Albert O. Duncan

Geriatric blunt multiple trauma: improved survival with early invasive monitoring.

Geriatric trauma survival rates are reported to approach 85%, but no series to our knowledge has included a predominance of multiply injured patients. In 1985, we treated 60 patients more than 65 years of age who sustained blunt multiple trauma, excluding burns and minor falls. A pedestrian-motor vehicle mechanism, initial BP less than 150 mm Hg, acidosis, multiple fractures, and head injuries all predicted mortality. To investigate this, in 1986, we began invasive monitoring in all patients with any of these risk factors and modified this in 1987 to emergent monitoring, postponing all but the most critical diagnostic studies. All patients included were hemodynamically stable after initial evaluation. Attempts were made to optimize all patients with volume, inotropes, and afterload reduction as needed. There was no difference between 1986 and 1987 in patient age, injury severity, or per cent of patients requiring operation. In 1986, mean time from ED admission to monitoring was 5.5 hours. Eight of 15 patients had an initial cardiac output (CO) less than 3.5 L/M and/or mixed venous saturation (MVO2) less than 50%. All developed progressive pump failure despite therapy and died within 24 hours. The other seven had an initial CO between 3.4-5.5 L/M, but five had an MVO2 less than 50%. All augmented their CO with therapy over 6-12 hours to a mean CO of 6.8 L/M and resolved their MVO2, but six died from MOF. Survival was 7%. In 1987-88, we reduced time to monitoring to 2.2 hours by limiting diagnostic tests. Thirteen of 30 patients treated had an initial CO less than 3.5 L/M.(ABSTRACT TRUNCATED AT 250 WORDS)

Early open reduction and internal fixation of the disrupted pelvic ring.

Early open reduction and internal fixation (ORIF) of extremity fractures in patients with multiple injuries has been demonstrated to be safe, improve survival, and decrease the incidence of respiratory failure. Complications leading to abandonment of planned operative fixation and death in several patients with pelvic fractures led us to initiate a policy of early ORIF of the disrupted pelvic ring. Early ORIF of the pelvis was performed in 15 multiply injured patients between May 1984 and August 1985. Patients ranged in age from 13 to 79 years, their Hospital Trauma Index-ISS scores ranged from 14 to 68, and number of preoperative transfusions ranged from 0 to 42. Types of fractures were A-P compression, two, lateral compression, one, vertical shear, seven, complex, two, and acetabulum with ring disruption, three. All patients were resuscitated, transported in pneumatic antishock garments, and evaluated by abdominal and pelvic CT scan (in two patients following celiotomy). Preoperative angiograms to assess retroperitoneal hemorrhage in eight patients resulted in identification and control of significant bleeding in five. The mean time from injury to pelvic stabilization was 38 hours. Seven patients underwent ORIF within the first 24 hours. In most cases simultaneous anterior and posterior internal fixation was performed with the patient in the lateral decubitus position. Excluding associated procedures, operative time averaged 5.1 hours. Intra-operative transfusions averaged 4 units (range, 0-11). Rigid fixation was achieved in all patients. Most patients were out of bed by the third postoperative day. No patient developed respiratory failure. Two patients developed wound infections. Modification of our technique has avoided this complication in the latter part of this series.(ABSTRACT TRUNCATED AT 250 WORDS)

Vertebral artery injury--diagnosis and management.

The literature on vascular trauma contains little information on the management of vertebral artery injuries. We have reviewed our experience consisting of 23 patients with vertebral artery injuries caused by 19 gunshot wounds, two stab wounds, one shotgun wound, and one blunt injury. Twelve patients sustained unilateral vertebral artery thrombosis, seven patients had vertebral AV fistulae (three jugular vein, four vertebral vein) and four patients sustained mural injury without thrombosis. Six patients (26.1%) developed major neurologic deficits of which five could be directly attributed to CNS missile injury. One patient had transient vertebrobasilar ischemia on the basis of a vertebral AV fistula. Four of the seven vertebral AV fistulae were managed solely by therapeutic embolization and two patients early in the series underwent surgical management alone. One patient had therapeutic embolization of the proximal vertebral artery and operative distal vertebral artery ligation for an AV fistula. The four patients who died (17.4%) did so as a direct result of their CNS missile injury. We conclude that: 1) unilateral vertebral artery occlusion seldom results in a neurologic deficit if there is a normal contralateral vertebral artery and PICA (posterior inferior cerebellar artery) blood supply is preserved; 2) accurate assessment of a vertebral artery injury requires contralateral vertebral arteriogram; 3) management of vertebral artery injury is simplified by proximal, and if possible distal, therapeutic embolization; 4) an anterior approach to the C1-2 vertebral artery is a satisfactory method of obtaining distal surgical control, obviating the need to unroof the bony canal of the vertebral artery; 5) angiography is necessary in penetrating neck trauma to identify occult vascular injuries.

Central venous oxygen saturation: a useful clinical tool in trauma patients.

