Galen V. Poole

Laparoscopic surgery during pregnancy

BACKGROUND Animal studies have demonstrated fetal acidosis during carbon dioxide pneumoperitoneum. This finding suggests a potential adverse effect of CO2 pneumoperitoneum on fetal outcome in humans. PATIENTS AND METHODS We reviewed our recent experience with laparoscopic surgery performed under general anesthesia and with the use of CO2 pneumoperitoneum, in pregnant women with appendicitis or cholecystitis. We compared these womens charts and pregnancy outcomes with those of pregnant women who underwent formal laparotomy during the same period of time. RESULTS Seven pregnant patients underwent laparoscopic surgery, and there were 4 fetal deaths among them (3 during the first postoperative week, and another 4 weeks postoperatively). Five pregnant patients underwent formal laparotomy, of whom 4 subsequently progressed to term and 1 was lost to follow-up. CONCLUSIONS Our recent experiences together with the available animal data suggest that caution should be used when considering nonobstetrical laparoscopic surgery in pregnant women. This experience suggests that additional clinical and laboratory investigations may be indicated to evaluate fetal risk associated with such surgery.

Pelvic fracture from major blunt trauma. Outcome is determined by associated injuries

Pelvic hemorrhage has been implicated as the cause of death in 50% of patients who die following pelvic fractures. To establish correlates of morbidity and mortality from pelvic fractures due to blunt trauma, we reviewed 236 patients treated during 4 years. The average age of the 144 men and 92 women was 31.5 years, the average Injury Severity Score was 21.3, the average blood requirement was 5 units, and the average hospital stay was 16.8 days. One hundred fifty-two patients (64.4%) were injured in motor vehicle accidents, 33 (14%) had motor vehicle-pedestrian accidents, 16 (6.8%) had crush injuries, 12 (5.1%) each had either motorcycle accidents or falls, and 11 (4.6%) had miscellaneous accidents. Eighteen patients (7.6%) died, with seven (38.9%) deaths due to hemorrhage. Only one death was caused by pelvic hemorrhage. Other deaths were due to hemorrhage from other sites (6), head injury (5), sepsis or multiple-organ failure (4), pulmonary injury (1), and pulmonary embolus (1). None of the septic deaths was related to a pelvic hematoma. Multivariate multiple regression analysis showed that the severity of injury was correlated with indices of severity of pelvic fractures such as fracture site (p less than 0.0001), fracture displacement (p less than 0.005), pelvic stability (p less than 0.0001), and vector of injury (p less than 0.01). However death could not be predicted on the basis of these indices of severity (p greater than 0.28). Of the nine patients who underwent pelvic arteriography, three required embolization of actively bleeding pelvic vessels, but seven had intra-abdominal hemorrhage that required laparotomy, and eight developed a coagulopathy. Massive bleeding from pelvic fractures was uncommon, and the major threat of hemorrhage was from nonpelvic sites. Furthermore, although injury severity was correlated with the severity of the pelvic fracture, hospital outcome was determined by associated injuries and not by the pelvic fracture.

The immune microenvironment of human fracture/soft-tissue hematomas and its relationship to systemic immunity.

