Larry Martin

1,000 Consecutive Ultrasounds for Blunt Abdominal Trauma

Diagnostic peritoneal lavage (DPL) and computed tomography (CT) are the primary diagnostic modalities used in the evaluation of patients with suspected blunt abdominal trauma (BAT). DPL is fast and accurate but is associated with complications. CT is also accurate, yet requires stability and transportability of the patients. Ultrasound (US) has been suggested as an aid in evaluating BAT. We evaluated US in the initial assessment of BAT in 1000 patients. Patients were eligible for the study if they met specified trauma criteria and had suspected BAT. We then followed the outcome of the patients and their further work-up. US showed a sensitivity of 88%, a specificity of 99%, and an accuracy of 97% for detecting intraabdominal injuries. We conclude that emergency ultrasound may be used as the initial diagnostic modality for suspected blunt abdominal trauma.

Open Versus laparoscopic appendectomy : a prospective randomized comparison

ObjectiveThe authors compare open and laparoscopic appendectomy in a randomized fashion with regard to length of operation, complications, hospital stay, and recovery time. MethodsAdult patients (older than 14 years of age) with the diagnosis of acute appendicitis were randomized to either open or laparoscopic appendectomy over a 9-month period. All patients received preoperative antibiotics. The operative time was calculated as beginning with the incision and ending when the wound was fully closed. Patients that were converted from laparoscopic to open appendectomy were considered a separate group. Return to normal activity and work were determined by questioning during postoperative clinic, telephone, or mailed questionnaire. ResultsThere was a total of 169 patients randomized, 88 to the open and 81 to the laparoscopic group. The groups were similar demographically. Of the 81 laparoscopic patients, 13 (16%) were converted to open. In the open group, 70 patients (79.5%) had acute appendicitis and 21 (23.9%) had perforative appendicitis. In the laparoscopic group, 62 patients (76.5%) had acute appendicitis and 10 (12.3%) had perforative appendicitis. There was no statistical difference in the return to activity or work between the laparoscopic and open groups. The operative time was significantly longer in the laparoscopic group (102.2 minutes vs. 81.7 minutes, p < 0.01). The hospital stay of 2.2 days in the laparoscopic group and 4.3 days in the open group was statistically different (p = 0.007). There was no difference in the hospital stay for those with acute appendicitis (1.89 days vs. 2.61 days, p = 0.067) compared with those with a normal appendix but with pelvic inflammatory disease (1.1 days vs. 2.3 days, p = 0.11). There was a significant difference in patients with perforative appendicitis (1.5 days vs. 9.5 days, p < 0.01). The hospital cost for patients having laparoscopic appendectomy was

Can ultrasound replace diagnostic peritoneal lavage in the assessment of blunt trauma

6077 and for an open appendectomy

New Substrates for the Radioassay of Angiotensin Converting Enzyme of Endothelial Cells in Culture

7227 (p = 0.164). There were no increased complications associated with the laparoscopic technique. ConclusionLaparoscopic appendectomy is comparable to open appendectomy with regard to complications, hospital stay, cost, return to activity, and return to work. There was a greater operative time involved with the laparoscopic technique. Laparoscopic appendectomy does not offer any significant benefit over the open approach for the routine patient with appendicitis.

Occult herpes family viral infections are endemic in critically ill surgical patients.

Diagnostic peritoneal lavage (DPL) and computed tomography (CT) are the primary diagnostic modalities in the evaluation of patients with suspected blunt abdominal trauma (BAT). Diagnostic peritoneal lavage is fast and accurate but associated with complications. Computed tomography is also accurate, yet requires that patients be stable and transportable. A prospective study was designed to determine the utility of emergency ultrasound (US) studies in the initial assessment of BAT. Two hundred acutely injured patients with suspected BAT were evaluated with US. Patients were eligible for the study if they met trauma criteria and had suspected BAT. Subsequently, without knowledge of the US results, DPL or CT was performed. Ultrasound showed a sensitivity of 83%, a specificity of 100%, and an accuracy of 97% in detecting intra-abdominal injuries. Six injuries were missed but only one was felt to be significant. If US had been used in all 200 patients, 199 would have had appropriate care. We conclude US is reliable in the detection of free intraperitoneal fluid and may be used in place of DPL or CT.

