed injuries, readmission rate, intensive care unit (ICU) and length of hospital stay. Results: There are 473 patients with blunt chest trauma included in the study. The study patients were divided into two groups according to the age range: group 1: 289 patients were included and aged 18-64 years; group 2: 184 patients were included and aged 65-99 years . Elderly patients in group 2 more often required ICU admission (11.4% vs. 5.2%), had a longer length of ICU stay (days) (median 11 vs. 6, p = 0.01), and the length of hospital stay (days) (median 14 vs. 6, p = 0.04). Injuries identified on chest CT has led to a change of management in 4.4% of young patients in group 1 and in 10.9% of elderly patients in group 2 with initially normal CXR. Chest CT resulted in a change of management in 12.8% of young patients in group 1 and in 25.7% of elderly patients in group 2 with initially abnormal CXR. Conclusion: Chest CT led to a change of management in a substantial proportion of elderly patients. Therefore, we recommend chest CT as a first-line imaging modality in patients aged over 65 years with isolated blunt chest trauma.     

Prospective evaluation of the sensitivity of physical examination in chest trauma

BACKGROUND: Chest radiographs are routine for patients presenting with blunt and penetrating chest trauma. The accuracy of physical examination in the diagnosis of hemopneumothorax in these patients is unclear. A prospective study was performed to define the utility of routine portable chest radiographs in 676 trauma patients. METHODS: Over 19 months (January 2000-July 2001), 676 patients who presented with penetrating or blunt chest trauma were interviewed and examined for signs and symptoms of hemopneumothorax. The incidence of chest pain or tenderness and tachypnea was noted and both lung fields were auscultated. A portable chest radiograph was then performed on all the patients. RESULTS: All the patients were hemodynamically stable. Five hundred twenty-three patients sustained blunt trauma, with seven hemopneumothoraces (1.3%). The negative predictive values of auscultation, pain or tenderness, and tachypnea were 99& to 100%. One hundred fifty-three patients sustained penetrating chest trauma. Of these injuries, 68 were gunshot wounds and 85 were stab wounds. Twenty-four (16%) of these patients had hemopneumothoraces. The sensitivities of auscultation, pain or tenderness, and tachypnea were 50%, 25%, and 32%, respectively. The negative predictive values of these tests were < 91%. CONCLUSION: Blunt chest trauma patients who are hemodynamically stable with a normal physical examination do not require a routine chest radiograph. In contrast, all victims of penetrating trauma require chest radiographs because many will have hemopneumothorax in the absence of clinical findings.     

Rhabdomyolysis after penetrating trauma

Rhabdomyolysis (RHAB) is a known complication following blunt trauma. RHAB after penetrating trauma has not been studied. The objective of this study was to evaluate the incidence, risk factors, and complications of RHAB following penetrating trauma. Over a 5-year period, penetrating trauma patients admitted to our intensive care unit (ICU) were studied. Significant RHAB was defined as a CK level of 5000 U/L or higher. There were 873 patients (29 +/- 12 years old, 92% male), of whom 767 (88%) had abnormal CK levels (range 520-165,943 U/L), and 111 patients (13%) developed significant RHAB. Victims of penetrating trauma who sustain vascular and severe extremity injury are at a sixfold increased risk to develop significant RHAB. Patients with significant RHAB had a higher rate of renal failure (23% vs 7%, P < 0.0001) and longer ICU stay (15 +/- 26 days vs 8 +/- 12 days, P < 0.0001). CK elevations and significant RHAB are common after penetrating trauma. Patients who sustain vascular and severe extremity injury as a result of their penetrating wounds are at high risk to develop significant RHAB, resulting in renal failure and prolonged ICU stay. Therefore, critically injured penetrating trauma patients should be routinely screened with CK levels.     

