John F. Perry

Diagnostic peritoneal lavage: Fourteen years and 2,586 patients later☆☆☆

During a fourteen year period, diagnostic peritoneal lavage was 98.5 per cent accurate in determining the presence or absence of blunt intraabdominal injuries among 2,586 patients. Of these, 69.4 per cent had a negative lavage and 29.2 per cent a positive lavage. Six patients (0.2 per cent) had a false-positive lavage. Thirty-two patients (1.2 per cent) had a false-negative lavage; however, all but one of these patients underwent exploratory laparotomy on the basis of clinical acumen or other diagnostic tests.

Blunt maternal trauma: a review of 103 cases.

One hundred three pregnant women hospitalized following blunt trauma had injuries classified as: major (20%); minor (17%); or significant (63%). Maternal mortality related only to the severity of maternal injuries: 24% of women who sustained major injuries died. Pregnancy ended unsuccessfully in 18% of all women with known pregnancy outcome. The incidence of unsuccessful pregnancy was 61% following major injuries and 27% following minor injuries. Insignificant maternal injuries did not affect pregnancy outcome. Fetal survival did not relate to gestational age per se. Pregnancy uniformly ended unsuccessfulla in the presence of maternal death, placental injury, uterine injury, and direct fetal injury, and occurred in 80% of women admitted in hemorrhagic shock. An understanding of the ways that the anatomic and physiologic changes of pregnancy alter the nature and frequency of maternal injuries and that maternal response to injury is altered is essential. The best chance for fetal survival is to assure maternal survival.

Diagnostic peritoneal lavage in blunt abdominal trauma.

: Diagnostic peritoneal lavage is accurate and safe. It leads to fewer unnecessary laparotomies than if clinical examination alone is used and nearly eliminates deaths from undiagnosed abdominal injuries. Persons with clinical abdominal findings, shock, altered sensorium, and severe chest injuries after blunt trauma should undergo the procedure.

Open pelvic fracture: a lethal injury.

Twenty-two of 604 patients (4%) with pelvic fracture (PF) had open fractures. Eight per cent of all pedestrian and motorcycle accidents resulted in open PF, compared to 0.8% of all vehicular accidents. With one exception, all patients sustained multiple injuries. The mortality rate for an open PF was 50%, in marked contrast to 10.5% for a closed PF. Of more importance, the pelvic fracture was the primary cause of death in 73% of those dying with an open PF and in 30% of those dying with a closed PF. The higher mortality is due to an increased risk of infection and to massive hemorrhage because of a high risk of concomitant major vessel injury, as well as increased diffuse retroperitoneal hemorrhage, in these open fractures. Therapy directed to restoring blood volume, identifying and repairing major vessel injury, and attempting to decrease the diffuse retroperitoneal hemorrhage is essential. If drainage is necessary, it should be accomplished with a closed system. Immediate colostomy and use of antibiotics should decrease the infectious complications.

Major vascular injuries secondary to pelvic fractures: An unsolved clinical problem

Twelve patients sustained sixteen pelvic fracture-related iliac and femoral arterial (5) and venous (11) injuries. Death was due in large part to delays in recognition and direct operative control of the major vascular disruption. Prompt operative exploration of all pedestrians admitted in hemorrhagic shock will open pelvic fractures characterized by a double break in the pelvic ring should reduce the 83 per cent mortality currently associated with this combination of injuries.

Blood Supply to Hepatic V2 Carcinoma Implants as Measured by Radioactive Microspheres.

Conclusions 1. Radioactive microspheres reach a concentration in hepatic metastases averaging 4 times the concentration in surrounding liver parenchyma when infused via the hepatic artery. 2. When delivered into the portal system radioactive microspheres reach metastases in only an average of one-third their concentration in the surrounding liver. 3. Spill-over of radioactive microspheres 15 μ in diameter from liver to lungs and kidneys is negligible. 4. Arteriovenous shunts in liver and in V2 carcinoma are either few in number or are less than 15 μ in diameter.