The immune environment of human soft-tissue injury is unstudied. We studied fracture soft-tissue hematomas (FxSTH) in 56 patients with high-energy bony fractures. FxSTH serum and mononuclear cells (MNC) as well as fracture patient plasma and blood MNC were studied. Twenty healthy controls donated plasma and MNC. Soluble tumor necrosis factor (TNF)-alpha, interleukin (IL-1 beta, IL-2, 6, 8, 10, 12, and interferon-gamma were studied by enzyme linked immunosorbent assay. Cells were studied by flow cytometry after cell-membrane stains for CD-14, TNF-alpha (mTNF), and human leukocyte antigen-DR, or intracellular stains for TNF (icTNF) and IL-10. Thirty-six patients with Injury Severity Score < 15 were analyzed further to evaluate the effects of isolated fracture on systemic immunity. Cytokines were rarely detectable in control plasma. TNF-alpha, IL-1 beta, IL-2, and interferon-gamma were rarely found in FxSTH serum or fracture patient plasma. All FxSTH sera were rich in IL-6, peaking before 48 hours (12,538 +/- 4,153 vs. 3,494 +/- 909 pg/mL, p = 0.02, U test). In Injury Severity Score < 15, IL-6 was not detectable in most early fracture patient plasma, but rose after 48 hours (p = 0.028). FxSTH serum IL-8 peaked after 48 hours (440 +/- 289 vs. 4,542 +/- 1,219 pg/mL, p = 0.006) and circulating IL-8 appeared after 72 hours. IL-6 and IL-8 showed gradients from FxSTH serum to paired PtS (p < 0.05, Wilcoxon). IL-10 was abundant (884 +/- 229 pg/mL) in FxSTH serum < 24 hours old. FxSTH serum IL-12 peaked late (3,323 +/- 799 pg/mL, day 4-7) then fell (p < 0.001, analysis of variance). Only IL-12 was higher in fracture patient plasma (1,279 +/- 602 pg/mL) than FxSTH serum (591 +/- 327 pg/mL) during the first 48 hours (p = 0.032, U test). On flow cytometry, control monocytes expressed 201 +/- 31 mTNF sites/cell, but icTNF was absent. mTNF was up-regulated after injury more in FxSTH monocytes (3,202 +/- 870 sites/cell) than peripheral blood monocytes (584 +/- 186 sites/cell) (p < 0.05 vs. peripheral blood monocytes by Wilcoxon, p < 0.001 vs. control monocytes by U test). Intracellular IL-10 was abundant in all MNC, but varied widely after injury. Fracture and peripheral blood monocytes expressed far less human leukocyte antigen-DR than control monocytes. Fractures create an inflammatory local environment. Proximal mediators are cell-associated and relatively confined to the wound, but soluble IL-6, IL-8, and IL-10 are abundant and probably exported. Systemic MNC have complex responses to local injuries. These may reflect the combined impact of multiple soluble cytokines initially generated within the wound. FxSTH appear to be a potentially important source of immunomodulatory cytokines in trauma.

Trauma in pregnancy: The role of interpersonal violence

OBJECTIVE Our purpose was to determine what role interpersonal violence as intentional injury plays in the pregnant trauma victim. STUDY DESIGN We performed a retrospective review of medical records. RESULTS During a 9-year period in a single university medical and trauma center, 203 pregnant women were treated for a physically traumatic event. Sixty-four women (31.5%) were victims of intentional injury, in most cases by the husband or boyfriend. Although the mean Injury Severity Score was higher in women with fetal death than in women with successful pregnancy outcomes (7.25 vs 1.74, respectively; p < 0.01), 5 of the 8 women with fetal losses incurred these despite an apparent absence of physical injury (maternal Injury Severity Score = 0). CONCLUSIONS Interpersonal violence during pregnancy is a frequent and increasingly common cause of maternal injury. The inconsistent relationship between Injury Severity Score and serious fetal injury or death is underscored by the loss of 5 fetuses despite an Injury Severity Score of 0.

Practice management guidelines for nutritional support of the trauma patient.

