Bernard R. Boulanger

Traumatic rupture of the thoracic aorta: Should one always operate immediately?

Although the traditional therapy for blunt traumatic rupture of the thoracic aorta (TRA) is immediate operative repair, there may be a selective role for delayed repair, particularly in patients with head trauma, respiratory failure, or cardiac dysfunction. The present study examines the hypothesis that TRA can be managed by selective delayed operative repair. Clinical data were collected from 59 consecutive patients with TRA at a regional trauma unit. All TRAs were at the aortic isthmus. Patients were retrospectively classified into three groups: group I (n=12) included patients who either arrived in extremis or rapidly became unstable during triage; group II (n=3) included patients who had no contraindications to early repair and underwent repair at the time of diagnosis; and group III (n=44) consisted of patients who because of concomitant injuries or sepsis required initial admission and management in the intensive care unit until their clinical status had improved sufficiently to allow for deliberate delayed operative repair of the TRA. The delay ranged from 1 day to 7 months. Eight patients have yet to undergo repair and remain well at follow-up from 1 to 4 years. Overall survival rates in groups I, II, and III were 17%, 100%, and 82%, respectively. The surgery-related mortality rate in group III was 10% (three patients). Only two (4.5%) patients in group III died as a result of a ruptured aorta within 72 hours of admission. In conclusion, contrary to surgical doctrine, TRA may not require immediate operative repair in all cases, but may instead be managed selectively depending on the patients clinical status.

Injuries missed during initial assessment of blunt trauma patients

OBJECTIVEnTo determine the incidence and clinical significance of undiagnosed injuries in blunt trauma patients at our institution.nnnDESIGNnRetrospective analysis of blunt trauma admissions over a 1-year period. Missed injury (MI) was defined as any injury recorded after the initial 24 hours.nnnRESULTSnOf 432 patients studied, 59 (13.6%) had MI. Fractures were the most common MI. Thirty-five percent of MI were detected during repeated physical examination and 28% after patients were conscious and able to voice concerns.nnnCONCLUSIONnOver 10% of all blunt trauma patients had undiagnosed injuries. Forty percent of the MI had clinical implications. The most effective method of diagnosis consists of repeated clinical assessments. Special attention should be focused on patients with severe anatomical injuries, obtunded or intubated.

Lower airway injuries and anaesthesia

PurposeThe perioperative management of lower airway injuries is a difficult clinical problem. Since few reviews present the management of this injury from an anaesthetic perspective, we undertook a literature review of this topic.SourcesA computerized search of the National Library of Medicine database using tracheal or bronchial injury as key words produced 140 English language citations. An eight-year chart review outlining our experience in an urban Canadian setting is also presented.FindingsThe most frequent findings in patients with injury to the lower airway are dyspnoea and surgical emphysema. Other findings include cough, haemoptysis, sucking neck or chest wounds, mediastinal emphysema or pneumothorax. Endoscopy with a fiberoptic scope is the technique of choice for diagnosis, airway management and as a preparatory step in planning of the surgical repair. An airway technique employing direct vision is preferable to blind attempts during tracheal intubation. The use of a double lumen endobronchial lube or selective endobronchial intubation may be needed to achieve adequate pulmonary ventilation. A number of prospective randomized clinical trials comparing conventional mechanical ventilation with high frequency jet ventilation in patients with acute lung injury have demonstrated no difference in effectiveness of ventilation or oxygenation.ConclusionsPatients with lower airway injuries usually present when they are least expected and are a challenge to manage. The clinical presentation of a lower airway injury may be overt or subtle. Resuscitation and anaesthetic management are directed towards control of the airway, maintenance of adequate pulmonary ventilation and management of blood loss.RésuméObjectifLa gestion périopératoire des traumatismes des voies aériennes inférieures est complexe. Comme sa gestion anesthésique n’a jamais été explorée à fonds, les auteurs ont effectué un tour d’horizon de la littérature portant sur ce type de blessure.SourceUne recherche informatisée des données de la National Library of Medicine utilisant les mot clés traumatisme (injury) trachéal et bronchique a révélé 140 références en langue anglaise. La révision des dossiers de huit années d’expérience dans un milieu urbain canadien est aussi présentée.RésultatsLa dyspnée et l’emphysème chirurgical sont les signes les plus fréquents des blessures aux voies aériennes inférieures. L’endoscopie fibroptique constitue la technique de choix pour le diagnostic, la gestion des voies aériennes et l’approche préparatoire à la chirurgie. Une technique de vision directe est préférable aux tentatives d’intubation à l’aveugle de la trachée. L’utilisation du tube endobronchique à double lumière ou l’intubation endobronchique sélective peuvent s’avérer nécessaires pour ventiler adéquatement. Plusieurs études cliniques randomisées et prospectives visant à comparer la ventilation mécanique conventionnelle avec la ventilation à jet à haute fréquence n’ont pas démontré de différences en ce qui concerne l’efficacité de la ventilation et de l’oxygénation.ConclusionsLes lésions traumatiques des voies respiratoires inférieures sont ordinairement inattendues et représentent un défi de taille. La lésion traumatique des voies respiratoires inférieures peut se manifester cliniquement ou demeurer discrète. La réanimation et la gestion anesthésique visent à contrôler les voies aériennes, à maintenir une ventilation adéquate et à traiter l’hémorragie.