An accurate method of estimating acute blood loss is essential in the evaluation of injured patients. Central venous oxygen (CVO2) saturation has been shown to be a sensitive and reliable correlate of blood loss in an animal model but its clinical validity is unproven. We evaluated 26 consecutive patients with an injury mechanism suggesting blood loss but who were deemed stable after initial evaluation. Vital signs (pulse, blood pressure, pulse pressure, urine output, CVP) and CVO2 saturation were serially measured. Blood loss was estimated by direct intracavitary collection or serial hematocrits and acute transfusion requirements. Despite stable vital signs, ten patients (39%) had CVO2 saturations under 65%. These patients had more serious injuries, significantly larger estimated blood losses, and required more transfusions than those patients with CVO2 saturation greater than 65%. Linear regression analysis demonstrated the superiority of CVO2 saturation to predict blood loss with a p value less than 0.005 relative to any of the normally followed parameters. CVO2 saturation is a reliable and sensitive method for detecting blood loss. It is a useful tool in the evaluation of acutely injured patients.

Resuscitation of multiple trauma and head injury: Role of crystalloid fluids and inotropes

Objectives: To determine the hemodynamic responses to blunt trauma with a closed‐head injury and to investigate the effect that volume resuscitation has on intracranial pressure. Design: Prospective study with retrospective analysis of patient data and hemodynamic responses. Setting: Surgical intensive care unit at an inner‐city, Level I trauma center. Patients: Consecutive patients (n = 30) who sustained multiple system injury, including a closed‐head injury that was severe enough to require intracranial pressure monitoring but not a craniotomy. Interventions: All patients underwent invasive hemodynamic monitoring with percutaneous arterial and pulmonary arterial catheters. Serum lactate concentrations and hemodynamic and oxygen transport variables were measured every 4 hrs. Intracranial pressures and vital signs were recorded each hour. Attempts were made to achieve a state of nonflow‐dependent oxygen consumption and a normal serum lactate concentration. Measurements and Main Results: Despite being normotensive and neither tachycardiac nor oliguric, 80% of patients had evidence of inadequate tissue perfusion. Only 50% of the remaining patients had an adequate response to volume. The other 50% received vasodilating inotropic agents. Despite volume loading and the administration of inotropic agents, intracranial pressure did not increase. This observation was found in patients who showed clinically important intracranial pathology on computed tomography scan, as well as in all other patients. Intracranial pressure did not correlate with the amount of fluid or blood infused or with hemodynamic performance, but intracranial pressures did correlate with serum lactate concentrations. Conclusions: Many patients with diffuse blunt trauma closed‐head injuries, even when they are normotensive, have evidence of impaired peripheral perfusion. Volume infusion and vasodilating inotropic support improve oxygen transport without increasing intracranial pressure. The observed relationship between intracranial pressure and the serum lactate concentration requires further study. (Crit Care Med 1994; 22:1610–1615)

PACKING AND RE-EXPLORATION FOR PATIENTS WITH NONHEPATIC INJURIES

We retrospectively reviewed the clinical records of 11 patients admitted to the trauma service at Kings County Hospital who underwent packing and temporary closure for severe nonhepatic injuries. The mean ISS was 37 and the mean Abdominal Trauma Index value was 48. Operative findings included 17 major vascular injuries. Although the mean blood pressure was 105 mm Hg during the procedure, the patients required an average of 17 units of blood and all were acidotic, hypothermic, and coagulopathic. Acidosis persisted in all patients and the mean base excess was -13 at closure. A conscious decision was made to terminate the procedure when surgical bleeding was controlled. Patients were resuscitated and warmed in the ICU and returned to the operating room within 48 hours. Seven of the 11 patients survived. Of the eight patients who survived to return to the operating room, all required gastrointestinal procedures at re-exploration. This preliminary experience supports packing to control coagulopathic bleeding, use of temporary abdominal closure, and further ICU resuscitation with a planned second laparotomy for definitive management of gastrointestinal injuries in patients with severe nonhepatic injuries.

Evaluation of Occult Cardiac Injuries Using Subxiphoid Pericardial Window

During 1987, we performed diagnostic subxiphoid pericardial windows on all stable patients with juxta-cardiac penetrating injuries. This excluded any patient with clinically diagnosed tamponade or shock. Fifty-one patients underwent subxiphoid diagnostic pericardiotomy for suspected cardiac injuries. Forty patients were normotensive on presentation and 11 experienced transient hypotension. All patients were easily resuscitated in the Emergency Department. The time from admission to operation ranged from 20 minutes to 6 hours (average, 2.5 hours). Twelve patients (23.5%) had hemopericardium at the time of subxiphoid diagnostic pericardiotomy (SDP), and cardiac injury was confirmed at sternotomy in all. Two patients (16%) in the positive group were admitted with systolic blood pressures less than 100 mm Hg compared to nine (23%) in the negative group. One patient had a systolic to diastolic pressure gradient less than 30. Central venous pressures in this group of patients ranged from 8 to 23 cm H2O. Nine patients who had pericardial window solely on the basis of location of the injury had positive findings. All nine patients were normotensive on admission, had CVPs less than 12, and had no other overt clinical signs of injury. This represents an overall occult injury rate of 17.6%. At sternotomy, there were eight ventricular, two pulmonary artery, one aortic root, and one atrial injury, all repaired. Two patients in this group had associated abdominal injuries as did 11 in the negative group, all of whom required operation, and may have explained the hypotension in negative patients. There were no complications of SDP and all negative patients were discharged on the second hospital day.(ABSTRACT TRUNCATED AT 250 WORDS)

Injuries missed at operation: nemesis of the trauma surgeon.