Nutritional support is an integral, though often neglected, component of the care of the critically injured patient. Our understanding of the metabolic changes associated with starvation, stress, and sepsis has deepened over the past 20 to 30 years, and along with this has come a greater appreciation for the importance of the timing, composition, and route of administration of nutritional support to the trauma patient. Although supportive data exist for many of our current nutritional practices, the trauma surgeon cannot assume that interventions that are successful in laboratory animals or even in the critically ill nontrauma patient will produce the same results in critically ill trauma patients. Stanley J. Dudrick, MD, one of the forefathers of surgical nutrition in this country, put it this way: “. . .we do get ourselves into an awful lot of trouble and lack of consensus as a result of mixing in animal data together with normal, starved man data when we are talking about trauma, especially in burns.” For this reason, the recommendations provided in this guideline are based, when at all possible, on studies using trauma or burn patients. Nevertheless, a brief discussion of some of the basic science principles of nutritional support is provided in the following section as a backdrop for the clinical studies presented in this guideline. This practice management guideline is a compilation of six separate guidelines; each addresses a specific aspect of the nutritional support of the trauma patient. These topics are presented in the following order: A. Route of nutritional support (total parenteral nutrition vs. total enteral nutrition). B. Timing of nutritional support (early vs. late). C. Site of nutritional support (gastric vs. jejunal). D. Macronutrient formulation (how many calories and what proportion of protein, carbohydrate, and fat?). E. Monitoring of nutritional support (which tests and how often?). F. Type of nutritional support (standard vs. enhanced). Each subguideline is a separate and free-standing document, with its own recommendations, evidentiary tables, and references. Where possible, we have attempted to eliminate redundancy and ensure consistency among the guidelines. Yet, because of substantial differences in both the quantity as well as the quality of supporting scientific data for each topic, and the fact that certain clinical circumstances are not conducive to a single guideline, concise and consistent recommendations were not always possible. Even when Class I (prospective, randomized, controlled) studies were available, limited patient numbers and inconsistent definitions rendered study conclusions less authoritative that they might have otherwise been. Recognizing the need to incorporate the major recommendations from the subguidelines into a logical overall approach to the nutritional support of the trauma patient, a summary algorithm is provided at the conclusion of the guideline (Fig. 1). Because of the scope of this document, many of the recommendations from the subguidelines could not be included in the algorithm. In addition, distinguishing between the various levels of recommendations (I, II, and III) within the algorithm was not practical. Nevertheless, the algorithm provides a safe, reasonable, and literature-supported approach to nutritional support and, we hope, will provoke constructive discussion and stimulate further investigation.

Lower Extremity Fracture Fixation in Head-injured Patients

Compared with nonsurgical management or delayed repair, early fracture fixation can reduce the incidence of pulmonary complications in patients with long-bone fractures of the lower extremities. Blunt trauma victims often have multiple nonskeletal injuries that might influence the risk of pulmonary complications, and when head injuries are present it has been a common practice to delay nonemergent operations for several days to protect the injured brain. We conducted a retrospective review of 114 patients with multiple trauma whose injuries included head trauma and a fracture of the neck or shaft of the femur or shaft of the tibia to determine if delayed stabilization of lower extremity fractures increased the risk of pulmonary complications or reduced the risk of cerebral complications. Forty-six patients underwent surgical fixation of their fractures within 24 hours of injury (early fixation), 26 patients had their fractures repaired more than 24 hours after injury (late fixation), and 42 patients did not undergo surgical fracture fixation. The risk of pulmonary complications was not related to the timing of surgical fracture fixation but was strongly influenced by the severity of injuries to the head and to the chest (p less than 0.001). Furthermore, a delay in fracture fixation did not protect the injured brain; the risk of CNS events was determined by the severity of the head injury (p less than 0.0001). Early fracture fixation in patients with head injury may be appropriate because it simplifies patient care and does not seem to worsen the head injury, but it does not prevent pulmonary complications in these high-risk patients.

Computed tomography in the management of blunt thoracic trauma.

Computed tomographic (CT) scanning has proved to be valuable in evaluating the head and abdomen of victims of blunt trauma; CT scans of the thorax often are obtained on patients with blunt torso trauma, but their value for this purpose is unclear. We conducted a prospective study to evaluate the role of chest CT scanning in thoracic trauma. Hemodynamically stable patients at least 18 years old with an estimated Abbreviated Injury Scale--Thorax score of 2 or greater underwent a contrast-enhanced CT scan of the chest, usually in conjunction with CT scans of the head, abdomen, or both. Thirteen patients were dead on arrival, 14 required emergency surgical procedures, and 13 were too unstable to undergo chest CT scan. Thirty-three patients were not included because they refused to participate or the protocol was not followed. Forty-six men (69%) and 21 women with a mean age of 42.7 years completed the study. Sixty-one were injured in motor vehicle crashes, four were injured in falls, and one each was injured by assault and by crushing forces. Injury Severity Scores ranged from 4 to 45, with a mean of 20.5. Four patients died (6%), three from head injury and one from multiple organ dysfunction. Chest roentgenography (CXR) was superior to CT scanning in identifying rib fractures, but CT scanning was more sensitive than CXR for pneumothorax, fluid collections, and infiltrates (p < 0.001); CT scanning also was more specific for aortic injury. Despite this quantitative superiority, the abnormalities missed by CXR but identified by CT scanning infrequently led to a change in management.(ABSTRACT TRUNCATED AT 250 WORDS)