Management Of Lower Extremity Arterial Trauma

To develop means of measuring angiotensin converting enzyme of endothelial cells in culture, we have synthesized benzoyl-Phe-Ala-Pro-OH (I), benzoyl-Pro-Phe-Arg-OH (II) and benzoyl-Gly-His-Leu-OH (III), each bearing a 3H-atom on the para-position of its benzoyl moiety. All three of the acylated tripeptides are substrates for the enzyme. Substrate I exhibits the lowest Km (12.5 micrometer) and yields the most sensitive assay: the enzyme of 10(6) cells can be measured in a 30 min incubation at 37 degrees C. Radiolabelled reaction product is separated from substrate by extraction of acidified reaction mixture with an organic solvent, and the rate of formation of product can be quantified by liquid scintillation counting of the organic phase. Substrate III can also be used to measure angiotensin converting enzyme of cells but requires longer incubations (180--240 min) and high salt concentrations (0.75 M Na2SO4). Substrate II is not specific: it is hydrolyzed by more than one enzyme of endothelial cells.

The role of computed tomography in selective management of gunshot wounds to the abdomen and flank

ObjectiveHerpes family viruses have been recognized as pathogens for many years in immunosuppressed transplant or human immunodeficiency virus patients, but they have garnered little attention as potential pathogens in the nonimmunosuppressed critically ill. The objective of this study was to define the prevalence of and risk factors for development of herpes family virus infection in chronic critically ill surgical patients. DesignProspective epidemiologic study. SettingA 38-bed surgical intensive care unit in a major university hospital. PatientsNonimmunosuppressed intensive care unit patients in intensive care unit for ≥5 days. InterventionsNone; patients received no antiviral treatment during the study. Measurements and Main ResultsWeekly cultures for cytomegalovirus (CMV) and herpes simplex virus, viral serologies, and T-cell counts were performed. The prevalence (95% confidence interval) of positive respiratory cultures for herpes simplex or CMV was 35% (22–49%); 15% (5–25%) cultured positive for CMV, 23% (11–35%) cultured positive for herpes simplex virus, and one patient’s respiratory secretions culturing positive for both CMV and herpes simplex virus. The prevalence of CMV viremia was only 5.8% (1–10%). CMV+ patients had longer hospital admissions, intensive care unit admissions, and periods of ventilator dependence than CMV− patients, despite having comparable severity of illness scores. CMV+ patients also had significantly higher numbers of blood transfusions, prevalence of steroid exposure, and prevalence of hepatic dysfunction, and all were immunoglobulin G positive at the beginning of the study. In contrast, herpes simplex virus–positive patients had lengths of hospital admissions, lengths of intensive care unit admissions, and periods of ventilator dependence comparable with patients without viral infections (p > .05). ConclusionsThere is a significant prevalence (22–49%) of occult active herpes family viruses in chronic critically ill surgical patients. The clinical significance of these viral infections is unknown, although CMV+ patients have significantly higher morbidity rates than CMV− patients. Several factors suggest pathogenicity, but further study is needed to define causality.

