Jonathan M. Saxe

The technique of visceral packing : recommended management of difficult fascial closure in trauma patients

Since 1986, we have cared for 17 patients whose abdomen could not be closed because of bowel edema and loss of abdominal wall compliance. These patients were managed by a technique of visceral packing with the intestines kept in place by a combination of rayon cloth, gauze packs, and retention sutures. This packing was changed in the operating room under general anesthesia until the edema was sufficiently resolved to allow for closure. Two patients died within 24 hours of operation from irreversible shock. The remaining 15 patients had their fascia successfully closed with an average of two additional anesthetics. There was one case of fasciitis associated with the development of an intra-abdominal abscess and one patient died of late sepsis. There was no early postoperative ventilatory compromise or acute oliguric renal failure. Other direct complications have been minor with no enterocutaneous fistulae, dehiscence, or incisional hernia. Visceral packing of posttraumatic abdominal wounds circumvents expected complications of intraperitoneal hypertension and enhances the chance for survival. Its ease and low morbidity also lends itself to a wide variety of other uses.

Massive Steroids Do Not Reduce the Zone of Injury After Penetrating Spinal Cord Injury

The National Acute Spinal Cord Injury Study II concluded in 1990 that high-dose methylprednisolone (MP) improved neurologic recovery after acute spinal cord injury (ASCI). We tested this conclusion by analysis of 54 patients with ASCI; 25 patients were treated without MP before 1990 whereas 29 patients were treated with MP after 1990. Neurologic deficit was assessed regularly, in most cases daily. Motor and sensory scores on admission, and best results at one-half week (days 2 to 4), 1 week (days 6 to 10), 2 weeks (days 11 to 21), 1 month, and 2 months were noted for both groups. Motor assessment was recorded in 22 muscle segments on a scale of 0 (complete deficit) to 5 (normal); the range, thus, was 0 to 110. The 23 patients with closed injuries demonstrated no difference in improvement with or without MP. In contrast, MP was associated with impaired improvement in the patients with penetrating wounds; the 15 patients with no MP therapy had an admission motor score of 49, which increased by 6.9 at one-half week, whereas the 16 patients treated with MP had an admission motor score of 48, which decreased by 0.3 at one-half week (p = 0.03). The neural status seen by day 4 persisted throughout the next 2 months. Changes in sensation paralleled the changes in motor function. We conclude that MP therapy for penetrating ASCI may impair recovery of neurologic function.

Lower Esophageal Sphincter Dysfunction Precludes Safe Gastric Feeding After Head Injury

Early nutrition is advocated for patients with head injury to counter the postinjury hypermetabolic state. The gastric route of feeding often leads to vomiting and aspiration pneumonitis. This study was designed to identify the role of lower esophageal sphincter (LES) function in this complication. The LES function was assessed within 72 hours of admission in 16 patients with a head injury and a Glasgow Coma Scale (GCS) score less than 12 (range, 3-11). Other admission assessments included an APACHE II score of 11.7, Injury Severity Score (ISS) of 30.5, and a Revised Trauma Score (RTS) of 6.4. These studies were repeated 1 week postinjury in five patients. Dysfunction of the LES was present in all 16 patients; the average gastric-to-esophageal pressure difference was -0.49 mm Hg (range, -0.59 to 2.5) compared with a normal value of greater than 20 mm Hg. The five patients restudied at 1 week had a gastric-to-esophageal pressure difference of 13.3 mm Hg (range, -3.4 to 36.6 mm Hg). The single patient with a GCS score below 12 at 1 week had a low LES tone. These data show that LES dysfunction accompanies acute head injury and contributes to aspiration pneumonitis after early gastric feeding. Nutrition in patients with low GCS scores should be parenteral or via the jejunum.

Diagnosis of Blunt Intestinal and Mesenteric Injury in the Era of Multidetector Ct Technology—are Results Better?

