Farouck N. Obeid

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.

Urban trauma: a chronic recurrent disease

Urban trauma, often presumed to be an acute episodic event, may actually be a chronic recurrent disease related to the lifestyle, environment, and other factors of its victims. To test this idea an attempt was made to obtain 5-year followup for 501 consecutive survivors of violent trauma seen at one hospital, 1980-1981. Followup information for these patients was obtained from medical records at four local Level I trauma centers, death certificates, Medical Examiners records, and police crime computer files. Of the 501 patients, 263 had medical followup including 148 patients with one trauma and 115 patients with recurrent trauma. Of these 263 patients, 200 (76%) were unemployed and 164 (62%) abused alcohol or drugs. From 1982-1987 142 out of 263 patients were involved in 133 crimes and 52 died. These data suggest that urban trauma is a chronic disease with a recurrent rate of 44% and a 5-year mortality rate of 20%.

Factors influencing survival of elderly trauma patients.

Information on factors that influence survival of older it patients after traumatic injury is limited. To determine differences between survivors and nonsurvivors, 39 patients over age 60 were studied. Pre-existing disease, type of trauma, and shock did not influence survival. The trauma score, injury severity score, and acute physiology score did not predict survival. Survivors had higher hemoglobin, lower systemic vascular resistance, and higher oxygen delivery than nonsurvivors. Septic complications increased the risk of multisystem organ failure and death.

Trauma pneumonectomy revisited : The role of simultaneously stapled pneumonectomy

OBJECTIVE The aim of this study was to compare simultaneously stapled pneumonectomy (SSP) with individual ligation (IND) as a method for performing urgent pneumonectomy (Py) for trauma. METHODS Twelve patients who required Py were reviewed. SSP was performed in nine cases and IND in three cases. The two groups had statistically similar injury severity scores, presenting systolic blood pressures, and Trauma and Injury Severity Score derived probabilities of survival. An animal model of Py was developed, in which seven animals underwent SSP and seven underwent IND methods. Burst pressures of the pulmonary artery and bronchus were calculated after 14 days. RESULTS There were no differences noted in survival rates between SSP (5 (56%)) and IND (1 (33%)), nor in incidence of bronchopleural fistula. The SSP group had a significantly shorter operative time compared with that of IND (88.9 +/- 14.3 minutes vs 213 +/- 57.8 minutes, respectively, p - 0.01). The animal study revealed no difference in burst pressures of the bronchus (SSP = 662.9 +/- 169.9 mm Hg vs. IND = 591.4 +/- 193.2 mm Hg, p = 0.752) or of the pulmonary artery (SSP = 554.3 +/- 195.1 mm Hg vs. IND = 477.7 +/- 247.5 mm Hg, p = 0.529). CONCLUSION Survival after pulmonary injuries that require Py depends upon the rapidity of hilar control and of the procedures itself. Simultaneously stapled pneumonectomy is an effective and rapid method of dealing with such rare injuries.

Coagulopathy and Intraoperative Blood Salvage (ibs)

The use of potentially contaminated shed blood and the contribution of autotransfused blood to coagulopathy are controversial issues associated with intraoperative blood salvage (IBS) in trauma patients. Intraoperative blood salvage was used in 154 trauma patients and resulted in reinfusion of 7.97 units per patient. Moderate to severe abnormalities of the prothrombin time (PT) and partial thromboplastin time (PTT) occurred in 39 patients (31%). Prolongation of the PT and PTT occurred with increasing transfusion. Coagulopathy was seen in patients receiving greater than 15 IBS units and in patients receiving greater than 50 combined units of blood. Of the 66 patients with bowel injury, 58 patients received shed blood. Patients with bowel injury showed no increase in infection but did develop prolongation of PT and PTT at lower levels of IBS transfusion. Based on the results of this study, patients receiving greater than 15 units of IBS transfusion require careful monitoring and factor replacement, and IBS transfusion should be limited to less than 10 units in patients with bowel injury.

Anterior mediastinal abscess after closed sternal fracture.