Injuries missed at initial operation have the potential to cause the most disastrous complications in trauma patients. Over the past 5 years, 12 patients have required re-operation for 14 injuries missed at initial laparotomy and/or thoracotomy. Six missed injuries were vascular, two each in the thorax, pelvis, and retroperitoneum. The other eight were visceral: three small bowel (one patient), two pancreatic, and one each of the heart, ureter, and diaphragm. Five patients (42%) died, three with missed vascular and two with missed visceral injuries. Three died due to complications directly related to their missed injuries, while the unrecognized injury did not play a significant role in the other two. Indications for re-operation in patients with vascular injuries were hypotension in two patients, persistent output from drains in three, and refractory acidosis in one. Re-exploration in visceral injuries was for clinical sepsis in three patients, DIC in one, cardiac tamponade in one, and persistent chest tube drainage in one. Eleven of the 12 patients presented to the E.D. in shock. All patients had multiple injuries with a mean of 3.25 organ systems injured. Hypotension, coagulopathy, and/or hypothermia (T less than 92 degrees) were felt to have contributed to missing the injury in five of the patients with vascular, and three of the patients with visceral injuries. In the four other patients, injuries were missed due to inadequate exploration or a low index of suspicion in the presence of multiple injuries.(ABSTRACT TRUNCATED AT 250 WORDS)

Nonoperative management of blunt abdominal trauma: The role of sequential diagnostic peritoneal lavage, computed tomography, and angiography

STUDY OBJECTIVE To determine the usefulness of sequential nonoperative diagnostic studies in the evaluation and treatment of stable patients after blunt abdominal trauma. DESIGN AND SETTING Retrospective review of a prospective treatment plan in a large urban Level I trauma center. PARTICIPANTS Fifty-two patients deemed stable after initial evaluation following blunt abdominal trauma. INTERVENTIONS Patients with a positive diagnostic peritoneal lavage for red blood cells underwent abdominal computed tomography (CT) scanning. If CT demonstrated a visceral injury, it was followed by diagnostic angiography. Attempts were made to treat on-going bleeding by transcatheter embolization. RESULTS Fifteen patients had negative CT scans and were successfully observed. In the other 37 patients, CT identified 17 liver, 16 splenic, and eight kidney injuries; eight extra-peritoneal bleeds; and one mesenteric hematoma. Six of these patients were observed. Thirty underwent diagnostic angiograms. Twelve had no active bleeding, and all were observed successfully. Seventeen underwent successful embolization of the bleeding site(s). One had injuries not controllable by embolization and required exploration. Six patients required laparotomy later in their course, but none had intra-abdominal bleeding or a missed intestinal injury. Despite being performed after diagnostic peritoneal lavage, CT missed only two injuries. There was one main complication, delayed recognition of a diaphragmatic injury. Three patients died, two from multiple organ failure and one from a pulmonary embolus; none was believed to be related to this technique. With our algorithm, 45 patients (86%) were spared laparotomy. CONCLUSION Diagnostic peritoneal lavage and CT are complementary when evaluating blunt abdominal trauma. Diagnostic peritoneal lavage is an effective screening tool. CT may be reserved for stable patients with a positive diagnostic peritoneal lavage to specify the organs injured. Bleeding often may be treated by embolization, limiting the rate of surgery.

Management of transpelvic gunshot wounds

The records of 98 patients with transpelvic gunshot wounds from 1983 to 1988 were reviewed: 22 patients were admitted in shock and required aggressive resuscitation and immediate exploration, and 76 patients were normotensive and were evaluated with diagnostic peritoneal lavage, angiography, cystography, proctoscopy, CT scan, and contrast-enhanced CT enema in various combinations as indicated. Using this approach, 40 stable patients were observed without operation and discharged without complications. Fifty-eight patients were explored: 20 had both arterial and hollow viscus injuries. Thirty-nine major vascular injuries were evaluated: 27 were ligated and 12 repaired. Other injuries were colon, 27; including seven rectal perforations, multiple small bowel perforations, five bladder, one ovarian, four ureteral, three caval, three renal, and two distal aortic injuries. Colon injuries associated with vascular injuries were treated with colostomy and ligation of the vessel with extra-anatomic bypass when revascularization was required. Overall 12 patients died as a result of their injuries, a mortality of 12.2%. However, 50% of the patients who were admitted in shock died. Two external iliac artery injuries and two ureteral injuries were missed at initial operation. Penetrating trauma to the pelvis presents a serious challenge because of the complex anatomy of the region. Patients in shock have a high incidence of vascular injury and subsequent exsanguination, and associated visceral injuries may complicate their management. However, stable patients may be managed without operation, when appropriate diagnostic techniques fail to demonstrate an injury. Arterial ligation and extra-anatomic bypass should be considered for vascular injury with gross fecal contamination.