BACKGROUND Blunt Bowel and Mesenteric injuries (BBMI) can present diagnostic difficulties and are occasionally recognized in a delayed fashion. Most studies evaluating these injuries predate multidetector Computerized Tomography (CT) scan technology. We set out to analyze whether the current era of multislice CT scanning has led to changes in the incidence of missed injuries in BBMI or altered the patterns of diagnosis. METHODS All patients with blunt small and large intestinal injury as well as mesenteric lacerations, recognized in the operating room (OR) between November 2000 and December 2006 were identified from the trauma registry. A 4 slice helical multidetector CT scanner was in use for abdominal CT scans during the first portion of the study (November 2000-July 2005) whereas a 16 slice scanner was in use in the second portion (July 2005-December 2006). Rectal injuries and serosal tears were excluded. RESULTS Eighty-two patients were identified with BBMI. Twenty-five patients went directly to the OR for laparotomy after a positive Diagnostic Peritoneal Lavage, a positive Focused Abdominal Sonogram or other injury. Of the 57 patients who underwent CT, findings indicating possible BBMI were present in 46 patients (80.7%). These included free fluid without solid organ injury (50.9%), free air (10.5%), active mesenteric bleeding (10.5%), and bowel swelling (5.3%). Eleven patients (19.3%) had delayed bowel or mesenteric injury recognition with the diagnosis ultimately made by repeat CT or in the OR (range, 1-10 days). CONCLUSION Missed injuries remain common in BBMI even in the current era of multislice CT scanners. Free fluid w/o solid organ injury, though not specific, continues to be an important finding. Adjuncts to CT continue to be necessary for the optimal diagnosis of bowel injuries.

Prediction of Rib Fracture Injury Outcome by an Artificial Neural Network

Outcome-based therapy is becoming the standard for assessing patient care efficacy. This study examines the ability of an artificial neural network to predict rib fracture injury outcome based on 20 intake variables determined within 1 hour of admission. The data base contained 580 patient records with four outcome variables: Length of hospital stay (LOS), ICU days, Lived, and Died. A 522-patient training set and a 58-patient test set were randomly selected. Nine networks were set up in a feed-forward, back-propagating design with each trained under different initial conditions. These networks predicted the test set outcome variables with an accuracy as high as 98% at the 80% testing level. Internal weight matrix examination indicated that age, ventilatory support, and high trauma scores were strongly associated with both ICU days and mortality. Being female, injury severity, and injury type were associated with increased LOS. Smoking and rib fracture number were low-level predictors of the four outcome variables.

Neurologic Outcomes with Cerebral Oxygen Monitoring in Traumatic Brain Injury

BACKGROUND Optimizing cerebral oxygenation is advocated to improve outcome in head-injured patients. The purpose of this study was to compare outcomes in brain-injured patients treated with 2 types of monitors. METHODS Patients with traumatic brain injury and a Glasgow Coma Scale score<8 were identified on admission. A polarographic cerebral oxygen/pressure monitor (Licox) or fiberoptic intracranial pressure monitor (Camino) was inserted. An evidence-based algorithm for treatment was implemented. Elements from the prehospital and emergency department records and the first 10 days of intensive care unit (ICU) care were collected. Glasgow Outcome Scores (GOS) were determined every 3 months after discharge. RESULTS Over a 3-year period, 145 patients were entered into the study; 81 patients in the Licox group and 64 patients in the Camino group. Mortality, hospital length of stay, and ICU length of stay were equivalent in the 2 groups. More patients in the Licox group achieved a moderate/recovered GOS at 3 months than in the Camino Group (79% vs 61%; P = .09). CONCLUSION Three-month GOS revealed a clinically meaningful 18% benefit in patients undergoing cerebral oxygen monitoring and optimization. Six-month outcomes were also better. Unfortunately, these important differences did not reach significance. Continued study of the benefits of cerebral oxygen monitoring is warranted.

Educating Grade School Children Using a Structured Bicycle Safety Program

BACKGROUND Prevention is understudied in trauma care. Furthermore, the effectiveness of prevention outreach programs is not well documented. We attempted to verify that elementary school educational programs effectively create retained knowledge. METHODS Three hundred fifty-one students (grades 1-3) viewed a bicycle safety videotape and then listened to a structured discussion of bicycle safety rules. Coded pretests were given before and identical posttests were given immediately after the session. Tests were readministered 1 month later to evaluate retained knowledge. Two hundred fifty-one students completed all three tests. RESULTS Students showed significant (p < 0.01) improvement in retained knowledge about riding with traffic, wearing a bicycle helmet, warning pedestrians when riding on sidewalks, and stopping before riding into the street. CONCLUSION We conclude that prevention programs are effective and result in retained knowledge. Further analysis is recommended to evaluate retained knowledge at greater intervals after the original education.