Timing of urgent thoracotomy for hemorrhage after trauma: a multicenter study

HYPOTHESIS: It is possible to quantify an amount of thoracic hemorrhage, after blunt and penetrating injury, at which delay of thoracotomy is associated with increased mortality. DESIGN: A retrospective case series. SETTING: Five urban trauma centers. STUDY SELECTION: Patients undergoing urgent thoracotomy (within 48 hours of injury) for hemorrhage (excluding emergency department thoracotomy). DATA EXTRACTION: Respective registries identified patients who underwent urgent thoracotomy. Injury characteristics, initial and subsequent chest tube outputs, time before thoracotomy, and outcomes were evaluated. MAIN OUTCOME MEASURE: Death. RESULTS: One hundred fifty-seven patients (36 with blunt and 121 with penetrating injuries) underwent urgent thoracotomy for hemorrhage between January 1, 1995, and December 31, 1998. Mortality correlated with mean (+/- SD) Injury Severity Score (38 +/- 19 vs 22 +/- 12.6 for survivors; P<.01) and mechanism (24 [67%] for blunt vs 21 [17%] for penetrating injuries; P<.01). Mortality increased as total chest blood loss increased, with the risk for death at blood loss of 1500 mL being 3 times greater than at 500 mL. Blunt-injured patients waited a significantly longer time to thoracotomy than penetrating-injured patients (4.4 +/- 9.0 h vs 1.6 +/- 3.0 h; P =.02) and also had a greater total chest tube output before thoracotomy (2220 +/- 1235 mL vs 1438 +/- 747 mL; P =.001). CONCLUSIONS: The risk for death increases linearly with total chest hemorrhage after thoracic injury. Thoracotomy is indicated when total chest tube output exceeds 1500 mL within 24 hours, regardless of injury mechanism.     

Determination of functional outcome following upper extremity arterial trauma

Upper extremity arterial trauma may lead to significant disability with a poor functional outcome. This study represents a retrospective review of all trauma patients presenting to a university-affiliated medical center. Patients suffering from upper extremity arterial injuries requiring treatment were identified. The injured vessels were identified along with the mechanism of injury and method of repair. The degree of functional disability was evaluated by using a previously validated questionnaire, the Disabilities of the Arm, Shoulder, and Hand (DASH) Outcome Measure. Between September 1999 and December 2004, 17 patients presented with traumatic arterial injury to the upper extremity, with 9 and 8 patients suffering from blunt and penetrating traumas, respectively. One patient required amputation representing a limb salvage rate of 94%. The mean length of hospitalization was significantly shorter for penetrating trauma (5.1 vs 12 days, P = .03), with blunt trauma victims being more prone to coexisting orthopedic injuries (P = .009). Length of follow-up did not differ between the 2 groups and ranged from 1-60 months. Patients with blunt trauma tended, although not statistically significant, to have higher DASH scores (61.8 vs 22.8, P = .08), indicating a greater degree of disability. By utilizing a validated disability questionnaire, this study confirms that patients suffering from blunt injuries to upper extremity arteries are more likely to have greater degrees of disability affecting everyday activities.     

Pulmonary tractotomy versus lung resection: viable options in penetrating lung injury.

