Frederick D. Brenneman

Blunt diaphragmatic and thoracic aortic rupture: An emerging injury complex

Although both blunt diaphragmatic rupture (BDR) and thoracic aortic rupture (TAR) have been extensively discussed, the association of both injuries has been infrequently mentioned. The purpose of this study was to examine the current prevalence and clinical characteristics of combined BDR and TAR at an adult regional trauma unit. Among 3,886 trauma victims, 69 (1.8%) had a BDR and 44 (1.1%), a TAR. Seven patients (10% of all patients with a BDR) had both injuries. All 7 were victims of motor vehicle crashes and had a mean Injury Severity Score of 35. All TARs were just distal to the origin of the left subclavian artery. Five patients underwent repair of both injuries and survived, 1 patient had only the BDR repaired and survived, and 1 died during emergency thoracotomy, for a survival rate of 86%. Five patients had laparotomy and repair of the BDR in the presence of an unrepaired TAR. The TARs were repaired by the clamp-and-sew technique, three of them with primary repair and two with interposition tube grafts. Concomitant BDR and TAR appears to be an emerging injury complex with both diagnostic and therapeutic challenges. The presence of BDR demands a rigorous search for associated TAR.

Routine Preoperative “One-Shot” Intravenous Pyelography Is Not Indicated in All Patients With Penetrating Abdominal Trauma

BACKGROUNDnTo determine which patients need a one-shot intravenous pyelogram (IVP) before laparotomy for penetrating abdominal trauma.nnnSTUDY DESIGNnOver a 15-month period, 240 laparotomies were performed for penetrating trauma at our urban level I trauma center. Prospectively collected data included clinical suspicion of genitourinary injury, results of preoperative IVP, intraoperative findings, and operative decisions influenced by the IVP.nnnRESULTSnPreoperative IVP was performed in 175 patients (73%). Of these, 71 (41%) had suspicion of a renal injury based on the presence of a flank wound or gross hematuria. The IVP was believed to influence operative decisions in six patients, all in this group. Each of these six patients had either a shattered kidney or a renovascular injury and had a nephrectomy performed with the knowledge that a normal functioning kidney was present on the contralateral side. No patient without a flank wound or gross hematuria had an IVP that was judged to be helpful intraoperatively. Preoperative IVP was helpful only in patients with flank wounds or gross hematuria. Nephrectomy was performed in two additional patients who did not undergo IVP, both of whom presented in shock.nnnCONCLUSIONSnRoutine preoperative IVP is not necessary in all patients undergoing laparotomy for penetrating trauma. The number of IVPs can be safely reduced by 60% if the indications are narrowed to include only those stable patients with a flank wound or gross hematuria.

Are needle decompressions for tension pneumothoraces being performed appropriately for appropriate indications

Thoracic injuries are a leading cause of mortality intrauma patients [1]. Even so, many life-threatening thoracicinjuries can be managed nonoperatively by simple ther-apeutic procedures [2]. One example is needle decompres-sion of tension pneumothoraces. Left untreated, a tensionpneumothorax results in the continuous accumulation of airin the pleural space, which impairs both ventilation andvenous return to the heart resulting in intractable shock [3].Generally, needle decompressions (NDs) are performedby physicians and highly trained prehospital paramedics.Previous studies have shown that performing ND in theprehospital setting results in few complications and mayimprove trauma outcomes [4-7]. Even so, these investiga-tors have also underscored the importance of training andquality improvement initiatives to minimize complicationsassociated with this procedure; in particular, they felt thatmore attention should be focused on teaching the appro-priate indications and anatomical landmarks for performingND [7,8]. The purpose of this study is to evaluate theprehospital performance of needle decompression byexperienced paramedics.

Retrograde urethrocystography impairs computed tomography diagnosis of pelvic arterial hemorrhage in the presence of a lower urologic tract injury.

BACKGROUNDnThere is controversy about the appropriate sequence of urologic investigation in patients with pelvic fracture. Use of retrograde urethrography or cystography may interfere with regular pelvic CT scanning for arterial extravasation.nnnSTUDY DESIGNnWe performed a retrospective study at a regional trauma center in Toronto, Canada. Included were adult blunt trauma patients with pelvic fractures and concomitant bladder or urethral disruption who underwent initial pelvic CT before operation or hospital admission. Exposure of interest was whether retrograde urethrography (RUG) and cystography were performed before pelvic CT scanning. Main outcomes measures were indeterminate or false negative initial CT examinations for pelvic arterial extravasation.nnnRESULTSnSixty blunt trauma patients had a pelvic fracture and either a urethral or bladder rupture. Forty-nine of these patients underwent initial CT scanning. Of these 49 patients, 23 had RUG or conventional cystography performed before pelvic CT scanning; 26 had cystography after regular CT examination. Performing cystography before CT was associated with considerably more indeterminate scans (9 patients) and false negatives (2 patients) for pelvic arterial extravasation (11 of 23 versus 0 of 26, p < 0.001) compared with performing urologic investigation after CT. In the presence of pelvic arterial hemorrhage, indeterminate or false negative CT scans for arterial extravasation were associated with a trend toward longer mean times to embolization compared with positive scans (p=0.1).nnnCONCLUSIONSnExtravasating contrast from lower urologic injuries can interfere with the CT assessment for pelvic arterial extravasation, delaying angiographic embolization.

Blunt left hepatic duct injury

A 36-year-old male was involved in a high-speed motorcycle crash. Upon arrival at the Sunnybrook Health Science Centre, he was awake and alert, but restless, pale and diaphoretic with a systolic blood pressure of 80 mmHg, a heart rate of 130, and a respiratory rate of 40. A left anterolateral flail chest was evident, and a chest tube drained a left pneumothorax. Peritoneal lavage was positive for blood and the patient was urgently prepared for a laparotomy. Other injuries included an open midshaft fracture of the right femur with an ipsilateral undisplaced trochanteric fracture, and a closed left humeral fracture. At laparotomy, the large haemoperitoneum was partially due to a deep splenic laceration, requiring a splenectomy. In addition, there was avulsion of the gastroduodenal artery from the hepatic artery, and haemostasis was achieved with gastroduodenal artery ligation. Bile staining was noted in the porta hepatis, and exploration revealed a left hepatic duct injury with duct wall tissue loss and retraction of 30 per cent of the circumference (See Figure I). A #lO French latex T-tube (C.R. Bard Inc.) was placed in

Rectovaginal Fistulas and Intraoperative Bowel Injury

A rectovaginal fistula is an abnormal epithelium-lined communication between the rectum and vagina. There is nothing more physically and psychologically disabling than the aura of the incontinence of gas and fecal matter. There still remains controversy as to the best primary surgical corrective technique but an even more challenging decision is the approach to the patient who has failed corrective surgery. What is the role of a defunctioning stoma and when should more advanced surgical techniques be used? This section of the chapter outlines a practical and scientific approach to answer these difficult and controversial questions.