M. Luxenberg

Features of 164 Bladder Ruptures

We reviewed 164 cases of bladder rupture from external trauma. Of these patients 145 (88 per cent) suffered blunt trauma, and 59 (35.5 per cent) suffered intraperitoneal, 93 (57.5 per cent) extraperitoneal and 12 (7 per cent) both types of rupture. Bladder rupture owing to blunt trauma was caused by a compression (burst) type of injury in all patients with intraperitoneal rupture and in 24 per cent of those with extraperitoneal rupture. In the remaining instances of extraperitoneal rupture pelvic bone fragments corresponded to the site of the injury. Although surgical repair has been the traditional method of management of all bladder ruptures, nonoperative (catheter) management of extraperitoneal rupture was successful in most cases.

EARLY ENTERAL FEEDING DOES NOT ATTENUATE METABOLIC RESPONSE AFTER BLUNT TRAUMA

Enteral feeding very early after trauma has been hypothesized to attenuate the stress response and to improve patient outcome. We tested this hypothesis in a prospective, randomized clinical trial in patients with blunt trauma. Following resuscitation and control of bleeding, 52 patients were randomized to receive early feedings (target, < 24 hours) or late feedings (target, 72 hours). Feeding was given via nasoduodenal feeding tubes. A rapid advance technique was used to achieve full volume and strength within 24 hours (goal, 1.5 g protein/kg.day). Patients who underwent at least 5 days of therapy were considered to have completed the study: 38 in all, 19 in each feeding group. Patients were similar in age, gender, Injury Severity Score, and mean PaO2/FiO2 ratio. The early group, however, had more patients with a PaO2/FiO2 < 150. After feeding began, the amount fed per day was the same in both groups. We found no significant differences in metabolic responses as measured by plasma lactate and urinary total nitrogen, catecholamines, and cortisol. Both groups achieved nitrogen retention. In addition, we found no significant differences in intensive care unit (ICU) days, ventilator days, organ system failure, specific types of infections, or mortality, although the early group had a greater number of total infections. In this study, early enteral feeding after blunt trauma neither attenuated the stress response nor altered patient outcome.

Value of Early Operation in Blunt Testicular Contusion with Hematocele

The use of ultrasound for evaluation of blunt testicular injury with hematocele allows contusion to be differentiated from rupture, and some authors advocate reserving surgical management for rupture. Our experience with the conservative management of 20 men with testicular contusion and hematocele was not encouraging. Of the patients 8 (40 per cent) required delayed exploration that involved orchiectomy in 3 (15 per cent) because of unresorbed hematoma or infection despite antibiotic use. In contrast, early surgical exploration in 19 patients reduced the morbidity and duration of disability, and resulted in an orchiectomy rate of 0.

Clinical Indications for Radiographic Evaluation of Blunt Renal Trauma

The evaluation of patients with blunt renal trauma has become controversial. We tested the hypothesis that renal contusion can be diagnosed clinically and that these patients do not require radiographic evaluation. To evaluate the association of microhematuria without shock and with renal contusion, we reviewed the medical records of 831 patients with hematuria following blunt renal trauma. Microscopic hematuria without shock was noted in 160 of 241 patients without and 334 of 590 with associated injuries. Of the former 160 patients 159 had renal contusion and 1 had a renal laceration, while of the latter 334 patients 329 had renal contusion, 3 had renal laceration, 1 had renal rupture and 1 had a pedicle injury. Most patients with microscopic hematuria and no shock after blunt renal trauma had a renal contusion, especially those with no associated injury. All of the patients with renal contusions experienced no complications from nonoperative management. However, avoiding a radiographic evaluation in patients with blunt renal trauma plus microhematuria and no shock would miss a few cases of severe renal injury.

Conservative or immediate surgical management of Blunt renal injuries

From 1969 to 1981, 1,176 blunt renal injuries were recorded in 1,166 patients (10 patients had bilateral injuries). Conservative management of 27 patients with severe renal injuries resulted in a delayed renal operation in 30 per cent and total renal loss in 22 per cent. A review of the published series of the conservative management of patients with severe renal injuries (laceration, rupture and pedicle injury) shows a renal surgery rate of 13 to 68 per cent, a renal loss rate of 3 to 33 per cent and a significant complication/renal surgery rate of 13 to 76 per cent. In our patients 88 per cent with severe renal injuries had associated injuries and 73 per cent of these underwent immediate laparotomy for intra-abdominal injury. Immediate renal surgery in 59 patients with severe renal injuries resulted in a nephrectomy rate of 6.5 per cent of 31 renal lacerations, 100 per cent of 14 renal ruptures and 50 per cent of 14 pedicle injuries. Of the 14 patients with pedicle injuries 6 (43 per cent) had immediate vascular repair, with salvage of the kidney. Immediate surgical management of the patients with severe renal injuries obviated the need for a second exploration in a severely injured patient, reduced morbidity and resulted in increased renal salvage.

Renal pedicle injury in patients with multiple injuries.

