Daniel L. Diamond

Prospective Study of Blunt Aortic Injury: Multicenter Trial of the American Association for the Surgery of Trauma

BACKGROUND Blunt aortic injury is a major cause of death from blunt trauma. Evolution of diagnostic techniques and methods of operative repair have altered the management and posed new questions in recent years. METHODS This study was a prospectively conducted multi-center trial involving 50 trauma centers in North America under the direction of the Multi-institutional Trial Committee of the American Association for the Surgery of Trauma. RESULTS There were 274 blunt aortic injury cases studied over 2.5 years, of which 81% were caused by automobile crashes. Chest computed tomography and transesophageal echocardiography were applied in 88 and 30 cases, respectively, and were 75 and 80% diagnostic, respectively. Two hundred seven stable patients underwent planned thoracotomy and repair. Clamp and sew technique was used in 73 (35%) and bypass techniques in 134 (65%). Overall mortality was 31%, with 63% of deaths being attributable to aortic rupture; mortality was not affected by method of repair. Paraplegia occurred postoperatively in 8.7%. Logistic regression analysis demonstrated clamp and sew (p = 0.002) and aortic cross clamp time of > or = 30 minutes (p = 0.01) to be associated with development of postoperative paraplegia. CONCLUSIONS Rupture after hospital admission remains a major problem. Although newer diagnostic techniques are being applied, at this time aortography remains the diagnostic standard. Aortic cross clamp time beyond 30 minutes was associated with paraplegia; bypass techniques, which provide distal aortic perfusion, produced significantly lower paraplegia rates than the clamp and sew approach.

Ultrasound-guided hepatic cryosurgery in the treatment of metastatic colon carcinoma. Preliminary results.

Cryosurgery, the in situ freezing of cancer, has been proposed in the past as a possible treatment for unresectable hepatic tumors. Its advantage lies in the fact that it is a very focal treatment sacrificing less normal tissue than surgical resection, allowing treatment of multiple lobes. Because cryosurgery does not affect large vessels, tumors in difficult locations, such as adjacent to the inferior vena cava (IVC), can be treated. With the use of intraoperative ultrasound to place the cryoprobes and monitor the freezing process, 18 patients with unresectable metastatic colon carcinoma confined to the liver were treated. Of the 18 patients treated, 4 (22%) are in complete remission as determined by computed tomography (CT) scans and carcinoembryonic antigen (CEA) levels, with a mean follow‐up of 28.8 months. Four patients (22%) were not adequately treated at the time of cryosurgery. The number of lesions frozen in each patient ranged from 1 to 12, with a mean of 6 lesions. Fourteen patients had bilobar disease; three patients had previous right lobectomies with recurrences in their remaining left lobes prior to cryosurgery, and one patient had unilobar disease. Mean survival of the 14 cases with recurrence was 21.4 months, with 2 of the 14 still alive. Ultrasound‐guided hepatic cryosurgery appears to be an effective treatment for metastatic colon carcinoma to the liver that is unresectable (including patients with bilobar and multiple lesions). These preliminary results indicate that the procedure warrants further study.

Acute mortality associated with injuries to the pelvic ring: the role of early patient mobilization and external fixation.

PURPOSE To analyze the effect on mortality of a protocol for early mobilization with external fixation of patients with pelvic ring injuries. METHODS From 1981 through 1988, 605 patients with pelvic ring fractures and dislocations were treated. In 1982, a protocol for early external fixation of hemodynamically unstable patients and those with structurally unstable pelvic fracture patterns to achieve early mobilization to an upright chest position was initiated. Mortality rates were compared between 1981 (pre-protocol), 1982 (transitional), and 1983 through 1988, after initiation of a protocol of care that included external fixation of the pelvic injury. No statistical changes occurred from 1983 through 1988. RESULTS Mortality rates in pelvic ring injury patients fell from 26% in 1981, to 6% in 1983 through 1988 (p < 0.001), whereas during the study period the mean injury Severity Score (ISS), 23, did not change. The mortality rate of a group of consecutive patients with comparable ISSs, but without pelvic ring injuries did not change. The mortality rate in patients with systolic blood pressure < 100 mm Hg at admission fell from 41% in 1981 to 21% 1983 through 1988 (p = 0.0001). Mortality in patients with closed head injuries associated with pelvic ring injuries fell from 43% in 1981 to 7% from 1983 through 1988 (p = 0.0001). The proportion of patients undergoing external fixation rose from 3% in 1981 to 31% in 1983 through 1988 (p = 0.0001). CONCLUSIONS An organized protocol including external fixation and early patient mobilization to an upright chest position reduced mortality associated with injuries of the pelvic ring. Orthopedic stabilization of major skeletal injuries should be viewed as part of patient resuscitation, not reconstruction.