BACKGROUND: Emergency lung resection following penetrating chest trauma has been associated with mortality rates as high as 55-100%. Pulmonary tractotomy is advocated as a rapid alternative method of dealing with deep lobar injuries. We reviewed our experience with resection and tractotomy to determine whether method of management affects mortality or if patient presentation is more critical in determining outcome. METHODS: A retrospective review of all patients with chest injury seen at an urban Level I trauma center from 2/89-1/99 was performed. All patients undergoing parenchymal surgery were included. Records were abstracted for grade of injury, type of resection, presenting systolic blood pressure (SBP), temperature, Injury Severity Score (ISS), operative time, and estimated blood loss (EBL). Mortality and thoracic complications were compared between groups. RESULTS: Two hundred forty-six of 2736 patients with penetrating chest trauma underwent thoracotomy, with 70 (28%) requiring some form of lung resection. There were 11 (15.7%) deaths. Patients who died had lower SBP (53 +/- 32 mm Hg vs 77 +/- 28 mm Hg), lower temperature (32.5 degrees +/- 1.3 degrees C vs 34.3 degrees +/- 1.2 degrees C), higher ISS (33 +/- 13 vs 23 +/- 9), and greater EBL (9.8 +/- 4.3 liters vs 2.8 +/- 2.1 liters) compared with survivors (p < 0.05 for all). Mortality was also increased in the presence of cardiac injury (33% with vs 12% without) and the need for laparotomy (26% with vs 9% without) (p < 0.05 for all). Tractotomy was associated with an increased incidence of chest complications (67% vs 24%, p = 0.05) compared with lobectomy with no difference in presenting physiology, operative time, or mortality. CONCLUSION: Lung resection for penetrating injuries can be done safely with morbidity and mortality rates lower than previously reported. Patient outcome is related to severity of injury rather than type of resection. Tractotomy is associated with a higher incidence of infectious complications and is not associated with shortened operative times or survival.     

Trauma faculty and trauma team activation: impact on trauma system function and patient outcome.

OBJECTIVE: To determine the impact of the presence of an attending trauma surgeon during trauma team activation on system function and patient outcome. METHODS: After a retrospective review of medical records and trauma registry, a comparative study between two American College of Surgeons Committee on Trauma Level I trauma centers was performed. One center (Hennepin County Medical Center) required a chief surgical resident, two junior residents, and a board-certified emergency medicine faculty to be present in the emergency department for all trauma team activations. The attending trauma surgeon was notified at the time of trauma team activation and was neither required to be present in the emergency department at time of patient arrival nor in the hospital 24 h/day. The other center (St. Paul Ramsey Medical Center) required a chief surgical resident, two junior residents, a board-certified emergency medicine faculty member, and an attending trauma surgeon to be present in the emergency department for all trauma activations and in hospital 24 hours/day. Over a 21-month period, all major trauma patients (Injury Severity Score > 15 or emergent operation within 4 hours of admission and any Injury Severity Score) that triggered trauma team activation were examined. Resuscitation time, time to incision, probability of survival, and mortality were analyzed. RESULTS: Resuscitation time was shorter at St. Paul Ramsey Medical Center when compared with Hennepin County Medical Center. Analysis by mechanism of injury demonstrates that this was true for blunt trauma (39+/-13 vs. 27+/-12 minutes, p = 0.001) and for penetrating trauma (28+/-14 vs. 24+/-17 minutes, p = 0.01). Subgroup analysis of penetrating trauma victims demonstrated that there was a significant difference in resuscitation times for gunshot wounds but not for stabs. There was no difference in how quickly operations could be initiated for blunt trauma patients. However, in penetrating cases, time to incision was significantly shorter at St. Paul Ramsey Medical Center (50+/-29 vs. 66+/-43 minutes, p = 0.01). There was no significant difference in mortality for any category of Trauma and Injury Severity Score probability of survival in blunt or penetrating trauma. Analysis of "in-house" and "out-house" time intervals demonstrated no difference in survival in any mechanism of injury, nor was there a difference in overall mortality. CONCLUSION: The presence of a trauma surgeon on the trauma team reduced resuscitation time and reduced time to incision for emergent operations, particularly in penetrating trauma. However, it had no measurable impact on mortality based on Trauma and Injury Severity Score probability of survival. Attending trauma surgeon presence on the trauma team improves in-hospital trauma system function without affecting patient outcome.     

