John C. Mayberry

Hypercoagulability is most prevalent early after injury and in female patients

BACKGROUND Hypercoagulability after injury is a major source of morbidity and mortality. Recent studies indicate that there is a gender-specific risk in trauma patients. This study was performed to determine the course of coagulation after injury and to determine whether there is a gender difference. We hypothesized that hypercoagulability would occur early after injury and that there would be no difference between men and women. METHODS This was a prospective cohort study. Inclusion criteria were admission to the intensive care unit, Injury Severity Score > 4, and the ability to obtain consent from the patient or a relative. A Thrombelastograph (TEG) analysis was performed and routine coagulation parameters and thrombin-antithrombin complexes were measured within 24 hours of injury and then daily for 4 days. RESULTS Sixty-five patients met criteria for entry into the study. Their mean age was 42 +/- 17 years and their mean Injury Severity Score was 23 +/- 12. Forty patients (62%) were men. The prevalence of a hypercoagulable state by TEG was 62% on day 1 and 26% on day 4 (p < 0.01). Women were significantly more hypercoagulable on day 1 than men as measured by the time to onset of clotting (women, 2.9 +/- 0.7 minutes; men, 3.9 +/- 1.5 minutes; p < 0.01; normal, 3.7-8.3 minutes). Mean platelet counts, international normalized ratios, and partial thromboplastin times were within normal limits throughout the study. Thrombin activation as measured by thrombin-antithrombin complexes decreased from 34 +/- 15 microg/L on day 1 to 18 +/- 8 microg/L (p < 0.01) on day 4, consistent with the prevalence of hypercoagulability by TEG. CONCLUSION Hypercoagulability after injury is most prevalent during the first 24 hours. Women are more hypercoagulable than men early after injury. The TEG is more sensitive than routine coagulation assays for the detection of a hypercoagulable state.

Blunt thoracic trauma: flail chest, pulmonary contusion, and blast injury

Blunt thoracic trauma can result in significant morbidity in injured patients. Both chest wall and the intrathoracic visceral injuries can lead to life-threatening complications if not anticipated and treated. Pain control, aggressive pulmonary toilet, and mechanical ventilation when necessary are the mainstays of supportive treatment. The elderly with blunt chest trauma are especially at risk for pulmonary deterioration in the several days postinjury and should be monitored carefully regardless of their initial presentation. Blunt thoracic trauma is also a marker for associated injuries, including severe head and abdominal injuries.

The influence of elastic compression stockings on deep venous hemodynamics

To determine the effect of elastic compression stockings on deep venous hemodynamics we measured ambulatory venous pressure, venous refill time, maximum venous pressure with exercise, amplitude of venous pressure excursion, and duplex-derived common femoral and popliteal vein diameter and peak flow velocities with and without stockings in 10 healthy subjects and 16 patients with chronic deep venous insufficiency. The effects of below-knee and above-knee 30 to 40 torr and 40 to 50 torr gradient stockings were studied. Despite documentation of substantial stocking compressive effects by skin pressure measurements, neither below-knee or above-knee elastic compression stockings significantly improved ambulatory venous pressure, venous refill time, maximum venous pressure with exercise, or the amplitude of venous pressure excursion in healthy patients or in patients with deep venous insufficiency (p greater than 0.05). In patients with deep venous insufficiency stockings modestly increased popliteal vein diameter and flow velocity in the upright resting position (p less than 0.02). After tiptoe exercise without stockings deep venous peak flow velocity increased in healthy patients and in patients with deep venous insufficiency by a mean of 103% in the popliteal vein and 46% in the common femoral vein (p less than 0.01). With the application of elastic compression stockings only modest augmentation of deep venous flow velocity occurred in both groups above that seen in the bare leg after exercise. Thus elastic compression stockings did not improve deep venous hemodynamic measurements in patients with deep venous insufficiency. The beneficial effects of stockings in the treatment of deep venous insufficiency must relate to effects other than changes in deep venous hemodynamics.

Surveyed Opinion of American Trauma, Orthopedic, and Thoracic Surgeons On Rib and Sternal Fracture Repair

INTRODUCTION Rib and sternal fracture repair are controversial. The opinion of surgeons regarding those patients who would benefit from repair is unknown. METHODS Members of the Eastern Association for the Surgery of Trauma, the Orthopedic Trauma Association, and thoracic surgeons (THS) affiliated with teaching hospitals in the United States were recruited to complete an electronic survey regarding rib and sternal fracture repair. RESULTS Two hundred thirty-eight trauma surgeons (TRS), 97 orthopedic trauma surgeons (OTS), and 70 THS completed the survey. Eighty-two percent of TRS, 66% of OTS, and 71% of THS thought that rib fracture repair was indicated in selected patients. A greater proportion of surgeons thought that sternal fracture repair was indicated in selected patients (89% of TRS, 85% of OTS, and 95% of THS). Chest wall defect/pulmonary hernia (58%) and sternal fracture nonunion (>6 weeks) (68%) were the only two indications accepted by a majority of respondents. Twenty-six percent of surgeons reported that they had performed or assisted on a chest wall fracture repair, whereas 22% of surgeons were familiar with published randomized trials of the surgical repair of flail chest. Of surgeons who thought rib fracture or sternal fracture repair was rarely, if ever, indicated, 91% and 95%, respectively, specified that a randomized trial confirming efficacy would be necessary to change their negative opinion. CONCLUSIONS A majority of surveyed surgeons reported that rib and sternal fracture repair is indicated in selected patients; however, a much smaller proportion indicated that they had performed the procedures. The published literature on surgical repair is sparse and unfamiliar to most surgeons. Barriers to surgical repair of rib and sternal fracture include a lack of expertise among TRS, lack of research of optimal techniques, and a dearth of randomized trials.