BACKGROUND Although sternal fractures after blunt chest trauma are markers for significant impact, the fracture itself is generally not associated with any specific wound complications. Mediastinal abscess and sternal osteomyelitis rarely occur after blunt trauma or cardiopulmonary resuscitation. Management of such complications is difficult, and requires a spectrum of operative procedures that range from simple closure to muscle flap reconstruction. METHODS The trauma registry of a Level I trauma center was used to identify patients suffering a sternal fracture between January of 1994 and August of 1997. Records were reviewed for the mechanism of injury, length of hospital stay, and posttraumatic mediastinal abscess. RESULTS Twenty-six patients were identified with sternal fracture. No clinically significant cardiac or aortic complications were noted. Three patients, all with a history of intravenous drug abuse and requiring central venous access in the emergency room, developed methicillin resistant Staphylococcus aureus mediastinitis. Sternal re-wiring and placement of an irrigation system successfully treated all three patients. CONCLUSION Posttraumatic mediastinal abscess is an uncommon complication of blunt trauma in general and sternal fracture in particular. It can be recognized by the development of sternal instability. Risk factors include the presence of hematoma, intravenous drug abuse, and source of staphylococcal infection. Treatment with early debridement and irrigation can avoid the need for muscle flap closure.

Antibiotics for penetrating abdominal trauma: A prospective comparative trial of single agent cephalosporin therapy versus combination therapy

In this prospective, comparative study, 129 patients who sustained penetrating abdominal trauma were randomized to receive preoperatively, and for 3-5 days postoperatively, one of three antibiotic regimens: Group I--cefotaxime (CTX) (2 Gm Q8H), Group II--cefoxitin (2 Gm Q6H), or Group III--clindamycin (900 mg Q8H) and gentamicin (3-5 mg/kg/day in divided doses Q8H). The three groups were similar in terms of the following: age, sex, severity of injury, number of organs injured, colon injuries, shock, blood transfusions, or positive intraoperative cultures. Septic complications occurred as follows: Group I--6.9%, Group II--2.3%, and Group III--6.9%. The three regimens ranked as follows in terms of therapy costs: CTX less than cefoxitin less than clindamycin and gentamicin. It is concluded that single agent therapy with a cephalosporin is preferable to combination therapy on the basis of equivalent effectiveness, lower toxicity, and lower costs.

Perforation of the Small Bowel after Insertion of Feeding Jejunostomy: A Case Report

Feeding jejunostomy has become a useful method of feeding many patients with upper digestive tract dysfunction from a variety of causes. Although problems infrequently do occur with the tube itself, such as dislodgement or obstruction, most patients tolerate the procedure well. We report here a case of perforation of the jejunum that was caused by the tube itself and required reoperation. As with many problems in surgery, careful attention to technical details should help prevent this and other problems after feeding tube insertion.

Care of the Multiple Injured Patient with Thoracic Trauma

The multiple injured patient with thoracic trauma may pose a difficult challenge to the surgeon. Although the majority of chest injuries (85%) can be managed non-operatively, the presence of these injuries complicates the evaluation and treatment of concurrent extrathoracic trauma. The principles of Advanced Trauma Life Support (ATLS) published by the American College of Surgeons Committee on Trauma, combined with new insight into the concepts of deranged metabolism and physiologic exhaustion, can help one formulate a strategy for prioritizing diagnostic studies, optimizing resuscitative efforts, and conducting appropriate early definitive management. Our principal goal is to avoid prolonged shock by ensuring adequate oxygen delivery and circulating blood volume, and thereby, prevent secondary organ insults. Ideally, during these maneuvers, the physiologic stress response should be blunted with appropriate analgesics and/or sedation. Reduction and immobilization of skeletal trauma also serves to reduce physiologic stress and prevent complications. By outlining the goals of treatment for commonly encountered concomitant injuries, we hope to illustrate how these principles can be integrated for decision-making on the management of patients with serious thoracic trauma.

The Risks of Pulmonary Arterial Catheterization

Pulmonary arterial catheters have been widely accepted as useful for monitoring the critically ill patient. New modifications allowing transvenous cardiac pacing, Hiss bundle electrocardiography and continuous monitoring of mixed venous saturation promise to increase the acceptance and use of these catheters. The 52 per cent combined major and minor complication rate documented in this study suggest that enthusiasm for pulmonary arterial catheterization should be tempered with caution. Serious complications and death do occur with these devices and may be more frequent than previously recognized. Use of a pulmonary arterial catheter should be undertaken for defined indications, with a reasonable expectation of benefit from the data obtained and with a clear understanding of the risks involved.