Dale Oller

Thoracic Aorta Injuries: Management and Outcome of 144 Patients

Rupture of the thoracic aorta from blunt injury is often lethal. Methods of operative repair vary, based on the surgeons preference and circumstances. The primary hypothesis of this study was that operative management choices would correlate with outcome. Data on demographics, injury mechanism, initial evaluation, diagnostic procedures, operative treatment, and outcome were obtained from chart review at the states eight trauma centers. Rates of paraplegia and survival were compared for different methods of operative repair. Of 63,507 hospitalized trauma patients, 144 patients sustained thoracic aortic injury (incidence = 0.23%). Sixty-four died (44.1%), most of whom died in the emergency department (26) or the operating room (12). Eighty-six patients had complete operative data for analysis, including cross-clamp time and methods of repair. No patient in the group with a cross-clamp time of less than 35 minutes developed paraplegia (p = 0.02). For the patients with longer cross-clamp times, 6 of 14 patients (42.9%) undergoing clamp and sew repair developed paraplegia, as compared to 2 of 37 patients (5.4%) repaired on bypass (p = 0.005). This study suggests that the rate of paraplegia after repair of thoracic aortic injury can be minimized with short cross-clamp times or the use of bypass when long cross-clamp times can be anticipated.

Carotid artery trauma: A review of contemporary trauma center experiences☆☆☆★

PURPOSE Many issues surrounding the management and outcome of carotid artery injuries remain controversial. The purpose of this study was to review a large contemporary experience with such injuries in the setting of designated trauma centers. METHODS A statewide computerized trauma registry was used to identify all patients with injuries to the common or internal carotid arteries from October 1987 to June 1993. The records of 82 such patients were retrieved and analyzed. RESULTS Overall mortality and stroke rates were 17% and 28%, respectively. Patients presenting with coma or shock had a particularly bad prognosis (50% and 41% mortality, respectively). Internal carotid injuries resulted in mortality and stroke rates of 21% and 41%, respectively, compared with 11% each for common carotid injuries. Patients with blunt injuries had a much higher stroke rate (56% vs 15%) but had lower mortality (7% vs 22%) than did patients with penetrating injuries. Airway compromise and associated injuries did not affect prognosis. Operative repair and percutaneous balloon occlusion had the best survival and functional outcomes. CONCLUSIONS Operative repair offers the best chances for recovery in all categories of patients regardless of injury mechanism. Ligation is useful only as a last-resort lifesaving effort. Shock and neurologic impairment are poor prognostic factors but should not negate repair.

A statewide, population-based time-series analysis of the outcome of ruptured abdominal aortic aneurysm.

OBJECTIVES The purpose of this study was to perform the first statewide, population-based, time-series analysis of the frequency of ruptured abdominal aortic aneurysm (RAAA), to determine the outcomes of RAAA, and to assess the association of patient, physician, and hospital factors with survival after RAAA. The hypotheses of the study were as follows: 1) the rate of RAAA would increase over time and 2) patient, surgeon, and hospital factors would be associated with survival. BACKGROUND Ruptured abdominal aortic aneurysm is a life-threatening emergency that presents the surgeon with a technically demanding challenge that must be met and surmounted in a short time if the patient is to survive. METHODS Data were obtained from the following four separate data sources: 1) the North Carolina Hospital Discharge database, 2) the North Carolina American Hospital Association database, 3) the North Carolina State Medical Examiners database, and 4) the Area Resource File. All patients with the diagnosis of an abdominal aortic aneurysm (AAA) were selected for initial assessment. Patients were grouped into those with and those without rupture of the abdominal aneurysm. RESULTS During the 6 years of the study, 14,138 patients were admitted with a diagnosis of AAA. Of these, 1480 (10%) had an RAAA. The yearly number of patients with elective AAAs increased 33% from 1889 in 1988 to 2518 in 1993. The yearly number of RAAAs increased 27% from 203 to 258. The mortality rate for AAA was 5%, as compared with 54% in RAAA patients. The patients age was found to be the most powerful predictor of survival. Univariate logistic regression analyses demonstrated an association of the surgeons experience with RAAA and patient survival after RAAA. Analysis of the survival rates of board-certified and nonboard-certified surgeons demonstrated that patients with RAAAs who were treated by board-certified surgeons had significantly better survival. When the survival was compared in small (less than 100 beds) and large (more than 100 beds) hospitals, survival was significantly better in the larger hospitals. CONCLUSIONS Ruptured abdominal aortic aneurysm remains a highly lethal lesion, even in the best of hands. Despite the many improvements in the care of seriously ill patients, there was no significant improvement in the survival of RAAA during this study. This suggests that early diagnosis is the best hope of survival in these patients. The study demonstrated that survival after RAAA was related most strongly to patient age at the time of the RAAA. The physicians and the hospitals experience with RAAA, the physicians background as measured by board certification, and the type of hospital at which the operation was performed (small vs. large) also may be associated with survival. These findings may have important implications for the regionalization of care and the education and credentialling of physicians. Given the lack of recent progress of improving the outcome of RAAA, aggressive efforts to treat patients before rupture are appropriate.

