Kenneth G. Swan

Outcome of complex venous reconstructions in patients with trauma.

PURPOSE The role of complex venous reconstructions (CVRs) in patients with major trauma remains a controversial topic. This study evaluates the patency and clinical outcome of CVRs in a major urban trauma center. METHODS Between 1979 and 1994 the records of 92 patients with 100 injuries to the iliac, femoral, and popliteal venous system were reviewed. The incidence of edema, pulmonary embolism, and limb loss was documented in 75 men and 17 women (mean age of 27 years, range 14 to 59 years). The 30-day patencies were assessed in all patients with either impedance plethysmography (n = 16), venography (n = 40), or duplex scan (n = 36). Long-term patencies were assessed in 14 patients monitored for 0.5 to 9 years (mean 3.2 years). RESULTS Mechanisms of injury consisted of 58 gunshot wounds, 23 stab wounds, 6 shotgun wounds, and 5 blunt injuries. There were 112 associated injuries, 41 of which were concomitant arterial injuries. Forty-five of the 100 venous injuries were repaired with CVRs and included 6 (13%) spiral vein grafts, 8 (18%) panel vein grafts, 8 (18%) reversed saphenous vein interposition grafts, 8 (18%) end-to-end repairs, and 15 (33%) vein patch repairs. Thirty-day patency rates for these repairs were 50%, 50%, 75%, 88%, and 87%, respectively, and an overall patency rate of 73% was observed. The remaining 55 injuries were treated with ligation (n = 27) or lateral venorrhaphy (n = 28). The cumulative 30-day patency rate for all venous repairs was 81% (59 of 73). Fourteen patients, nine of whom had CVRs, were available for long-term follow-up. In this group CVRs demonstrated a 100% patency. One patient with a spiral vein graft repair of the common femoral vein had severe reflux causing intermittent edema and mild lipodermatosclerosis. No pulmonary emboli, limb loss, or deaths were identified in patients undergoing CVRs. CONCLUSION Patients with CVRs had a 30-day patency rate of 73%. Of this group panel and spiral vein grafts were less successful, exhibiting only a 50% 30-day patency rate, whereas end-to-end and vein patch repairs were successful in 88% and 87% of cases, respectively. Our overall evaluation suggests that use of CVRs results in successful venous repair; however, the postoperative patency of interposition panel and spiral grafts suggests selective use of these techniques.

Principles of ballistics applicable to the treatment of gunshot wounds.

Ballistics is the science of the motion of a projectile through the barrel of a firearm (internal ballistics), during its subsequent flight (external ballistics), and during its final complicated motion after it strikes a target (terminal ballistics). Wound ballistics is a special case of terminal ballistics. Although wound ballistics is at best sets of approximations, its principles enter usefully into an evaluation of a gunshot wound and its treatment. A special consideration in these cases is their medicolegal aspects. At a minimum, the medical team receiving the patient should exert care not to destroy the clothing and in particular to cut around and not through bullet holes, to turn over to law enforcement officials any metallic foreign body recovered from the patient, and to describe precisely, or even to photograph, any entrance or exit wounds.

Penetrating extremity trauma: Identification of patients at high-risk requiring arteriography

Indications for arteriography in patients with penetrating trauma to the extremities remain controversial. Some clinicians have recommended universal use of arteriography, whereas others prefer to rely on physical findings alone. To better define our indications for contrast studies, we reviewed clinical data on 306 patients (349 extremities) with penetrating trauma who were admitted during a prior 2-year period (1985 to 1987). Injuries were caused by stab wounds in 50 (14.3%) extremities and by gunshot wounds in 299 (85.7%) extremities. Twenty-seven of the 50 stab wounds (54%) required urgent exploration based on physical findings, whereas 23 underwent arteriography. None of these studies showed unsuspected arterial injury. Twenty-nine of 299 gunshot wounds (9.7%) underwent mandatory exploration, and arteriograms were performed on 270 extremities; findings in 30 studies (11.1%) were positive for unsuspected arterial injuries. Gunshot wounds were categorized according to location and number of arteriograms with positive results. Arteriograms of lateral thigh and upper arm injuries resulted in no positive outcomes. Positive study results were recorded in 22.9% of calf injuries, 20% of forearm and antecubital injuries, 9.5% of popliteal fossa injuries, 9.0% of medial and posterior thigh injuries, and 8.3% of medial and posterior upper arm injuries. We recommend arteriography for penetrating injuries to these high-risk areas. However, clinical evaluation alone is accurate for identification of arterial trauma with lateral thigh or upper arm wounds and stab wounds to the extremities.

