George L. Jordan

Abbreviated laparotomy and planned reoperation for critically injured patients.

The triad of hypothermia, acidosis, and coagulopathy in critically injured patients is a vicious cycle that, if uninterrupted, is rapidly fatal. During the past 7.5 years, 200 patients were treated with unorthodox techniques to abruptly terminate the laparotomy and break the cycle. One hundred seventy patients (85%) suffered penetrating injuries and 30 (15%) were victims of blunt trauma. The mean Revised Trauma Score, Injury Severity Score, and Trauma Index Severity Score age combination index predicted survival were 5.06%, 33.2%, and 57%, respectively. Resuscitative thoracotomies were performed in 60 (30%) patients. After major sources of hemorrhage were controlled, the following clinical and laboratory mean values were observed: red cell transfusions--22 units, core temperature--32.1 C, and pH--7.09. Techniques to abbreviate the operation included the ligation of enteric injuries in 34 patients, retained vascular clamps in 13, temporary intravascular shunts in four, packing of diffusely bleeding surfaces in 171, and the use of multiple towel clips to close only the skin of the abdominal wall in 178. Patients then were transported to the surgical intensive care unit for vigorous correction of metabolic derangements and coagulopathies. Ninety-eight patients (49%) survived to undergo planned reoperation (mean delay 48.1 hours), and 66 of 98 (67%) survived to leave the hospital. With the exception of intravascular shunts, there were survivors who were treated by each of the unorthodox techniques. Of 102 patients who died before reoperation 68 (67%) did so within 2 hours of the initial procedure. Logistic regression showed that red cell transfusion rate and pH may be helpful in determining when to consider abbreviated laparotomy. The authors conclude that patients with hypothermia, acidosis, and coagulopathy are at high risk for imminent death, and that prompt termination of laparotomy with the use of the above techniques is a rational approach to an apparently hopeless situation.

Intra-abdominal packing for control of hepatic hemorrhage: a reappraisal.

Presently available techniques for control of hepatic hemorrhage in patients with extensive parenchymal injuries include direct suture, topical hemostatic agents, hepatotomy or resectional debridement with selective vascular ligation, lobectomy, and selective hepatic artery ligation. In many trauma centers the placement of intra-abdominal packing for hepatic tamponade has been an infrequently used technique in recent years. From 1 July 1978 to 1 September 1980, ten patients with continued hepatic parenchymal oozing following all attempts at surgical control of extensive injuries were treated by the insertion of intra-abdominal packing around the liver as a last desperate maneuver. Packing was removed at relaparotomy in four patients and through abdominal drain sites in five patients. Nine of ten patients survived, and there were no instances of rebleeding following removal of the packing. Four patients developed postoperative perihepatic collections and two of the four patients underwent reoperation for drainage. Based on the recent experience at the Ben Taub General Hospital, intra-abdominal packing for control of exsanguinating hepatic hemorrhage appears to be a lifesaving maneuver in highly selected patients in whom coagulopathies, hypothermia, and acidosis make further surgical efforts likely to increase hemorrhage.

Packing for control of hepatic hemorrhage

From July 1978 to July 1985, 1,348 patients with hepatic injuries were treated. During this period, 66 patients (5.3% or 9.4 patients/year) required perihepatic packing. Penetrating wounds accounted for 77.2% of injuries requiring packing. Seventeen patients died in the operating room from massive hepatic and other intra-abdominal injuries and were excluded from further analysis. Perihepatic packing was inserted in 41 patients at a first operation and at a second or third operation in eight others. The major indications for packing were post-repair coagulopathies (85.5%) and extensive subcapsular hematomas or capsular avulsion (12.2%). Packing was removed from 28 surviving patients (28/49 = 57.1%) at an average of 3.7 days following insertion. Pack removal was accomplished by laparotomy in 24 patients (85.7%) and extraction through a hole in the body wall in four others. Ten postoperative intra-abdominal fluid collections, hematomas, or abscesses occurred in nine patients (9/49 = 18.4%) surviving the first operation. Perihepatic packing continues to be a life-saving adjunct in a highly selected group of patients with the most severe hepatic injuries and nonmechanical bleeding at the completion of repairs or extensive subcapsular hematomas.

Management of 1000 consecutive cases of hepatic trauma (1979-1984).

From 1979 to 1984, 1000 patients with hepatic injuries were treated at one urban trauma center. Penetrating wounds were present in 86.4% of patients. Simple hepatorrhaphy, use of topical hemostatic agents, or drainage alone were the only forms of therapy required in 881 patients, and 65 (7.3%) died. Extensive hepatorrhaphy or hepatotomy with selective vascular ligation, resectional debridement or resection, selective hepatic artery ligation, or perihepatic packing were required, often in combination, in 119 patients, and 40 (33.6%) died. Uncomplicated recoveries occurred in 798 of the 918 patients (86.9%) surviving greater than 48 hours. In the remaining 13.1% of patients, intra-abdominal abscess formation was the most common late complication (32/918 = 3.5%). Mortality for the entire series of 1000 patients was 10.5%, with 78.1% (82/105) of all deaths occurring in the perioperative period from shock or transfusion-related coagulopathies.