Blunt diaphragmatic and thoracic aortic rupture: An emerging injury complex

Although both blunt diaphragmatic rupture (BDR) and thoracic aortic rupture (TAR) have been extensively discussed, the association of both injuries has been infrequently mentioned. The purpose of this study was to examine the current prevalence and clinical characteristics of combined BDR and TAR at an adult regional trauma unit. Among 3,886 trauma victims, 69 (1.8%) had a BDR and 44 (1.1%), a TAR. Seven patients (10% of all patients with a BDR) had both injuries. All 7 were victims of motor vehicle crashes and had a mean Injury Severity Score of 35. All TARs were just distal to the origin of the left subclavian artery. Five patients underwent repair of both injuries and survived, 1 patient had only the BDR repaired and survived, and 1 died during emergency thoracotomy, for a survival rate of 86%. Five patients had laparotomy and repair of the BDR in the presence of an unrepaired TAR. The TARs were repaired by the clamp-and-sew technique, three of them with primary repair and two with interposition tube grafts. Concomitant BDR and TAR appears to be an emerging injury complex with both diagnostic and therapeutic challenges. The presence of BDR demands a rigorous search for associated TAR.

A comparison between a Canadian regional trauma unit and an American level I trauma center

Although there has been recent comparison of the Canadian and American health care systems, the issue of trauma has received little attention. Data were collected on all adult motor vehicle crash (MVC) victims admitted to the Sunnybrook Trauma Unit (CAN), Toronto, Canada, and the R Adams Cowley Shock Trauma Center (USA), Baltimore, Maryland from July 1986 through July 1990. Similar MVC victims at CAN and USA had equivalent mortality rates with similar discharge dispositions (p = NS), but patients at USA were twice as likely to be admitted to the ICU and had longer ICU stays (p < 0.01). The hospital-based cost for an average MVC patient at CAN was significantly less than for an average patient at USA and professional charges were at least five times greater at USA. This study provides some insight into the differences in trauma care between Canada and the United States.

Blunt left hepatic duct injury

A 36-year-old male was involved in a high-speed motorcycle crash. Upon arrival at the Sunnybrook Health Science Centre, he was awake and alert, but restless, pale and diaphoretic with a systolic blood pressure of 80 mmHg, a heart rate of 130, and a respiratory rate of 40. A left anterolateral flail chest was evident, and a chest tube drained a left pneumothorax. Peritoneal lavage was positive for blood and the patient was urgently prepared for a laparotomy. Other injuries included an open midshaft fracture of the right femur with an ipsilateral undisplaced trochanteric fracture, and a closed left humeral fracture. At laparotomy, the large haemoperitoneum was partially due to a deep splenic laceration, requiring a splenectomy. In addition, there was avulsion of the gastroduodenal artery from the hepatic artery, and haemostasis was achieved with gastroduodenal artery ligation. Bile staining was noted in the porta hepatis, and exploration revealed a left hepatic duct injury with duct wall tissue loss and retraction of 30 per cent of the circumference (See Figure I). A #lO French latex T-tube (C.R. Bard Inc.) was placed in

The Ductus Diverticulum: False-Positive Angiographic Diagnosis of Traumatic Aortic Disruption

limitations when applied to the critically ill tranma patient: the length of time required for its performance and interpretation; the need for transportation to the radiology suite; and the use of radiocontrast dyes, which in the multiply injured patient have the potential for nephrotoxicity. CT scanning, especially the newer modifications such as helical scanning, show promise as a screening test before angiography, but its role as a primary diagnostic modality has not been established, s 10 TEE can be perfolrned in any acute care area of the hospital, and a