Prognosis of penetrating trauma in elderly patients: a comparison with younger patients

BACKGROUND: It has previously been shown that elderly patients have a worse prognosis than their younger counterparts after sustaining blunt trauma. This is due in part to a higher incidence of comorbid conditions as well as less physiologic reserve in an elderly population sustaining largely blunt trauma. We compared the outcome after penetrating trauma in elderly patients to matched "younger" patients to determine whether they had a similarly poor prognosis. METHODS: Elderly patients (> or = 65 years) were identified from our trauma registry. Sex, mechanism of injury, and Abbreviated Injury Score/Injury Severity Score were determined from the registry. Patients presenting with traumatic arrest were excluded. The registry was then searched for patients aged 15 to 40 years with the same sex, mechanism of injury, and Abbreviated Injury Score in each region. A chart review was then performed to determine additional details of their hospital stay. The two groups were then compared using Student's t test and Fisher's exact chi2 test, as appropriate. RESULTS: Eighty-five elderly patients (OLD group) were admitted with penetrating trauma between 1983 and 1998. They were compared with 85 matched young patients (YOUNG group). Each group included 66 male and 19 female patients. In each group, gunshot wounds occurred in 45.9%, stab wounds in 52.9%, and shotgun wounds in 1.2% of patients. The average Injury Severity Score in each group was 5.5 +/- 5.6 (range, 1-29) and the regional Abbreviated Injury Scores were likewise equal in both groups. The OLD patients had an average hospital stay of 6.9 +/- 9.1 days compared with 4.3 +/- 5.7 days in the YOUNG patients (p < 0.05). Twenty-seven OLD patients spent 7.3 +/- 9.2 days in the intensive care unit compared with 19 YOUNG patients who stayed 3.4 +/- 3.2 days (p < .05). A total of 91 comorbidities were identified in 58 OLD patients compared with 18 in 15 YOUNG patients (p < .0001). Eighty-six invasive procedures were performed in the OLD group compared with 96 in the YOUNG group (p = not significant). Nineteen OLD patients (22.3%) and 15 YOUNG patients (17.6%) suffered one or more complications, including death (p = not significant). A total of 91% of surviving OLD patients were discharged to home compared with 100% of surviving YOUNG patients (p < .01). CONCLUSION: Elderly patients who sustain penetrating trauma have more comorbidities than their younger counterparts. This may account for their longer hospital stay and lesser ability to be discharged home. These patients do not have an increased complication rate and should continue to be managed aggressively.     

Diaphragmatic injuries: recognition and management in sixty-two patients.

Between 1979 and 1989, 62 patients were treated for traumatic injury of the diaphragm. Forty-five had penetrating injuries following stab wounds or gunshot wounds, and 17 had diaphragmatic tears from motor-vehicle and auto-pedestrian accidents. Forty-one patients sustained left-sided injuries; 20 patients sustained right sided injuries; and one patient sustained bilateral ruptures. All patients underwent exploratory laparotomy and diagnosis was confirmed at surgery. Diaphragmatic injury was suspected in only 17 (27%) patients preoperatively. The chest radiograph showed nonspecific abnormalities in 48 (77%) patients and was diagnostic in 15 (24%) patients. Six patients had diagnostic peritoneal lavage; five were positive and one was negative. Computerized tomography (CT) of the lower thorax and abdomen was performed on 11 (18%) patients, but not one scan was diagnostic. Fluoroscopy in two patients was helpful. All patients had other associated injuries. The liver, spleen, or stomach were frequently injured in association with penetrating diaphragmatic lacerations. Bony fractures, splenic injuries, and head trauma were more commonly found with blunt diaphragmatic ruptures. The average hospital stay for the penetrating injuries was 11 days and for blunt trauma was 16 days. The operative mortalities was 2 per cent for penetrating injuries and 12 per cent for blunt injuries.     

Hepatic injuries: management and outcome.