Abdominal gunshot wounds. An urban trauma center's experience with 300 consecutive patients

From July 1983 through December 1987, 300 consecutive patients with penetrating gunshot wounds of the abdomen causing visceral or vascular injuries were treated. Resuscitative thoracotomy was required in 20 patients (6.6%), and only two survived. The most commonly injured organs were the small bowel (60%), colon (41.6%), liver (29.3%), vascular structures (24.6%), stomach (17.3%), and kidney (17.0%). The overall survival rate for the series was 88.3%; however, if only the 226 patients without vascular injuries are considered, the survival rate was 97.3%. In the 35 patients who died, the blood pressure on admission was 51 mmHg, 18 required a resuscitative thoracotomy, four visceral or vascular injuries were present, and the median blood replacement was 18 units. The cause of death was perioperative shock in 30 patients (85.7%), whereas five patients (14.3%) died of sepsis and multiple organ failure. The most common postoperative complication in survivors and patients who died later in the study was an intra-abdominal abscess (3.0%). Rapid conservative operative techniques for civilian gunshot wounds lead to few postoperative complications and an excellent survival rate, especially if vascular injuries are not present.

Major Complications of Percutaneous Subclavian Vein Catheters

Abstract New and reportedly safer techniques for subclavian venipuncture with the passage of central venous catheters appear regularly in the surgical literature 55–59 yet reports of major complications continue to appear as well. We have reported on eight patients with major complications of percutaneous subclavian vein catheters, two of whom died. In our own hospital an improved educational program for junior house staff and nurses has been instituted. Better supervision of junior house staff when performing this potentially lethal technique is necessary. Daily inspection of catheters, early removal of unnecessary catheters, and improved equipment should help to prevent these complications in the future.

Management of Combined Pancreatoduodenal Injuries

From 1969 to 1985, 129 patients with combined pancreatoduodenal injuries were treated at one urban trauma center. A total of 104 patients (80.6%) had penetrating wounds, and multiple visceral and vascular injuries were usually associated with the pancreatoduodenal injury. Primary repair or resection of one or both organs coupled with pyloric exclusion and gastrojejunostomy (68 patients) and drainage was used in 79 patients (61.2%) in the entire study and in 59% (36 of 61) of all patients treated since 1976. Simple primary repair of one or both organs and drainage was performed in 31 patients (24%), whereas the remaining 19 patients (14.8%) had pancreatoduodenectomies (13 patients) or no repair before exsanguination (six patients). Major pancreatoduodenal complications occurring in the 108 patients surviving more than 48 hours included pancreatic fistulas (25.9%), intra-abdominal abscess formation (16.6%), and duodenal fistulas (6.5%). The overall mortality rate for the study was 29.5% (38 of 129). The acute mortality rate with these injuries will remain high secondary to injuries to associated organs and vascular structures. The morbidity and late mortality rates related to the moderate to severe pancreatoduodenal injury itself can be decreased by the addition of pyloric exclusion and gastrojejunostomy to the primary repairs.

The injured colon.

Controversy continues regarding the initial management of civilian colon injuries. The main issues are the safety of colostomy versus the desirability of primary repair and the role of exteriorized repair. From 1979 through 1984, 727 patients with injuries to the colon were treated at a large urban trauma center. Ninety-seven per cent of injuries were caused by penetrating wounds. Ten patients died in the operating room prior to repair of the colon wound. For patients who survived long enough to have their injury treated, 52.4% were treated by primary repair, 32.9% were treated with colostomies, and 14.6% were treated with exteriorized repair. Of the factors that have been stated to influence decision making, the extent of the colon injury was the most important. Location, number, and type of associated injuries, fecal contamination, and shock were less important. However, none of these latter factors mandated performance of a colostomy. The overall mortality rate for the series was 9.9%. Forty-one out of 70 deaths occurred within the first 48 hours and were due to shock and hemorrhage. The mortality rate for primary repair was significantly lower than that for colostomies (p less than 0.01). The presence of shock and age greater than 40 were significant factors influencing mortality (p less than 0.01). Mortality also was directly related to the number and type of associated abdominal injuries. Abdominal abscess also occurred significantly less often in patients treated with primary repair than in those with colostomies (p less than 0.01). The use of exteriorized repair was successful in avoiding colostomy in 59% of patients. Primary repair can be performed with minimal morbidity and mortality and should be the mainstay of treatment for civilian colon injuries.

Traumatic injuries of the pancreas

Traumatic injuries of the pancreas have evolved from an uncommon encounter of even wartime wounds to a relatively common injury of todays civilian strife. A review of 448 patients sustaining pancreatic trauma demonstrated that the pancreatic injury alone contributes little to immediate or late mortality but is frequently a source of postoperative morbidity. Complications of pancreatic injury comprise almost half of those observed after trauma in such patients, but for the most part are self-limited and easily cared for. Survival among patients sustaining pancreatic injury depends mainly upon the degree of success with which the multiple associated injuries can be managed.

Liberal use of emergency center thoracotomy

Emergency center thoracotomy is a heroic technique of resuscitation and treatment which was revived in the 1960s to improve the survival of patients presenting with cardiac wounds. With excellent survival rates attained in such patients, the technique was extended to victims of trauma with other mechanisms and locations of injury. At present, the technique has a survival rate ranging from 3 to 20 percent; however, most recent series of unselected patients show a survival rate of 8 to 10 percent. In this series, there were no survivors when emergency center thoracotomy was utilized after a period of prehospital cardiopulmonary resuscitation. Patients with isolated stab wounds to the thorax, especially those with cardiac injuries, had the best survival rate of any subgroup in the series. If emergency center thoracotomy was utilized for patients with some vital signs on admission and with neck or truncal gunshot wounds, blunt trauma, or abdominal trauma, the survival rate decreased to 2 to 4 percent; however, the small but constant survival rate in all of these groups justifies its continued use.