Tube thoracostomy and trauma ― antibiotics or not?

: Controversy persists regarding the use of antibiotics in association with t tube thoracostomy for trauma patients. We conducted a prospective randomized study of patients requiring tube thoracostomy for pneumo- and/or hemothorax complicating blunt or penetrating thoracic trauma in an attempt to assess the efficacy of prophylactic antibiotic therapy. Fifty-eight patients were included in the study. The control group (Group I) included 28 patients who received no antibiotic therapy: the experimental group (Group II) included 30 patients who received cefoxitin (1.0 gm IV q 6 h) commencing before tube thoracostomy and terminating 12 hours after its removal. The incidence of infectious complications (pneumonia and/or empyema) was recorded. Among the patients not receiving antibiotics, eight of 28 (29%) developed infectious chest complications. Of the patients receiving antibiotics, there was one infectious complication (3%). This difference is statistically significant (p = 0.0227). Cultures demonstrated significant conversion from negative to positive both within each group and between groups. The organism most commonly recovered was S. aureus. Our findings strongly suggest that patients requiring tube thoracostomy for trauma, whether blunt or penetrating, should receive the benefit of systemic prophylactic antibiotic therapy.

Historical review of emergency tourniquet use to stop bleeding.

BACKGROUND Although a common first aid topic, emergency tourniquets to stop bleeding are controversial because there is little experience on which to guide use. Absent an adequate historical analysis, we have researched development of emergency tourniquets from antiquity to the present. METHODS We selected sources emphasizing historical development of tourniquets from books and databases such as PubMed. RESULTS The history of the emergency tourniquet is long and disjointed, mainly written by hospital surgeons with little accounting, until recently, of the needs of forward medics near the point injury. Many investigators often are unaware of the breadth of the tourniquets history and voice opinions based on anecdotal observations. CONCLUSIONS Reporting the historical development of tourniquet use allowed us to recognize disparate problems investigators discuss but do not recognize, such as venous tourniquet use. We relate past observations with recent observations for use by subsequent investigators.

Acute complications associated with greenfield filter insertion in high-risk trauma patients.

BACKGROUND Use of Greenfield filters (GFs) to prevent fatal pulmonary embolism (PE) in trauma patients is generally well accepted. Nonetheless, a surprisingly small number of trauma surgeons insert filters in their patients. Among the reasons cited is fear of complications. METHODS We observed three femoral arteriovenous fistulae (AVF) in trauma patients who had inferior vena caval placement of filters for PE prophylaxis in one 12-month period (academic year 1999). In an effort to document the magnitude of this problem, we evaluated trauma patients who had a GF inserted in academic year 2000. RESULTS During that year, 133 consecutive patients (8.6% of trauma admissions) received 133 GFs through a percutaneous approach. The most common isolated indications for GF insertion included closed head injuries (n = 28), multiple long bone fractures (n = 27), pelvic and acetabular fractures (n = 6), spinal cord injuries (n = 16), and vertebral fractures (n = 3). Five patients had documented deep venous thrombosis (DVT) diagnosed by duplex ultrasonography before GF placement, and 11 patients had other indications requiring a filter. There were 37 patients with more than one indication requiring filter placement. Most patients (57%) underwent preinsertion duplex scanning of their lower extremity veins; 77% of patients underwent postinsertion scanning. Filters were inserted an average of 6.8 +/- 0.6 (SE) days after trauma. No AVF were suspected clinically or detected ultrasonographically. No operative or postoperative complications occurred. DVT was observed in 30% of patients despite 92% prophylaxis; there was a 26% incidence of de novo thrombi detected. None of the patients evidenced DVT clinically. CONCLUSION Our data indicate that complications of GF insertion for prophylaxis against PE from DVT complicating trauma patients continue to be negligible. In addition, the incidence of insertion-site thrombosis may be lower than expected. Moreover, femoral AVF is a rare complication of this procedure.

Infrapopliteal arterial injury: prompt revascularization affords optimal limb salvage.