The use of transesophageal echocardiography in the evaluation of chest trauma.

Transesophageal echocardiography (TEE) has been used over the last 10 years (1982-1992) to study the heart and thoracic aorta. We set out to evaluate the diagnostic applications of TEE in patients with thoracic trauma. Specifically, TEE was performed on patients suspected of having either a cardiac contusion or an injury of the thoracic aorta. Fifty-eight patients admitted with thoracic trauma underwent TEE. Fifty of those patients suspected of having a cardiac contusion also underwent transthoracic echocardiography (TTE). The two diagnostic modalities were compared. In 21 of these patients a wide mediastinum was apparent on admission chest x-ray films. Nineteen of this latter group underwent thoracic angiography in addition to TEE. Two patients underwent post-mortem examination. Of the 50 patients undergoing both TEE and TTE, a cardiac contusion was detected by TEE in 26 patients. Transthoracic echocardiography detected only six contusions in this group. Of the 21 patients with a wide mediastinum, TEE detected three obvious aortic disruptions. These findings were confirmed in each case by angiography. In 16 cases TEE showed the aorta to be normal. This was confirmed on the angiogram in 14 cases and by autopsy in two cases. Transesophageal echocardiography revealed an aortic intimal irregularity distal to the left subclavian artery in two cases. The results of aortography were normal in these last two cases. As a diagnostic modality, TEE more accurately detected cardiac contusions than TTE (p less than 0.001) and was a very sensitive screening tool in the early evaluation of patients with a wide mediastinum.

Organ donor management and organ outcome : a 6-year review from a level I trauma center

A retrospective review of 114 solid organ donors over a 6-year period (1982-1987) was undertaken to identify problems in organ donor management and determine outcome of donated organs. Admission GCS was less than or equal to 4 in 84% of the donors. Complications included hypotension (81%), multiple transfusion requirements (63%), diabetes insipidus (53%), DIC (28%), arrhythmias (27%), cardiac arrest requiring CPR (25%), pulmonary edema (19%), hypoxia (11%), acidosis (11%), seizures (10%), and positive bacterial cultures (10%). Only 18% of organs were procured within 3 hours of brain death; 23% were procured more than 6 hours later. Six patients excluded from this study suffered cardiovascular collapse before their organs could be retrieved. From 114 organ donors, consent was obtained to procure 224 kidneys, 77 livers, 62 hearts, 35 pancreata, and ten heart-lung units. All 224 donated kidneys were procured and 202 were ultimately transplanted. Of 77 donated livers, 32 were procured; 31 transplanted. Of 62 donated hearts, 38 were procured; 29 transplanted and nine used for valves. Ten heart-lung units were donated; six were procured and transplanted. Of 35 donated pancreata, 11 were procured; only five were transplanted. Reasons for failure of donated organs to be procured or transplanted included abnormal organ characteristics, lack of compatible recipients, unavailability of surgical teams, organ injury during procurement, intraoperative arrest, and anatomic limitations precluding multiple organ procurement. This study identifies characteristics of organ donors and common organ-threatening complications. Rapid and continuing resuscitation of clinically brain dead trauma victims is mandatory.(ABSTRACT TRUNCATED AT 250 WORDS)

The utility of physiological status, injury site, and injury mechanism in identifying patients with major trauma.

