Donald D. Trunkey

Influence of a statewide trauma system on location of hospitalization and outcome of injured patients

OBJECTIVEnEvaluate the influence of implementing the Oregon statewide trauma system on admission distribution and risk of death.nnnDESIGNnRetrospective pre- and posttrauma system analyses of hospital discharge data regarding injured patients with one or more of the following injuries: head, chest, spleen/liver, pelvic fracture, and femur/tibia fracture.nnnMATERIALS AND METHODSnRisk-adjusted odds ratio of admission to Level I or II (tertiary care) trauma centers, and odds ratio of death were determined using hospital discharge abstract data on 27,633 patients. Patients treated in 1985-1987, before trauma system establishment, were compared to patients treated in 1991-1993 after the trauma system was functioning.nnnMEASUREMENTS AND MAIN RESULTSnAfter trauma system implementation, the odds ratio of admission to Level I or II trauma centers increased (odds ratio 2.36, 95% confidence interval 2.24-2.49). In addition, the odds ratio of death for injured patients declined after trauma system establishment (odds ratio 0.82, confidence interval 0.73-0.92).nnnCONCLUSIONSnThe Oregon trauma system was successfully implemented with more patients with index injuries admitted to hospitals judged most capable of managing trauma patients. The Oregon trauma system also appears beneficial since trauma system establishment is associated with a statewide reduction in risk of death.

Influence of a statewide trauma system on pediatric hospitalization and outcome

BACKGROUNDnDuring the years 1987-1991, a statewide trauma system was implemented in Oregon (Ore) but not in Washington (Wash). Incidence of hospitalization, frequency of death and risk-adjusted odds of death for injured children (< 19 years) in the two adjacent states were compared for two time periods (1985-1987 and 1991-1993).nnnMETHODSnState populations of injured children (International Classification of Diseases, 9th Revision-Clinical Modification, code 800-959) were identified through a Hospital Discharge Index. Hospitals in counties with a population density < 50 persons/square mile were designated rural. Incidence rates are events/10,000 pediatric population per year.nnnRESULTSnThe pediatric population increased in both states (Ore: 687,000-758,000; Wash: 1,159,000-1,336,000). Incidence of hospitalization for all injured children in entire states declined (Ore: 66.5-38.5; Wash: 54-33); also in rural hospitals (Ore: 67.5-32; Wash: 48 to 31). Seriously injured children (score on the Injury Severity Scale > 15) had a lower incidence in 1991-1993 of admission to rural hospitals (Ore: 2.98; Wash: 2.82) compared with incidence for entire states (Ore: 4.61; Wash: 4.62); in 1985-1987 the incidence was not different. Furthermore risk adjusted odds of death for seriously injured children was significantly lower in Oregon than in Washington in the later time period.nnnCONCLUSIONnBoth states show a similar temporal trend toward a declining frequency of death for children hospitalized with injuries. Injury prevention strategies appear to have reduced the number of serious injuries in both states. However, seriously injured children demonstrated a reduced risk of death in Oregon, consistent with benefit from a statewide trauma system.

Rib Fracture Repair: Indications, Technical Issues, and Future Directions

Rib fracture repair has been performed at selected centers around the world for more than 50xa0years; however, the operative indications have not been established and are considered controversial. The outcome of a strictly nonoperative approach may not be optimal. Potential indications for rib fracture repair include flail chest, painful, movable rib fractures refractory to conventional pain management, chest wall deformity/defect, rib fracture nonunion, and during thoracotomy for other traumatic indication. Rib fracture repair is technically challenging secondary to the human rib’s relatively thin cortex and its tendency to fracture obliquely. Nonetheless, several effective repair systems have been developed. Future directions for progress on this important surgical problem include the development of minimally invasive techniques and the conduct of multicenter, randomized trials.

Identification of a functional Ca2+-sensing receptor in normal human gastric mucous epithelial cells