Sixty-nine limbs with infrapopliteal arterial injuries were evaluated in 68 patients. Thirty-five (50%) cases were complicated by acute limb-threatening ischemia. Management consisted of revascularization (26 limbs), ligation (15 limbs), fasciotomy only (2 limbs), observation (18 limbs), and primary amputation (8 limbs). Penetrating injuries (n = 35) had a 33% incidence of ischemia and a reduced frequency of associated injury. One delayed amputation (3%) was required. In contrast, blunt injuries (n = 34) had a 68% incidence of ischemia and a greater frequency of associated injury. There were 20 amputations in the blunt group, including eight primary amputations performed in limbs with profound ischemia, complex open fractures, severe soft-tissue damage, and neural injury. Observation or ligation of single arterial injuries resulted in no early amputations. Associated local injuries in both groups included fracture or ligamentous disruption (64%), severe soft-tissue damage (32%), and nerve dysfunction (36%). In both groups, 15 of 35 ischemic limbs were salvaged by prompt revascularization (11 penetrating and four blunt injuries). Aggressive revascularization with autogenous repair or bypass is recommended for management of penetrating trauma. Though a good outcome will be achieved in some patients with combined blunt trauma and infrapopliteal arterial injury, the probability of delayed amputation and prolonged disability must be consciously integrated into the decision to pursue limb salvage. The prognosis for blunt injury complicated by arterial ischemia is poor; thus the severity of associated local and remote injuries will affect the results of revascularization program.

Decelerational thoracic injury

BACKGROUND Among the five major decelerational thoracic injuries [myocardial contusion (MC), traumatic aortic disruption (TAD), sternal fracture (SF), flail chest (FC), and tracheobronchial disruption (TBD)], coexisting injuries are seemingly rare. METHODS To test this hypothesis, we reviewed the records of all patients, with final diagnosis (FDX) codes of these injuries, treated at our Level I trauma center for the 10 years preceding 1997. RESULTS Among 142 patients, all victims of motor vehicle crashes, there were 38 MC, 36 TAD, 33 FC, 28 SF, and 7 TBD. There were six coexisting injuries (3.5%). Three patients with coexisting injury died in the operating room. All three had TAD; one of these three had TBD plus MC; one had additionally FC and MC and the third had FC in addition to the TAD. One patient with SF and probable MC died in the emergency room. Two patients with FC and a coexisting injury survived. One had MC, the other SF. CONCLUSION We conclude that these decelerational thoracic injuries, with the exception of sternal fracture, are sufficiently life threatening by themselves to cause fatality. When combined, the threat to life is potentiated. Death occurs at the scene or shortly after arrival in the ER. The diagnosis of one may help exclude the diagnosis of each of the other four. The role of sternal fracture in this paradigm remains an enigma.

Open gastrostomy for noninvasive ventilation users with neuromuscular disease.

Bach JR, Gonzalez M, Sharma A, Swan K, Patel A: Open gastrostomy for noninvasive ventilation users with neuromuscular disease. Objective:To report open gastrostomy for ventilator-assisted or -supported patients with altered nutritional status as a result of severe dysphagia and without tracheostomy, translaryngeal intubation, or general anesthesia. Avoiding intubation and general anesthesia decreases the risk of respiratory complications and can prolong noninvasive respiratory management. Design:The procedure was performed for 62 noninvasive intermittent positive-pressure ventilation users: 44 with amyotrophic lateral sclerosis, 10 with muscular dystrophy including 6 with Duchenne muscular dystrophy, and 8 with other conditions. All had vital capacities <40% of predicted normal. Noninvasive intermittent positive-pressure ventilation was provided in ambient air before, during, and after the procedure. Oxyhemoglobin saturation was maintained at 95% or greater and end-tidal CO2 <40 cm H2O by noninvasive intermittent positive-pressure ventilation and mechanically assisted coughing. Results:There were no complications of the procedure. All patients gained weight subsequently. Mean postgastrostomy survival was 38.8 ± 6.2 mos with 26 of the patients still alive. Eighteen of the 62 patients had no ventilator-free breathing ability before, during, or after the gastrostomy. Fifty-one patients eventually lost all ventilator-free breathing abilities without tracheostomy. Conclusions:Open gastrostomy can be performed safely without airway intubation or general anesthesia for patients with little or no autonomous breathing ability. It permitted continued survival without tracheostomy despite loss of all ventilator-free breathing abilities for 51 patients.

Traumatic aorto-caval fistula

Trauma is an unusual cause of fistula formation between the aorta and the inferior vena cava. Two cases of traumatic aorto-caval fistula treated at the New Jersey Medical School affiliated hospitals are presented and the literature on traumatic aorto-caval fistula reviewed. We found 14 previously reported cases. Delayed repair was performed in 12 (86%). Delays ranged from 5 days to 12 years postinjury. Cardiac decompensation, judged either clinically or by cardiomegaly evident on chest X-ray, was present in 75% of the patients undergoing delayed repair. The techniques available for repair and the criteria for utilizing delayed repair are discussed. In young, previously healthy patients, usually with smaller fistulae, we conclude that delayed repair can be used.