Eugene C. Mangiante

Silent deep vein thrombosis in immobilized multiple trauma patients

Although few trauma patients sustain fatal pulmonary embolism, a large population is at risk from nonfatal embolism due to unrecognized deep vein thrombosis (DVT). Thirty-eight of 39 immobilized trauma patients at bed rest for 10 days or longer had venographic study of their lower extremities to evaluate for the presence of silent DVT. Sixty percent of patients had silent DVT, with thrombi extending above the knee in half the patients with clot. DVT was documented in 67 percent of patients with major lower extremity fractures and 59 percent of patients without major fractures. DVT increased with increasing age but not with injury severity score.

Primary repair of colon wounds. A prospective trial in nonselected patients.

102 patients with penetrating intraperitoneal colon injuries were entered into a prospective study. Colon wound management was undertaken without regard to associated injuries or amount of fecal contamination. Primary repair was performed in 83 patients, segmental resection with anastomosis in 12, and resection with end colostomy in 7. There were no suture line failures in the primary repair group, and one suture line failure in the anastomosis group. The one failure was in a patient who underwent repeated explorations for bleeding before the leak occurred. The septic complication rate was 33% of the entire series and was unrelated to primary repair. Logistic regression analysis to identify risk factors for sepsis included transfusion greater than or equal to 4 units (p less than 0.02), more than two associated injuries (p less than 0.04), significant contamination (p less than 0.05), and increasing colon injury severity scores (p less than 0.02). The method of colon wound management, location and mode of injury, presence of hypotension (BP less than 90), and age did not significantly contribute to sepsis. We conclude that nearly all penetrating colon wounds can be repaired primarily or with resection and anastomosis, regardless of risk factors.

Factors affecting morbidity following hepatic trauma. A prospective analysis of 482 injuries.

During a 5-year period, 482 patients with liver injuries were studied prospectively: 65% resulted from penetrating and 35% from blunt injuries. The injuries were graded by the hepatic injury scale (grades I to VI); transfusion requirements and perihepatic abscesses correlated with increasing scores. Minor surgical techniques were needed in 338 patients and 144 patients required major techniques. Omental packing was used in 60% of the major injuries and yielded 7% mortality and 8% abscess rates. Gauze packs were used for management of 10% of major injuries and yielded 29% mortality and 30% abscess rates. The patients were randomized to no drain, closed suction, or sump drainage and respective perihepatic abscess rates were 6.7%, 3.5%, and 13% (p less than 0.03; suction compared to closed suction). Multivariate analysis demonstrated increasing abdominal trauma indices and transfusion requirements as well as sump drainage to be associated independently with perihepatic infection.

Fat embolism syndrome: prospective evaluation in 92 fracture patients

Hypoxemia following long bone or pelvic fracture (LBPF) is often attributed to fat embolism syndrome (FES), but the true incidence and etiology of postfracture pulmonary shunt (Qsp) are not well defined. Over 12 months, 92 patients with LBPF admitted to a Level I trauma center were prospectively evaluated. Arterial blood gases, Hct, platelet count, serum fibrinogen, serum lipase, and urinary fat bodies (UFB) were determined serially from admission through the fifth hospital day. Patients were evaluated daily by chest x-ray, vital signs, mental status, and presence of petechiae. Four patient groups were established: No Qsp, Qsp with pulmonary injury (Qsp + PI), Qsp without pulmonary injury or petechaie (FES - P), and Qsp without pulmonary injury and with petechiae (FES + P). Qsp indicated by an alveolar/arterial PO2 gradient greater than 100 torr developed in 49 (53%) of the patients. Pulmonary injury was present in 39 (81%) of those 49 and was at least partially responsible for the shunt. The remaining ten patients were diagnosed as having FES; four had petechiae (FES + P) and six were without petechiae (FES - P). The minimum incidence of FES in LBPF is therefore 11%.

A prospective study of 91 patients undergoing both computed tomography and peritoneal lavage following blunt abdominal trauma.

Recent reports comparing computed tomography of the abdomen (CTA) and diagnostic peritoneal lavage (DPL) following trauma have been contradictory. A 10-month prospective study was conducted at our trauma center comparing both methods. Criteria for entry into the study included suspected blunt abdominal trauma without indication for immediate laparotomy, with either equivocal abdominal examination, diminished sensorium, or neurologic deficit. Ninety-one patients meeting these criteria underwent CTA followed by DPL. CTA was performed using both oral and intravenous contrast; DPL was performed by the open technique with RBC greater than 100,000 mm3 or WBC greater than 500 mm3 as criteria for a positive examination. CTA was interpreted initially by available radiology staff and residents and retrospectively reviewed by an experienced tomographer blind to DPL and surgical results. Twenty patients in whom either test was positive underwent laparotomy; all others were admitted for observation and/or extra-abdominal surgery. Laparotomy revealed 26 organs injured in the 20 patients explored at admission; none of the observed patients required delayed laparotomy. The results of CTA and DPL were compared to the findings at laparotomy or the clinical course of those not explored. The sensitivity, specificity, and accuracy for initial CTA were 60%, 100%, and 91%; for review CTA 85%, 100%, and 97%; for DPL 90%, 100%, and 98%. We conclude that: even with experienced examiners, CTA offers no diagnostic advantage over DPL in blunt trauma; because of relative costs, we do not recommend the routine application of CTA; CTA is a reliable alternative when circumstances prevent the performance of DPL.

Carotid artery trauma: management based on mechanism of injury.