It has been suggested that if triage criteria are to identify accurately patients with major trauma, not only physiologic status, but also anatomic site and injury mechanism must be assessed. This study examined the influence of physiologic, injury site, and injury mechanism criteria on the diagnosis of major trauma in 2,057 trauma patients. Because the Trauma Score was found to be a highly specific indicator of major trauma (98.7%), the strategy adopted for isolating the factors that minimize inappropriate triage was to determine which, alone or in combination, are the most effective in identifying patients with major trauma among those with high Trauma Scores (greater than 12). Based on this analysis, a set of triage guidelines was developed. The application of these guidelines to the study population indicated an undertriage rate of 4.1 to 6.3% and an overtriage rate of 16.8 to 21.3%, depending on the definition of major trauma.

Cardiac Tamponade from Central Venous Catheters Report of a Case and Review of the English Literature

A case of acute cardiac tamponade caused by an internal jugular central venous catheter which was successfully treated is reported. The English litera ture is reviewed and shows that tamponade can occur up to 37 days after inser tion and has a 65% mortality. The tamponade is usually caused by the actual infusate and not by blood.

Acute subdural hematoma: morbidity and mortality related to timing of operative intervention.

In spite of major advances in the management of severe head injury (HI) acute subdural hematoma (ASDH) continues to be one of the most lethal of all intracranial injuries. Of 1,150 consecutive severe HI patients, 137 (12%) had ASDH. The following variables were assessed in regards to outcome morbidity/mortality from ASDH: mechanism of injury, age, sex, neurologic presentation, postoperative intracranial pressure (ICP), and timing from injury to operative evacuation of the ASDH. The only variables found to statistically correlate with outcome were presenting neurologic condition (p = 0.001) and elevated postoperative ICP greater than 45 mm Hg (p = 0.001). The timing from injury to operative evacuation of the ASDH in regards to outcome morbidity/mortality was not statistically significant even when examined at hourly intervals (p = 0.418).

Small intestinal adenocarcinoma complicating regional enteritis

Three new cases of small intestinal adenocarcinoma complicating Crohns disease are reported. Seventy‐five other cases have been reported to date. Analysis of these cases in comparison with de novo adenocarcinoma of the small bowel shows that they: (1) occur at a younger age; (2) occur in distal small bowel; (3) show a male predilection; and (4) have a worse prognosis. The increasing number of these cases suggests that small intestinal regional enteritis predisposes to adenocarcinoma. Improved prognosis can only be achieved with earlier diagnosis.

Defining the limits of survivorship after very severe head injury

BACKGROUND Reliable prediction of outcome after head injury is a daunting task. Although previous reports have highlighted the difficulties of determining outcome in the cohort of severe head injury Glasgow Coma Scale (GCS) score < or = 8), we wondered within the very severely injured population (GCS score 3-5) if a simple combination of clinical parameters may be predictive of poor outcome. METHODS All patients admitted to a Level 1 trauma center with a GCS score of 3 to 5 from 1986 to 1991 inclusive (380 patients) were retrospectively reviewed and outcome a minimum of 6 months after injury was determined by chart review or telephone. RESULTS Follow-up was accomplished in all but five patients (1.3%). Functional survival (nonvegetative) was correlated to admission GCS score, pupillary abnormalities, and age. As anticipated, overall functional survival was poor (12.5%), and even worse among those evidencing pupillary abnormalities (6.6%). Interestingly, there was an absence of survivors in the advanced age decades, with the oldest functional survivor of any GCS increasing in a stepwise fashion with increasing coma score. This translated into the oldest survivor of a GCS score of 3 being in their chronologic 30s, a score of 4 in their 40s, and a score of 5 in their 50s. Among patients older than these age decades, that is beyond this simple age/GCS cut-off (32.8% of cohort), there were no functional survivors (95% confidence interval 0, 2.4). CONCLUSIONS Within the population of very severely head injured patients (GCS score 3-5), the simple combination of age and admission GCS score appears to predict accurately non-functional outcome in almost one third of patients. If confirmed at other centers, this may have wide-ranging implications regarding counseling of families, utilization of resources, and the design of head injury studies.