The purpose of the present study was to determine whether human gastric mucous epithelial cells express a functional Ca2+-sensing receptor (CaR). Human gastric mucous epithelial cells were isolated from surgical tissues and cultured on glass coverslips, plastic dishes, or porous membrane filters. Cell growth was assessed by the MTT assay, CaR localization was detected by immunohistochemistry and confocal microscopy, CaR protein expression was assessed by Western immunoblotting, and intracellular Ca2+ concentration ([Ca2+]i) was determined by fura 2 spectrofluorometry. In paraffin sections of whole stomach, we found strong CaR immunohistochemical staining at the basolateral membrane, with weak CaR-staining at the apical membrane in mucous epithelial cells. Confocal microscopy of human gastric mucous epithelial cell cultures showed abundant CaR immunofluorescence at the basolateral membrane and little to no CaR immunoreactivity at the apical membrane. Western immunoblot detection of CaR protein in cell culture lysates showed two significant immunoreactive bands of 140 and 120 kDa. Addition of extracellular Ca2+ to preconfluent cultures of human gastric mucous epithelial cells produced a significant proliferative response. Changes in [Ca2+]i were also observed in response to graded doses of extracellular Ca2+ and Gd3+. The phospholipase C inhibitor U-73122 specifically inhibited Gd3+-induced changes in [Ca2+]i in the gastric mucous epithelial cell cultures. In conclusion, we have identified the localization of a functional CaR in human gastric mucous epithelial cells.The purpose of the present study was to determine whether human gastric mucous epithelial cells express a functional Ca2+-sensing receptor (CaR). Human gastric mucous epithelial cells were isolated from surgical tissues and cultured on glass coverslips, plastic dishes, or porous membrane filters. Cell growth was assessed by the MTT assay, CaR localization was detected by immunohistochemistry and confocal microscopy, CaR protein expression was assessed by Western immunoblotting, and intracellular Ca2+ concentration ([Ca2+]i) was determined by fura 2 spectrofluorometry. In paraffin sections of whole stomach, we found strong CaR immunohistochemical staining at the basolateral membrane, with weak CaR-staining at the apical membrane in mucous epithelial cells. Confocal microscopy of human gastric mucous epithelial cell cultures showed abundant CaR immunofluorescence at the basolateral membrane and little to no CaR immunoreactivity at the apical membrane. Western immunoblot detection of CaR protein in cell culture lysates showed two significant immunoreactive bands of 140 and 120 kDa. Addition of extracellular Ca2+ to preconfluent cultures of human gastric mucous epithelial cells produced a significant proliferative response. Changes in [Ca2+]iwere also observed in response to graded doses of extracellular Ca2+ and Gd3+. The phospholipase C inhibitor U-73122 specifically inhibited Gd3+-induced changes in [Ca2+]iin the gastric mucous epithelial cell cultures. In conclusion, we have identified the localization of a functional CaR in human gastric mucous epithelial cells.

Hepatic trauma: contemporary management

In the introduction, I posed several questions that were issues/controversies. The answers will probably be interpreted as equally controversial. I do not believe there is strong evidence that the incidence of liver injuries has increased. Diagnostic modalities have contributed to this seeming increase, as well as population increases and the concentration of severe liver injuries in trauma centers, now present in 35 states. I believe there are more blunt injuries now, relative to penetrating injuries. The peak of penetrating injuries occurred in the 1970s and 1980s and lasted almost 2 decades. I believe some authors are overly enthusiastic for nonoperative management. I am particularly critical of authors who do not include all components of the surgical armamentarium into their treatment of severe liver injuries. I also believe that the complications following nonoperative management are currently unacceptable, as documented in the references. I have shared with you the strategies for operative management, but there are equally good or better strategies in the surgical literature.

Delayed celiotomy for the treatment of bile leak, compartment syndrome, and other hazards of nonoperative management of blunt liver injury

BACKGROUNDnManagement of blunt liver injury is predominantly nonoperative. However, complications occur in 10% to 25% of patients, with half taking place more than 24 hours after injury. Few reports have addressed the management of the new pattern of these delayed complications, which is the objective of this study.nnnMETHODSnAdult patients admitted to our level one trauma center from 1995 to 2000 with blunt liver injury were identified. Demographic, physiologic and laboratory data, computed tomography (CT) and operative findings, and complications were reviewed.nnnRESULTSnBlunt liver injury was identified in 192 patients. Thirty-nine patients (20%) underwent immediate celiotomy. The remaining 153 patients were initially managed nonoperatively. Liver-related complications developed in 19 (12%) patients. Fifteen patients underwent delayed celiotomy to treat secondary inflammatory processes, from bile leak (6), hemorrhage (5), and hepatic abscess (1), and to treat abdominal compartment syndrome (2), and decompress hepatic compartment syndrome (1). Although no deaths or complications were directly caused by delayed celiotomy, 2 deaths (11%), occurring early in this series, were attributed to liver-related complications.nnnCONCLUSIONSnThese complications, occurring in 12% of patients with liver injuries, may be a consequence of initial nonoperative management. Although these findings do not negate nonoperative management of blunt liver injury, this approach can be hazardous and requires diligence to recognize and treat delayed and potentially fatal complications.