The spectrum of abdominal injuries associated with the use of seat belts

Several recent reports have described abdominal injuries occurring as a result of seat belt use, raising concerns about seat belts as an agent of injury in motor vehicle crashes. The purpose of this study was to characterize the distribution of abdominal injuries after motor vehicle crashes in belted and unbelted patients admitted to trauma centers. The mortality was higher in unbelted than belted patients (7% vs. 3.2%, respectively, p less than 0.0001). Unbelted patients also had significantly more frequent and more severe head injuries (50.0% vs. 32.9%, respectively, p less than 0.001). The incidence of abdominal injury was equal in both unbelted patients (13.9%), but the spectrum of organs injured was different in the two groups. Gastrointestinal tract injuries (stomach, small bowel, colon and rectum) were significantly more frequent in belted vs. unbelted patients (3.4% vs. 1.8%, respectively, p = 0.001). The frequency of liver and spleen injuries was the same in both groups. This study demonstrates that in patients admitted to trauma centers after motor vehicle crashes, belted and unbelted patients have an equal incidence of abdominal injury, but belted and unbelted patients have a different spectrum of injuries. Hollow viscus injuries are more common in belted crash victims. Seat belt use was associated with significantly fewer head injuries and deaths. Physicians evaluating trauma victims after motor vehicle crashes should be aware of the fact that the types of abdominal injuries may vary substantially depending on seat belt use.

Management outcomes in splenic injury: a statewide trauma center review

OBJECTIVE Clinical pathways now highlight both observation and operation as acceptable initial therapeutic options for the management of patients with splenic injury. The purpose of this study was to evaluate treatment trends for splenic injury in all North Carolina trauma centers over a 6-year period. METHODS Splenic injuries in adults over a 6-year period (January 1988-December 1993) were identified in the North Carolina Trauma Registry using ICD-9-CM codes. Patients were divided into four groups by method of management: 1) no spleen operation, 2) splenectomy, 3) definitive splenorrhaphy, and 4) splenorrhaphy failure followed by splenectomy. The authors examined age, mechanism of injury, admitting blood pressure, and severity of injury by trauma score and injury severity score. SUMMARY BACKGROUND DATA Comparisons were made between adult (17-64 years of age) and geriatric (older than 65 years of age) patients and between patients with blunt and penetrating injury. Resource utilization (length of stay, hospital charges) and outcome (mortality) were compared. RESULTS One thousand two hundred fifty-five patients were identified with splenic injury. Rate of splenic preservation increased over time and was achieved in more than 50% of patients through nonoperative management (40%) and splenorrhaphy (12%). Splenorrhaphy was not used commonly in either blunt or penetrating injury. Overall mortality was 13%. Geriatric patients had a higher mortality and resource utilization regardless of their mechanism of injury or method of management. CONCLUSIONS Nonoperative management represents the prevailing method of splenic preservation in both the adult and geriatric population in North Carolina trauma center hospitals. Satisfactory outcomes and economic advantages accompany nonoperative management in this adult population.

Quality of life and functional level in elderly patients surviving surgical intensive care.

BACKGROUND The elderly consume up to one third of health care resources and have become a target for cost reduction efforts. This study was performed to evaluate elderly survivors of surgical critical illness using perceived quality of life and activities of daily living as indicators of value of care. STUDY DESIGN Six hundred seventy-two patients age 70 years and older admitted to a surgical intensive care unit between October 1, 1992 and March 31, 1995 were studied. Intensive care unit and hospital length of stay, admission type and service, and severity of illness were integrated with preadmission and current activities of daily living in survivors. Perceived quality of life was assessed where obtainable from patient or direct proxy. RESULTS Activities of daily living were obtained on 342 (50.9%) and perceived quality of life evaluations on 240 (35.7%) of the initial study population. Median duration from admission to evaluation was 21 months. Activities of daily living scores decreased significantly overall from 4.75+/-0.72 (mean; +/- standard deviation) to 4.22+/-1.41, the proportion of completely independent patients fell from 84.9% to 72.0%, and the number of completely dependent patients rose from 0% to 3.8%. Perceived quality of life scores were not significantly different than scores in healthy patients living in the community. Using regression models, age, service, APACHE II score, and emergent operation or admission did not demonstrate relationships to changes in activities of daily living scores. CONCLUSIONS Although overall functional levels fell, rates of full dependency rose only slightly and perceived quality of life was high in a group of elderly patients surviving surgical intensive care. High hospital and postdischarge mortality should not motivate restriction of care for elderly patients requiring surgical intensive care given their high postillness subjective quality of life measures.

Comparison of the ability of adult and pediatric trauma scores to predict pediatric outcome following major trauma

The Pediatric Trauma Score (PTS) has been identified as the only accurate and adequate means of predicting outcome in pediatric trauma. In answer to the increasing number of trauma patients arriving at local hospitals, the ability of the adult Trauma Score (TS) to predict pediatric trauma outcome was tested. Of the total 2,604 pediatric trauma cases in the North Carolina State Trauma Registry, 441 had both a PTS and TS available for analysis. The primary measures of outcome were emergency department and hospital dispositions. Logistic regression demonstrated that TS (R2 = 0.50) was a stronger predictor of pediatric outcome and PTS (R2 = 0.35) for emergency department disposition and TS (R2 = 0.63) with PTS (R2 = 0.51) for hospital disposition. The correlation between TS and PTS was high (R = 0.8). Stepwise discriminant analysis demonstrated that TS was the stronger predictor of outcome and the PTS added only 9% (partial R2 = 0.09) more accuracy to TS for emergency department disposition and only 6% (partial R2 = 0.06) for hospital disposition. The results of this research demonstrate that TS is a useful method of predicting outcome in pediatric trauma. The use of both scores for each patient does not increase the predictive value of the scores.

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 (

Head CT scanning versus urgent exploration in the hypotensive blunt trauma patient.

22,500 vs.

Traumatic intrapericardial diaphragmatic hernia diagnosed by echocardiography

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.