Is Chest X-Ray an Adequate Screening Tool for the Diagnosis of Blunt Thoracic Aortic Injury?

BACKGROUND Blunt thoracic aortic injuries (BTAI) have a high mortality rate. For survivors, chest X-ray (CXR) findings are used to determine the need for further diagnostic testing with chest computerized tomography with angiography (CTA) or conventional angiography. We set to determine the adequacy of utilizing CXR alone as a screening tool for BTAI. METHODS All patients diagnosed with BTAI at a level I trauma-center during a 7-year-period were identified. CXRs of these patients and those of a control group of blunt trauma patients with an injury severity score >15 were reviewed by four trauma surgeons blinded to the diagnosis. Based on each CXR viewed, the surgeons decided if they would have proceeded to chest CTA, angiography, or required no further studies to rule out BTAI. RESULTS In the 7-year-period, 83 patients had BTAI. CXRs were available in 45 patients. The four surgeons viewed 96 CXRs including those of 51 controls. Based on the CXR appearance in patients with BTAI, the surgeons chose to proceed to chest CTA in 38 patients (84.4%), conventional aortography in two patients (4.4%), and no further testing in five patients (11.2%). A widened mediastinum (75%) and loss of the aorto-pulmonary window (40%) were the most frequent CXR abnormalities. Patients with BTAI were more likely to have an abnormal CXR-40 of 45 (88.8%) patients when compared with the controls-25 of 51 (49%)patients-p < 0.001. CONCLUSIONS Although CXR is a sensitive screening modality, it failed to identify the possibility of BTAI in 11% of patients. The liberal use of chest CTA after high speed motor vehicle crashes is recommended to minimize the incidence of missed BTAI.

Outcome of cervical near-hanging injuries

BACKGROUND Cervical near-hangings are not rare, but have received little attention in the trauma literature. Increasing numbers of patients received from our local jail and detention centers prompted this study. METHODS Seventeen-year review of a level I Trauma Center Registry identified 67 patients with cervical strangulation for study. Data were analyzed using the Mann-Whitney test to evaluate continuous predictors, and Fishers exact test for categorical predictors. RESULTS Ten of 67 patients died (14.9% mortality). Patients having a lower Glasgow Coma Score (GCS) at the scene (3.5 +/- 1.3 vs. 8.3 +/- 5.0; p = 0.001) and lower GCS in the emergency department (ED) (3.0 +/- 0.0 vs. 9.0 +/- 5.3; p < 0.001) were more likely to die. Injuries consisted predominantly of neck abrasions and anoxic brain injuries (83% mortality). Laryngeal fractures and carotid arterial injuries were detected. No cervical spine fractures were seen, but subluxations were identified. Forty-two percent of the patients were in detention centers when the near-hanging incident occurred. CONCLUSIONS Cervical near-hangings are referred to the Trauma Service for evaluation. Scene or ED GCS of 3 does not preclude neurologically intact survival, although mortality is high. In our study, the most useful prognostic factors were the need for airway control by intubation or cricothyrotomy, cardiopulmonary resuscitation, lower scene and ED GCS, and cerebral edema on CT Scan. Optimal evaluation includes head and neck CT and CT angiography of the neck. We plan to share these results with local authorities and encourage improvement in risk identification, with earlier involvement of mental health personnel.

Is routine tube thoracostomy necessary after prehospital needle decompression for tension pneumothorax

BACKGROUND Thoracic needle decompression is lifesaving in tension pneumothorax. However, performance of subsequent tube thoracostomy is questioned. The needle may not enter the chest, or the diagnosis may be wrong. The aim of this study was to test the hypothesis that routine tube thoracostomy is not required. METHODS A prospective 2-year study of patients aged ≥18 years with thoracic trauma was conducted at a level 1 trauma center. RESULTS Forty-one patients with chest trauma, 12 penetrating and 29 blunt, had 47 needled hemithoraces for evaluation; 85% of hemithoraces required tube thoracostomy after needle decompression of the chest (34 of 41 patients [83%]). CONCLUSIONS Patients undergoing needle decompression who do not require placement of thoracostomy for clinical indications may be assessed using chest radiography, but thoracic computed tomography is more accurate. Air or blood on chest radiography or computed tomography of the chest is an indication for tube thoracostomy.