Blunt cardiac injury.

In summary, the incidence of BCI following blunt thoracic trauma patients has been reported between 20% and 76%, and no gold standard exists to diagnose BCI. Diagnostic tests should be limited to identify those patients who are at risk of developing cardiac complications as a result of BCI. Therapeutic interventions should be directed to treat the complications of BCI. Finally, the prognosis and outcome of BCI patients is encouraging

Mechanism of peroxide-induced cellular injury in cultured adult cardiac myocytes.

Reactive oxygen species contribute to the tissue injury seen after reperfusion of ischemic myocardium. We propose that toxicity originates from the effect that mitochondrial peroxide metabolism has on substrate entry into oxidative pathways. To support our contention, cultured adult rat cardiomyocytes were incubated with physiological concentrations of peroxide. The cellular extract and incubation medium were analyzed for adenine nucleotides and purines by reverse‐phase high‐pressure liquid chromatography. Cellular glutathione efflux was determined by enzymatic analysis of the incubation medium. Pyruvate dehydrogenase (PDH) activity was determined in the cultured myocytes as well as in freshly isolated cardiac mitochondria using [1‐C14]pyruvate. Extracellular glutathione rose 3.3‐fold in response to small doses of peroxide (≈ 108 nmol/mg protein). Likewise, small quantities of peroxide reduced total cellular adenine nucleotides to 50–60% of control values with only a modest (0.95–0.91) reduction in energy charge ((ATP+ ½ ADP)/(ATP+ADP+AMP)). Peroxide‐treated myocytes selectively release inosine and adenosine, as only these two purine degradation products were detected in the incubation medium. The most dramatic response was a peroxide dose‐dependent inhibition of PDH activity in cultured myocytes as well as freshly isolated mitochondria; just 65 and 30 nmol peroxide/mg protein induced a 50% reduction in cellular and mitochondrial PDH activity, respectively. In conclusion, physiological quantities of peroxide potently inhibit PDH in cultured cardiomyocytes and isolated cardiac mitochondria. PDH inhibition blocks the aerobic oxidation of glucose and inhibits the oxidative phosphorylation of ADP, which in turn leads to cellular adenine nucleotide degradation.—Vlessis, A. A.; Muller, P.; Bartos, D.; Trunkey, D. Mechanism of peroxide‐induced cellular injury in cultured adult cardiac myocytes. FASEB J. 5: 2600‐2605; 1991.

Surveyed opinion of American trauma surgeons in management of colon injuries

BACKGROUNDnPrimary repair or resection and anastomosis of colon wounds have been advocated in many recent studies, but the proportion of trauma surgeons accepting these recommendations is unknown.nnnOBJECTIVEnTo determine the current preferences of American trauma surgeons for colon injury management.nnnMETHODSnFour hundred forty-nine members of the American Association for the Surgery of Trauma were surveyed regarding their preferred management of eight types of colon wounds among three options: diverting colostomy (DC), primary repair (PR), or resection and anastomosis (RA). The influence of selected patient factors and surgeons characteristics on the choice of management was also surveyed.nnnRESULTSnSeventy-three percent of surgeons completed the survey. Ninety-eight percent chose PR for at least one type of injury. Thirty percent never selected DC. High-velocity gunshot wound was the only injury for which the majority (54%) would perform DC. More than 55% of the surgeons favored RA when the isolated colon injury was a contusion with possible devascularization, laceration greater than 50% of the diameter, or transection. Surgeons who managed five or fewer colon wounds per year chose DC more frequently (p < 0.001) and PR less frequently (p < 0.001) than surgeons who managed six or more colon wounds per year.nnnCONCLUSIONnThe prevailing opinion of trauma surgeons favors primary repair or resection of colon injuries, including anastomosis of unprepared bowel. Surgeons who manage fewer colon wounds prefer colostomy more frequently.

Operative stabilization of a flail chest six years after injury

We report a case of operative stabilization of an incompetent upper chest wall 6 years following flail chest. The indications for stabilization were chronic pain and dyspnea associated with rib malunion and loss of hemithorax volume. At operation, multiple pseudoarthroses were encountered and partial resection of ribs three and four was required. Malleable plates were used to bridge the gaps created by the resection and were secured in place with sternal wire. The patient reported a dramatic relief of symptoms and, at 18 months postoperatively, continues to work full-time on his cattle ranch essentially pain-free.