A total of 52 patients with different grades of liver injuries were treated in a 1 year period: 32 patients had penetrating injuries and in 20 patients injuries resulted from blunt trauma. Blunt trauma victims were frequently associated with chest and head injuries and with skeletal fractures. A 4-fold incidence of associated intra-abdominal injuries was encountered in penetrating trauma victims. Blunt and gunshot victims commonly had severe grades of liver injuries (55% and 83.3%, respectively). Stab wounds caused simpler grades of injuries (86.7%). Suture hepatorraphy was the commonest procedure performed (57.7%).The other procedures applied to treat the injured liver were: selective ligation of the injured blood vessels (15.4%); packing (7.7%); and liver resection (3.8%). Two patients died on the operating table before any remedy was applied. The overall morbidity was 40.4%. The liver related complications constituted 17.3%. The total mortality was 13.5% and the liver related mortality was 9.6%.     

Vascular injuries in a rural state: a review of 978 patients from a state trauma registry.

The demographics, etiology, and outcome of 1148 vascular injuries suffered by 978 patients reported from eight trauma centers in a largely rural state to a trauma registry (NCTR) data base containing 26,617 patients entered over a 39-month time interval were analyzed. Vascular injury patients were more frequently transferred by helicopter (18%), referred from other hospitals (45%), transfused more blood (8 units mean/24 hours), had higher mean ISS values (14 vs. 9), had lower systolic blood pressures on admission (113 vs. 128 mm Hg), had higher emergency department mortality (3.3%), and required immediate surgery more often (79%) when compared with nonvascular injury NCTR patients (p = 0.0001). Vascular injury patients had significantly longer hospital stays (13 vs. 10 days), longer ICU stays (5 vs. 4 days), and greater hospital costs ($22,500 vs. $12,300) while incurring more serious AIS values for the regions of the chest, abdomen, and extremities. One hundred twenty-nine (13.1%) died, 97 after admission compared with a 6.2% mortality for NCTR nonvascular injury victims. Forty-seven percent of vascular injuries were extremity lesions; the amputation rate was 1.3%; and management was most often by simple repair (41.9%) or patching (22.2%). Rural vascular injury patients had a high incidence of blunt trauma (43.4%) and were older (average, 51 years); they were transported by helicopter more often (30.3%) and were frequently referred from another hospital (77.8%); they had longer ICU, ventilator, and hospital stays and greater hospital charges; and they had higher mortality (14.2%) compared with urban vascular trauma victims. The data suggest a need for the trauma care system to focus on earlier recognition, stabilization, and rapid transportation of this most seriously injured group of patients.     

Does the use of a flap during abdominoperineal resection decrease pelvic wound morbidity?

We hypothesized that the use of muscle flaps, known as tissue transfer (TT), at the time of abdominoperineal resection (APR) reduces perineal wound complications. A restrospective review of patients undergoing an APR at the University of Washington (1984-2003) was conducted. Perineal wound complications and eventual wound healing were compared in patients with and without TT. Ninety-two patients (mean age, 56.6 years) underwent APR; 23.9 per cent (n = 22) had concurrent TT. Patients undergoing TT were more likely to have cancer (91% vs. 77%, P = 0.05) and radiation therapy (86% vs. 52%, P < 0.01). Operative times were nearly 2 hours longer in patients having TT (7.4 hours +/- 2.5 hours vs. 5.6 hours +/- 1.8 hours, P = 0.03), but lengths of stay were similar (13 +/- 5.9 days vs. 12 +/- 7.6 days, P = 0.5). Patients undergoing TT had a higher rate of all wound-healing complications (59% vs. 40%, P = 0.1) and major wound-healing complications (32% vs. 26%, P = 0.6). However, these differences were not statistically significant. No differences in major complications were identified in patients with and without preoperative radiation therapy (26% vs. 28%, P = 0.8). Fifteen per cent (n = 14) of all patients failed to heal wounds at 6 months, but only 9 per cent (n = 2) of patients undergoing TT failed to heal their wounds at 6 months compared with 17 per cent (n = 12) in the non-TT group (P = 0.3). After controlling for important covariates, patients undergoing TT during an APR did not have a significantly lower rate of wound complications. The impact of TT on wound healing in patients with recurrent cancer and preoperative radiation therapy is suggestive of a benefit but requires prospective investigation.