Rib fracture pain and disability: can we do better?

OBJECTIVE The purpose of this study was to determine the magnitude and duration of pain and disability in patients with rib fractures treated using current standard therapy. This was a prospective case series. METHODS Injured patients with a chest radiographic diagnosis of one or more rib fractures between June 1, 2001, and October 31, 2001, were asked to participate. Pain levels were assessed at days 1, 5, 30, and 120 after injury using a visual pain scale (0-10). Disability at 30 days was assessed using the SF-36 Health Status Survey, and the total number of days lost from work/usual activity was recorded at day 120. The setting was a university-based Level I trauma center. RESULTS Forty patients with a mean of 2.7 +/- 1.6 rib fractures were enrolled. Twenty-three patients had isolated rib fractures and 17 patients had associated extrathoracic injuries. Mean rib fracture pain was 3.5 +/- 2.1 at 30 days and 1.0 +/- 1.4 at 120 days. For patients with associated extrathoracic injuries, rib pain was equivalent to pain in the rest of the body at all intervals. When compared with the chronically ill reference population of the RAND Medical Outcomes Study, our patients as a group were more disabled at 30 days (p < 0.001) in all categories except emotional stability, where they showed equivalent disability, and in their perception of general health, where they were significantly less disabled (p < 0.001). The total mean days lost from work/usual activity was 70 +/- 41. Patients with isolated rib fractures went back to work/usual activity at a mean of 51 +/- 39 days compared with 91 +/- 33 days in patients with associated extrathoracic injuries (p < 0.01). CONCLUSION Rib fractures are a significant cause of pain and disability in patients with isolated thoracic injury and in patients with associated extrathoracic injuries. Developing new therapies to accelerate pain relief and healing would substantially improve the outcome of patients with rib fractures.

Guidelines for Management of Small Bowel Obstruction

STATEMENT OF THE PROBLEMThe description of patients presenting with small bowel obstruction (SBO) dates back to the third or fourth century, when early surgeons created enterocutaneous fistulas to relieve a bowel obstruction. Despite this success with operative therapy, the nonoperative management o

Practice management guidelines for management of hemothorax and occult pneumothorax.

STATEMENT OF THE PROBLEMThoracic trauma is a notable cause of morbidity and mortality in American trauma centers, where 25% of traumatic deaths are related to injuries sustained within the thoracic cage.1 Chest injuries occur in ∼60% of polytrauma cases; therefore, a rough estimate of the occurrence

Absorbable Plates for Rib Fracture Repair: Preliminary Experience

BACKGROUND Absorbable prostheses are currently used in a variety of bone reconstructions and fixations. METHODS This is a case series of rib fracture fixation using absorbable plates and screws consisting of 70:30 poly(L-lactide-co-D,L-lactide) from April 2001 through November 2002. RESULTS Ten patients underwent rib fracture fixation with absorbable plates and screws. Indications included flail chest with failure to wean (five patients), acute pain with instability (four patients), and chest wall defect (one patient). All patients with flail chest weaned from mechanical ventilation successfully. All patients with pain and instability reported rapid subjective improvement or resolution. The patient with a chest wall defect repair returned to full athletic activity without limitations at 6 months. Thoracoscopic assistance was used in three cases and muscle-sparing incisions were used in eight cases. Two patients with screw fixation only developed loss of rib fracture reduction. One patient developed a wound infection requiring drainage. The period of follow-up ranged from 3 to 18 months. CONCLUSION Absorbable plates produce good clinical results and are an option for rib fracture repair. Two-point fixation (screw fixation plus suture cerclage) is required. Further refinements in technique should focus on minimally invasive methods.

Rib Fracture Fixation for Flail Chest: What Is the Benefit?

BACKGROUND Recently, rib fracture fixation for flail chest has been used increasingly at both academic and nonacademic trauma centers. Although a few small non-US studies have demonstrated a clinical benefit, it is unclear whether this benefit outweighs the added expense and potential perioperative complications related to the procedure. We therefore sought to determine if open reduction and internal fixation of ribs for flail chest (ORIF-FC) represents a cost-effective means for managing these patients. STUDY DESIGN A Markov transition state analysis was performed modeling the outcomes of the standard of care or ORIF-FC for flail chest. The incidences of ventilator-associated pneumonia, tracheostomy, sepsis, prolonged ventilation, deep vein thrombosis, pulmonary embolism, wound infection, and postoperative hemorrhage were obtained based on literature review. Medicare 2010 reimbursement costs were used for diagnoses and procedures. A quality of life improvement factor ranging from 0 to 15% improvement was used to estimate the improvement in pain and functional outcomes related to ORIF-FC. The most cost-effective treatment was then determined, ranging the incidences of ventilator-associated pneumonia and quality of life improvement factor. RESULTS Cost effectiveness was

Delayed celiotomy for the treatment of bile leak, compartment syndrome, and other hazards of nonoperative management of blunt liver injury

15,269 for ORIF-FC compared with