Eddy H. Carrillo

Evolution in the Management of Hepatic Trauma: A 25-Year Perspective

ObjectiveTo define the changes in demographics of liver injury during the past 25 years and to document the impact of treatment changes on death rates. Summary Background DataNo study has presented a long-term review of a large series of hepatic injuries, documenting the effect of treatment changes on outcome. A 25-year review from a concurrently collected database of liver injuries documented changes in treatment and outcome. MethodsA database of hepatic injuries from 1975 to 1999 was studied for changes in demographics, treatment patterns, and outcome. Factors potentially responsible for outcome differences were examined. ResultsA total of 1,842 liver injuries were treated. Blunt injuries have dramatically increased; the proportion of major injuries is approximately 16% annually. Nonsurgical therapy is now used in more than 80% of blunt injuries. The death rates from both blunt and penetrating trauma have improved significantly through each successive decade of the study. The improved death rates are due to decreased death from hemorrhage. Factors responsible include fewer major venous injuries requiring surgery, improved outcome with vein injuries, better results with packing, and effective arterial hemorrhage control with arteriographic embolization. ConclusionsThe treatment and outcome of liver injuries have changed dramatically in 25 years. Multiple modes of therapy are available for hemorrhage control, which has improved outcome.

Interventional techniques are useful adjuncts in nonoperative management of hepatic injuries.

BACKGROUND Nonoperative management has become the standard of care for hemodynamically stable patients with complex liver trauma. The benefits of such treatment may be obviated, though, by complications such as arteriovenous fistulas, bile leaks, intrahepatic or perihepatic abscesses, and abnormal communications between the vascular system and the biliary tree (hemobilia and bilhemia). METHODS We reviewed the hospital charts of 135 patients with blunt liver trauma who were treated nonoperatively between July 1995 and December 1997. RESULTS Thirty-two patients (24%) developed complications that required additional interventional treatment. Procedures less invasive than celiotomy were often performed, including arteriography and selective embolization in 12 patients (37%), computed tomography-guided drainage of infected collections in 10 patients (31%), endoscopic retrograde cholangiopancreatography with endoscopic sphincterotomy and biliary endostenting in 8 patients (25%), and laparoscopy in 2 patients (7%). Overall, nonoperative interventional procedures were used successfully to treat these complications in 27 patients (85%). CONCLUSION In hemodynamically stable patients with blunt liver trauma, nonoperative management is the current treatment of choice. In patients with severe liver injuries, however, complications are common. Most untoward outcomes can be successfully managed nonoperatively using alternative therapeutic options. Early use of these interventional procedures is advocated in the initial management of the complications of severe blunt liver trauma.

The Role of Thoracoscopy in the Management of Retained Thoracic Collections After Trauma

BACKGROUND Retained hemothorax and infected thoracic collections after trauma can be seen in up to 20% of patients initially treated with tube thoracostomy and have traditionally been treated nonoperatively, often with prolonged hospital stays. METHODS Twenty-five patients with retained thoracic collections were reviewed. They underwent 26 thoracoscopies to evacuate undrained blood with or without infection. RESULTS In 19 patients (76%), the collections were evacuated thoracoscopically. In 4 patients the procedure was converted to an open thoracotomy, and 2 patients required additional procedures to drain these collections. Failure of thoracoscopy correlated with the time between injury and operation and the type of collection, but not with the mechanism of injury. When thoracoscopy was performed in less than 7 days after admission, no cases of empyema were noted at operation. CONCLUSIONS Videothoracoscopy is an accurate, safe, and reliable operative therapy to evacuate retained thoracic collections. In 90% of the patients in whom the procedure was completed, good results were obtained, reducing hospital stay and possible complications. Videothoracoscopy should be the initial treatment in trauma patients with retained thoracic collections and should be used earlier and more frequently in these patients.

Blunt carotid artery injuries: difficulties with the diagnosis prior to neurologic event.