Laparoscopy in 121 consecutive patients with abdominal gunshot wounds

Extremity vascular trauma is common in most urban trauma centers and controversy remains about the optimal management of arterial injuries. We examined the records of 188 patients who had lower extremity arterial trauma from September 1987 to April 1992 to help clarify these issues. There were 142 (75.5%) gunshot wounds, 18 (9.6%) stab wounds, 5 (2.7%) shotgun wounds, and 23 (12.2%) patients with blunt trauma. There were 43 (22.9%) associated venous injuries. There were 10 repair failures in the acute postoperative period. There were no repair failures for the iliac artery. Three failures involved the superficial femoral artery (SFA), six were popliteal, and one tibial. Vein and polytetrafluoroethylene (PTFE) grafts were used to repair the SFA with equal success. Repair of the popliteal artery with PTFE failed in four of five cases, while vein grafts failed in only 2 of 19 cases (p < 0.01). Graft failure was associated with blunt trauma in 8 of 23 patients (35%), and always resulted in amputation. Penetrating injuries accounted for only 2 of 165 (1.2%) failures and were successfully redone with no amputations. Venous injury was present in all SFA failures. Popliteal vein injury was present in two PTFE and two vein grafts that failed. There were no infections of vein or PTFE grafts. In conclusion, PTFE and vein have equal graft patency for the repair of the iliac and femoral arteries. However, the patency of PTFE was significantly worse in the popliteal location. Vein grafts should be used for repair of this vessel. Graft failure and amputation were more common with popliteal and tibial injuries from blunt mechanisms.(ABSTRACT TRUNCATED AT 250 WORDS)

Negative Laparotomy in Abdominal Gunshot Wounds: Potential Impact of Laparoscopy

OBJECTIVE To determine whether computed tomography (CT) is an accurate diagnostic modality for the triage of hemodynamically stable patients with gunshot wounds of the abdomen and flank. METHODS A chart review of 83 trauma patients for whom abdominal CT was used as initial screening. RESULTS In 53 patients, CT revealed no evidence of peritoneal penetration, and in 15 patients, there was evidence of either peritoneal penetration or liver injury. There were no false results in these patients. Among 15 patients with questionable peritoneal penetration, cavitary endoscopy was performed in 11 and exploratory laparotomy was performed in 3, and 1 patient was initially observed and subsequently underwent exploratory surgery for a missed colonic injury. CONCLUSION In selected centers and in hemodynamically stable patients with abdominal and flank gunshot wounds, abdominal CT can be an effective and safe initial screening modality to document the presence or absence of peritoneal penetration and to manage nonoperatively stable patients with liver injuries. If there is any question of peritoneal penetration, cavitary endoscopy should be part of the protocol of nonoperative management.

Blunt splenic injuries: have we watched long enough?

OBJECTIVE The purpose of this study was to evaluate the sensitivity, specificity, and predictive value of diagnostic laparoscopy (DL) in a large group of stable patients with abdominal gunshot wounds (ABGSWs). DESIGN This study was a prospective case series developed by management protocol. MATERIALS AND METHODS In a 2 1/2-year period, DL was performed in 121 consecutive patients who were hemodynamically stable with ABGSWs and met protocol criteria. This represented 18% of all patients with ABGSWs seen in this period at the Ryder Trauma Center. The evaluation was conducted to determine peritoneal violation, the presence of intra-abdominal blood, and the need for exploration. MEASUREMENTS AND MAIN RESULTS There were 42 (35%) positive and 79 (65%) negative DLs. In patients with positive DL, 39 (92.8%) had exploratory laparotomy. In this group, 32 (82%) had therapeutic laparotomy, 6 (15.4%) had nontherapeutic laparotomy, and 1 (2.5%) had a negative laparotomy. In this patient, DL was felt to be inadequate by the attending surgeon, although no penetration or intraperitoneal blood were present, and a negative laparotomy was done. This represents a failure rate of 0.8%. There were 3 (7.2%) positive DLs, in whom laparotomy was not performed. These patients had isolated nonbleeding liver injuries, and nontherapeutic laparotomy was successfully avoided. The negative DL group was divided into 47 patients (60%) with isolated ABGSWs, and 32 patients (40%) with associated injuries, mostly orthopedic and thoracic. There were no false-negative DLs and no delayed laparotomies in these 121 patients. There was no mortality in this study group. The sensitivity for peritoneal penetration was 100%, and the specificity was 98.7%. The positive predictive value was 97.6%, and the negative predictive value was 100%. In deciding on need for laparotomy (i.e., injury requiring repair), DL had a positive predictive value of 82%; more importantly, the negative predictive value was 100%. CONCLUSIONS In stable patients with ABGSWs and questionable intra-abdominal injury, DL can be safely used. It is highly sensitive and specific. It can effectively reduce the incidence of negative and nontherapeutic laparotomies, and the overall morbidity and hospital stay in this group of patients.