Blunt trauma in adults and children: a comparative analysis

Trauma remains the major cause of death in children and young adults. Adult and pediatric patients differ significantly in both mechanism of and physiologic response to injury. We reviewed the records of all consecutive adult and pediatric blunt trauma patients admitted to a major metropolitan trauma center for a 10-year period. An extensive computerized database has been maintained for all patients since 1977. A comparative statistical analysis of mechanism of injury, specific organ injury, and clinical outcome was performed. Altogether, 1,722 adults and 289 children were treated during the study period. Blunt trauma accounted for 82.8% of adult and 94.3% of pediatric injury (p = 0.00005), and only these patients were considered for analysis. Diagnostic peritoneal lavage was performed in 249 children and 1,464 adults, with a respective accuracy of 99.6% and 97.2%. Mechanism of injury was comparable for both groups, although children were far more likely to be injured by falls, bicycle accidents, or struck by an automobile. Comparative analysis of specific injuries demonstrated significantly fewer pediatric chest (p = 0.001), spine (p = 0.03), and pelvic (p = 0.003) injuries. Central nervous system (CNS) injury in children was a strong determinant of outcome: serious pediatric CNS trauma was associated with a tenfold increase in mortality. Mortality for children in the absence of CNS injury was less than 3%. Spinal injury also appeared to be a predictor of poor outcome in the pediatric population, with an associated mortality of greater than 50%. Overall, survival was age independent (82.5% of adults and 85.8% of children were survivors.(ABSTRACT TRUNCATED AT 250 WORDS)

Injuries associated with splenic trauma

Renewed interest in conservative nonoperative management of splenic trauma in children led us to review our experience with this injury in 258 patients over the past 5 1/2 years. Blunt trauma was the predominant type of injury, occurring in 241 patients: 80% of these patients had associated extra-abdominal injuries, predominantly involving the head, chest, and extremities; 59% of patients with penetrating trauma had concomitant extra-abdominal injuries, mainly of the thorax. Serious concomitant intra-abdominal injuries requiring operative therapy were found in 36.5 and 94%, respectively, of patients sustaining splenic injury from blunt and penetrating trauma. Children under the age of 16 years exhibited a similar incidence (32.6 and 100%), respectively). Renal, hepatic, diaphragmatic, intestinal, mesenteric, and vascular injuries were most frequent. The pitfall of conservative nonoperative management lies in missing these concomitant serious intra-abdominal injuries. Diagnostic peritoneal lavage is most useful in defining the patients who should undergo exploratory laparotomy, therefore reducing morbidity and mortality secondary to neglected injuries.

Value of quantitative cell count and amylase activity of peritoneal lavage fluid.

From January 1974 through July 1979, 1,588 patients underwent diagnostic peritoneal lavage. The test had an accuracy of 98.6%, sensitivity of 94.3%, and specificity of 99.8%. It was true positive in 21.9%, false positive in 0.1%, false negative in 1.3%, and true negative in 76.6%. Fifty-nine patients from the true-positive group had grossly equivocal tests, but had positive lavage results based on quantitative cell count. Thus without cell count the test would have a sensitivity of 78.3%, accuracy of 94.8%, and specificity of 99.8. Eight patients had positive lavage based on WBC count but negative RBC count; all of these patients had bowel injuries. Measurement of lavage fluid amylase resulted in minimal or no improvement in the accuracy (0.06%), sensitivity (0.3%), or specificity (0.0%). Five of six patients with positive amylase levels but grossly negative tests had concomitant positive WBC count. The added cost of the amylase measurement is estimated to be

The management of human bite injuries of the hand.

154,472. Peritoneal lavage has high accuracy, sensitivity, and specificity. Cell counts significantly improve sensitivity. Patients with a grossly equivocal test but with a positive cell count should undergo laparotomy. The lavage-fluid amylase measurement is costly and is of insignificantly yield.