OBJECTIVE To evaluate the incidence, timing of diagnosis, clinical factors for adverse outcome, and role of anticoagulant, surgical therapy, or endovascular intervention for patients with blunt carotid artery injury (BCAI). METHODS Retrospective review of the records of patients who sustained BCAI between 1987 and 1997. RESULTS There were 18 men and 12 women, with an average age of 29 years. The diagnosis of BCAI was initially suspected in 15 patients after a major or new neurologic event, and in 15 patients after changes were shown by computed tomography. BCAI was confirmed by arteriography in 29 patients and by magnetic resonance angiography in 1 patient. Treatment consisted of antiplatelet therapy (n = 9), anticoagulation (n = 8), surgical repair (n = 6), observation (n = 4), and endovascular embolization (n = 3). With some type of treatment, 14 patients with no neurologic deficits remained stable; however, treatment improved the final neurologic outcome in 8 patients (20%). Three patients remained with severe deficits, and five patients died. CONCLUSION The consequences of BCAI may be devastating. In our study, there were no reliable means to suspect this injury before neurologic symptoms or abnormalities show on computed tomographic scan. Although external signs are occasionally helpful, most patients have no pattern of injury to suggest BCAI. For patients whose findings after neurologic examination do not correlate with those on the computed tomographic scan, an immediate angiogram is indicated. Occasionally, a proximal injury can be surgically repaired, but in most patients, anticoagulation therapy appears to be the best treatment to avoid or improve neurologic deficits.

Prehospital hypotension as a valid indicator of trauma team activation.

BACKGROUND Criteria for trauma team activation are continually being evaluated to ensure proper utilization of resources. We examined the impact of prehospital (PH) hypotension (systolic blood pressure < or = 90) on outcome (operative intervention and mortality) and its usefulness as an indicator for trauma team activation. METHODS A database was created by using the trauma registry for all nonburned, injured patients from July of 1993 through October of 1998 at our Level I trauma center. RESULTS Of 6,976 patients (83% blunt injury) in the database, 4,437 had a PH blood pressure recorded. Documented PH hypotension was present in 791 patients. Hypotension persisted in the emergency department (ED) in 299 patients, but 193 of them showed minimal or no signs of life on arrival. Four hundred ninety-two patients had PH hypotension but normal ED systolic blood pressure, and 130 patients developed ED hypotension after normal PH systolic blood pressure. Nearly half of the patients with hypotension were taken from the ED directly to the operating room primarily for hemorrhage control procedures. The early and late mortality rates of patients with PH and ED hypotension were 12% and 32%, respectively. Other PH interventions had minimal effect on mortality in the hypotensive patient. CONCLUSION Prehospital hypotension remains a valid indicator for trauma team activation. Even though most of the non-DOA patients (492 of 598) were stable on arrival to the ED, nearly 50% required operative intervention, and an additional 25% required intensive care unit admission. The trauma team should be activated and involved with these patients early.

The role of computed tomography in selective management of gunshot wounds to the abdomen and flank

OBJECTIVE To determine whether computed tomography (CT) is an accurate diagnostic modality for the triage of hemodynamically stable patients with gunshot wounds of the abdomen and flank. METHODS A chart review of 83 trauma patients for whom abdominal CT was used as initial screening. RESULTS In 53 patients, CT revealed no evidence of peritoneal penetration, and in 15 patients, there was evidence of either peritoneal penetration or liver injury. There were no false results in these patients. Among 15 patients with questionable peritoneal penetration, cavitary endoscopy was performed in 11 and exploratory laparotomy was performed in 3, and 1 patient was initially observed and subsequently underwent exploratory surgery for a missed colonic injury. CONCLUSION In selected centers and in hemodynamically stable patients with abdominal and flank gunshot wounds, abdominal CT can be an effective and safe initial screening modality to document the presence or absence of peritoneal penetration and to manage nonoperatively stable patients with liver injuries. If there is any question of peritoneal penetration, cavitary endoscopy should be part of the protocol of nonoperative management.

COMPLEX THORACIC INJURIES

Complex thoracic injuries are a leading cause of death in trauma patients. Four difficult problems of diagnosis and treatment are discussed, including (1) air leak not associated with pneumothorax, (2) management of major thoracic esophageal injuries, (3) penetrating trauma, and (4) retained hemothorax and empyema.

Effect of a clinical pathway for severe traumatic brain injury on resource utilization.