In a study of 41 patients seen over 24 years, renal pedicle injuries were associated with life-threatening multiple system injuries and the immediate surgical management of these associated injuries by general surgeons took precedence over that of the renal pedicle injury. The result was the delayed diagnosis of the renal pedicle injury with loss of function of the kidney. In an effort to improve the renal salvage rate aggressive management of renal pedicle injuries with immediate radiologic evaluation and early surgical treatment was instituted in 1969. The records of 41 renal pedicle injuries from 1959 to 1983 were evaluated. Blunt external trauma was the cause in 76%. All 41 patients had multiple system injuries, averaging 3.7 associated injuries per patient, with 35 (85%) having a laparotomy for intra-abdominal injuries and an overall mortality rate of 44%. Conservative management was followed in 13 patients, with injury to the renal artery in nine and a branch of the renal artery in four, with a renal loss/delayed nephrectomy rate of nine of nine (100%) renal artery injuries. Immediate surgical management was performed in 23 patients, with injury to the renal artery in nine, the renal artery and renal vein in four, a branch of the renal artery in two, and the renal vein in eight, with a renal salvage rate of seven of 21 (33%) renal artery and/or vein injuries. Five patients died on admission or on the operating room table. A significant renal salvage rate resulted from immediate radiologic evaluation and early surgical treatment of renal artery/vein injuries compared to zero salvage rate with conservative management.

Does Sternal Fracture Increase the Risk for Aortic Rupture

We retrospectively reviewed the records of 99 patients who suffered sternal fractures between 1968 and 1987. Patients ranged in age from 5 to 86 years. The most common cause of injury was a motor vehicle accident. The 99 patients were compared with a concurrent series of 2,106 patients with chest injuries and no sternal fractures. Traumatic aortic rupture occurred in 2 of 99 patients with sternal fractures (2%) and in 75 of 2,106 patients without sternal fracture (3.6%). This difference was not statistically significant by the Fisher exact test (p = 0.326). We conclude that traumatic aortic rupture does not occur more commonly in patients with sternal fracture when compared with other patients with blunt chest injuries.

Management of extraperitoneal ruptures of bladder caused by external trauma

We reviewed 105 cases of extraperitoneal bladder rupture admitted to our hospitals from 1959 to 1985. Primary suturing of the rupture was performed in 65 patients, and catheter drainage alone without suturing of the rupture was performed in 34. The incidence of blunt trauma causing the rupture of gross hematuria on admission, and of associated injuries was similar in both groups. There was a higher incidence of women older than sixty years in the group managed by catheter drainage alone, and a higher incidence of laparotomy for associated intra-abdominal injuries and a higher mortality rate in the group treated by primary suturing. There were three early complications in the group treated by suturing (hematuria with clot retention 2, sepsis contributing to death 1) and four early complications in the conservatively treated group (hematuria with clot retention 1, pseudodiverticulum with bone spike in its floor 1, persistent urinary fistula 1, and sepsis contributing to death 1). There were two late complications in 42 patients followed in the group treated by suturing (urethral stricture 1, frequency and dysuria 1), and three late complications in 14 patients followed in the conservatively treated group (hyperreflexic bladder 2, urethral stricture and vesical calculi 1). Catheter drainage alone for extraperitoneal rupture from external trauma was simple, quick to perform, and appealing in the multiple-injured patient. Although the early and late complication rates were higher in the conservatively managed group, there was no statistically significant difference from the group treated by primary suturing.

An analysis of risk factors for death at the scene following traumatic aortic rupture.

The hospital or medical examiner records of 75 victims of traumatic aortic rupture (TAR) were reviewed retrospectively. Among the 75 victims, 51 (68%) died at the scene. Those dead at the scene had higher Injury Severity Scores, 59.3 +/- 13.8, than those who survived to be hospitalized, 42.6 +/- 13.3 (p less than 0.001). The mean age of victims dead at the scene was not different than the mean age of those who arrived alive at the hospital. The incidence of death at the scene was significantly higher for patients with head injuries (p less than 0.01), victims with a second intrathoracic injury (p less than 0.025), and patients with associated intra-abdominal injury (p less than 0.001) compared to those without these injuries. A second fatal injury occurred in 51 (41.2%) of victims who died at the scene.

Management of Renal Artery Injuries from External Trauma

We reviewed the records of 27 patients with main renal artery injury admitted to our hospitals from 1959 through June 1986. Before 1969, 7 patients were hospitalized of whom 4 had nonsurgical management with total loss of function of the affected kidney, 2 had immediate nephrectomy and 1 died before treatment. Despite the nonfunctioning kidney no hypertension developed in 3 of the 4 patients followed for an average of 72 months. After 1969 when immediate radiological assessment and surgical management of main renal artery injuries were instituted 20 patients were hospitalized. Of 4 patients treated nonoperatively loss of function of the affected kidney resulted and hypertension occurred in 1, necessitating delayed nephrectomy, after an average followup of 3.5 months. Immediate nephrectomy was performed in 10 patients and vascular repair in 3. In both survivors who underwent vascular repair followup at 24 and 36 months, respectively, showed no hypertension but loss of approximately half of the function of the affected kidney. The other 3 patients died before treatment. Aggressive management reduced markedly the time from injury to diagnosis from a median of 48 hours before 1969 to 5 hours after 1969 but only a small number of patients were suitable for vascular repair, and this procedure did not restore complete function to the kidney.