Psychopathologic risk factors for intentional and nonintentional injury

OBJECTIVE Trauma has a high rate of recurrence, suggesting that some people are more injury-prone than others. This study was performed to evaluate some of the psychological and social factors that might influence the likelihood of traumatic injury. METHODS A case-control study was conducted to evaluate the relationship between selected psychosocial factors and traumatic injury. At a Level I trauma center, victims of intentional trauma (excluding attempted suicide), victims of nonintentional trauma, and patients undergoing elective surgery were interviewed by a person blinded to the purposes of the study. They were given an intelligence test and underwent a structured interview, yielding psychiatric diagnostic categories established in the third edition of the Diagnostic and Statistical Manual of Mental Disorders, Revised (DSM-III-R). RESULTS Trauma patients were younger than elective surgery patients (p < 0.01) and were more likely to be men (p < 0.01). Victims of intentional injury had a higher probability of alcohol use (p < 0.01) and admitted illicit drug use (p < 0.001) than either nonintentional injury victims or elective surgery patients. Victims of intentional injury were more likely to be unemployed than those in the other two groups (p < 0.02), whereas elective surgery patients were more likely to be retired (p < 0.05) or to be disabled (p < 0.0001). The average intelligence score was slightly above the median in the nonintentional trauma group and in the control group (55th percentile and 54th percentile, respectively), compared with a mean intelligence score equivalent to the 35th percentile in the victims of intentional trauma (p < 0.001). Thirty percent of elective surgery patients met diagnostic criteria for at least one category of psychopathology, compared with 50% of nonintentional trauma patients, and 63% of intentional trauma patients (p < 0.01, trauma vs. elective surgery). Logistic regression analysis identified six variables that were independently associated with an increased tendency to be a victim of trauma: younger age, lower intelligence, antisocial personality, mental retardation, depression, and low income. CONCLUSIONS Victims of trauma, both nonintentional, and especially intentional, have a high incidence of psychopathology. Victims of intentional trauma have significantly lower intelligence scores than either nonintentional injury or elective surgery patients. The high incidence of unemployment, alcohol abuse, and illicit drug use in victims of intentional injury might provide several opportunities for trauma prevention programs. Underlying psychological disorders will have to be addressed to reduce the likelihood of becoming a victim of trauma.

Surgical approach of choice for penetrating cardiac wounds.

One hundred nineteen patients suffered penetrating cardiac trauma over a 15-year period: 59 had gunshot wounds, 49 had stab wounds, and 11 had shotgun wounds. The overall survival rate was 58%. The most commonly injured structures were the ventricles. Twenty-seven patients had injuries to more than one cardiac chamber. Thirty patients had associated pulmonary injuries. Emergency thoracotomy was performed in 47 patients with 15% survival. Median sternotomy was used in 30 patients with 90% survival. Seventeen of the 83 patients with thoracotomies required extension across the sternum for improved cardiac exposure or access to the contralateral hemithorax. Only one patient with sternotomy also required a thoracotomy. All pulmonary injuries were easily managed when sternotomy was used. We conclude that sternotomy provides superior exposure for cardiac repair in patients with penetrating anterior chest trauma. We feel it is the incision of choice in hemodynamically stable patients. Thoracotomy should be reserved for unstable patients requiring aortic cross-clamping, or when posterior mediastinal injury is highly suspected.

Violence in America: a public health crisis--domestic violence

Domestic violence is a major public health problem. It is important that physicians are aware of the extent and pervasiveness of this disease. It is important to identify potential victims of domestic violence when they are encountered in the hospital or office environment. A few, short, carefully asked questions can serve an important surveillance and diagnostic function. Once domestic violence is identified, a well thought out, sensitive, safe plan of action should be discussed with the victim. In this way, not only will the current event be well managed, but also the potential for mitigating further domestic violence events will be initiated. Through this document, EAST hopes to add its voice to that of other physician groups to serve as a catalyst for broad education on the subject of domestic violence as well as activating victim advocacy among physicians and others who come into contact with this problem in their patients.