Fifty-six patients with carotid injuries were reviewed (35 penetrating and 21 blunt). Shock correlated with a profound neurologic deficit on admission (p less than 0.03) in those with penetrating wounds. Thirty-one percent had primary repair, 25% had interposition grafting, 17% were ligated, and 17% were anticoagulated. Two graft failures resulted in death. Three blunt common carotid injuries followed direct cervical soft-tissue trauma; 18 internal carotid (ICA) dissections followed apparent extreme neck extension or flexion. Seven had bilateral ICA dissections (39%); none of these died. All dissections were diagnosed by angiography prompted by a change in the neurologic examination or an initial neurologic deficit unexplained by CT scan. Seventy-one percent had major associated injuries; 43% intra-abdominal solid viscus, 24% pelvis/long bone fractures, and 24% cervical spine/facial fractures. Dissections were treated with anticoagulation; 60% improved, 23% were unchanged, and 17% deteriorated. It is concluded that interposition grafting should be avoided if possible following penetrating wounds; liberal angiography is warranted with incompatible CT findings following blunt trauma; and anticoagulation is safe and effective therapy for blunt carotid dissections.

Myocardial contusion in blunt trauma: clinical characteristics, means of diagnosis, and implications for patient management

The incidence, diagnosis, and impact on surgical management of myocardial contusion (MC) are incompletely defined. During a 12-month period, all patients admitted to a Level I trauma center with blunt trauma were prospectively evaluated for MC (n = 1,110). Those with anterior chest wall contusions, sternal or anterior rib fractures, or pain/tenderness of the anterior chest (n = 140, 13%) underwent immediate and daily ECG, and CPK isoenzymes were measured at admission and every 6 hours in the first 24 hours. Eighty-nine of these patients underwent gated ventricular angiography (GVA) and 66 underwent two-dimensional echocardiography (2D ECHO). MC was considered present if either: 1) CPK-MB was greater than or equal to 5% of total CPK, or 2) an abnormal admission ECG reverted to normal before patient discharge. Fifty-six patients (5% of admissions, 40% of those with apparent chest trauma) were positive by one or both criteria. Thirty patients (54%) were positive by CPK alone, 23 (41%) by both CPK and ECG, and three (5%) by ECG alone. Of the 53 with elevated CPK-MB, 14 (26%) were normal on admission with the remainder becoming elevated in the first 24 hours. 2D ECHO was abnormal in only three of 21 positive patients (14%), and GVA was abnormal in only three of 40 positive patients (7%). Surgical procedures requiring general anesthesia were performed in 37 (66%) of the positive patients. No significant arrhythmias developed under general anesthesia.

Superiority of closed suction drainage for pancreatic trauma. A randomized, prospective study.

During a 42-month period, 65 patients sustaining pancreatic injuries were treated. They were randomized on alternate days (two separate trauma teams) to receive sump (S) or closed suction (CS) drainage. Twenty-eight patients were randomized to S and 37 to CS; there were six early deaths, which precluded drainage analysis, leaving 24 evaluable S patients and 35 CS patients. Penetrating wounds occurred in 71% and blunt in 29%. No significant differences appeared between the groups with respect to age, Penetrating Abdominal Trauma Index (PATI), Injury Severity Score (ISS), or grade of pancreatic injury. Twelve patients in each group required resection and drainage for grade III injuries, with the remaining patients receiving external drainage alone. Five of twenty-four S patients versus one of thirty-five CS patients developed intra-abdominal abscesses (p less than 0.04). We conclude that septic complications after pancreatic injury are significantly reduced by CS drainage. Bacterial contamination via sump catheters is a major source for intra-abdominal infections after pancreatic trauma.

Colon trauma: Further support for primary repair

During a 5 year period, 137 patients who sustained intraperitoneal colon injuries were retrospectively analyzed. One hundred fourteen were considered for evaluation. The method of colon wound management and infectious complications thought to be secondary to the colon wound were reviewed. These patients were admitted to the trauma service and underwent exploratory laparotomy for their injuries. The penetrating abdominal trauma index, as well as other risk factors, were evaluated for their efficacy in predicting potential complications associated with the colon wound. Sixty-four percent of patients were managed by primary closure, 27 percent by end colostomy or end ileostomy, and 9 percent by exteriorization of the injury. The complication rates for these categories were 18, 42, and 40 percent, respectively. There were no significant differences in complications in terms of location and mode of injury. This review confirms that the presence of shock, transfusion (4 or more units), significant contamination, and associated injuries (evaluated by the penetrating abdominal trauma index) contribute to the development of complications. There were no disruptions of the suture line in the primary closure group. We believe that infections and septic complications are secondary to the original injury to the colon and not related to the method of repair. Primary repair of all colon wounds not requiring resection may be feasible. Prospective evaluation of that approach is indicated.

Epidural analgesia in thoracic trauma: effects of lumbar morphine and thoracic bupivacaine on pulmonary function

Changes in pulmonary function tests were compared in 14 thoracic trauma patients, of whom seven received thoracic epidural bupivacaine for analgesia and seven received lumbar epidural morphine. In both groups epidural analgesia decreased subjective pain levels when compared to parenteral narcotics which the patients received before epidural catheter placement. Patients in the bupivacaine group had statistically significant improvements in vital capacity and forced expiratory volume, and a decreased respiratory rate. Patients in the morphine group had no significant change in pulmonary function. The use of thoracic epidural bupivacaine for analgesia in post-traumatic chest injuries produced superior improvement in pulmonary function when compared to lumbar epidural morphine. (Crit Care Med 1990; 18:229)