BACKGROUND The usefulness of clinical pathways for the complex trauma patient is unclear. We analyzed the effect of a clinical pathway for severe traumatic brain injury (TBI) on resource utilization. METHODS A clinical pathway for severe TBI (Glasgow Coma Scale (GCS) score < or = 8 at 24 hours) was developed by a multidisciplinary team and used for all patients with severe TBI. Data were gathered prospectively for 15 months and compared with data from historical controls from the previous year. Patients who survived < 48 hours were excluded. RESULTS The clinical pathway was used for 84 patients with severe TBI and compared with 49 historical controls. No differences in Injury Severity Scores (27 vs. 27) or GCS scores at 24 hours (6.2 vs. 6.5) existed between control or pathway patients. There was an overall increase in the mortality rate of pathway patients (from 12.2 to 21.4%), but this was entirely attributable to withdrawal of care that was initiated by family members in patients with an average age of 71 years, an average GCS score of 4.7, and an average Injury Severity Score of 29. Among survivors, pathway patients had a significant decrease in ventilator days (11.5 +/- 0.9 vs. 14.6 +/- 1.2; p < 0.05), intensive care unit days (16.7 +/- 1.0 vs. 21.2 +/- 1.4; p < 0.05), and hospital days (23.4 +/- 1.2 vs. 31.0 +/- 3.0; p < 0.05). There were no differences in the incidence of complications or functional outcomes. CONCLUSION The use of a clinical pathway for severe TBI resulted in a significant reduction in resource utilization. This study suggests that clinical pathways may be a useful component of patient care after blunt trauma.

Risk-taking behaviors among adolescent trauma patients

BACKGROUND Alcohol is a major contributing factor in adult trauma and may adversely affect decision-making in other safety areas such as use of seatbelts and motorcycle helmets. The magnitude of risk-taking behavior and poor decision-making among adolescent trauma patients is not fully appreciated. Our objective was to determine the prevalence and pattern of risk-taking behavior among adolescents (age < or = 20 years) admitted to an adult Level I trauma center. METHODS The trauma registry was used to identify patients. Data collected included age, mechanism of injury, blood alcohol and urine toxicology results, seatbelt and helmet use, Glasgow Coma Score, Injury Severity Score, and outcome. RESULTS Fifteen percent of all admissions to an adult trauma center were adolescents (648 of 4,291). Twenty-one percent of adolescents (138 of 648) and 30% of adults (1,067 of 3,643) tested positive for blood alcohol on admission. Seatbelts were worn by only 19% of adolescent motor vehicle crash admissions versus 30% of adults. Only 7% of adolescents (6 of 83) with detectable alcohol used restraints, compared with 22% (67 of 310) without documented alcohol ingestion (p < 0.05). Adults were somewhat better at restraint use (16% of alcohol-positive patients and 36% without alcohol). Eight of 23 minors (35%) in motorcycle/bicycle crashes were wearing a helmet, compared with 95 of 168 adults (57%). Overall, 6.7% of adolescents and 8.6% of adults had positive toxicology screens. Adolescents with known alcohol consumption were twice as likely to have a positive toxicology screen for illegal drugs (15 vs. 7%; p < 0.05). Alcohol was also frequently detected among adolescents with mechanisms of injury other than motor vehicle and motorcycle crashes, such as violence (25%) and falls (44%). CONCLUSION Alcohol is frequently involved in all types of trauma, for adolescents as well as adults. This is often compounded by poor decision-making and multiple risk-taking behaviors.

Delayed laparoscopy facilitates the management of biliary peritonitis in patients with complex liver injuries.

BackgroundNonoperative management is now regarded as the best alternative for the treatment of patients with complex blunt liver injuries. However, some patients still require surgical treatment for complications that were formerly managed with laparotomy and a combination of image-guided studies.MethodsWe reviewed the medical records of 15 patients who had complex blunt liver injuries that were managed nonoperatively and in which biliary peritonitis developed.ResultsDelayed laparoscopy was performed 2–9 days after admission in patients with extensive liver injuries. All 15 patients had developed local signs of peritonitis or a systemic inflammatory response. Laparoscopy was indicated to drain a large retained hemoperitoneum (eight patients), bile peritonitis (four patients), or an infected perihepatic collection (three patients). Laparoscopy was successful in all patients, and there was no need for further interventions.ConclusionThe data indicate that as more patients with complex liver injuries are treated nonoperatively and the criteria for nonoperative management continue to expand, more patients will need some type of interventional procedure to treat complications that historically were managed by laparotomy. At this point, laparoscopy is an excellent alternative that should become part of the armamentarium of the trauma surgeons who treat these patients.