Mark A. Malangoni

Determinants of mortality for necrotizing soft-tissue infections.

OBJECTIVEnThe authors determined the risk factors of mortality in patients with necrotizing soft-tissue infections (NSTIs) and examined the incidence and mortality from NSTI secondary to Streptococcus pyogenes.nnnMETHODSnAll patients with NSTIs who were treated between January 1989 and June 1994 were analyzed for presentation, etiology, factors important in pathogenesis and treatment, and mortality.nnnRESULTSnSixty-five patients were identified with NSTIs secondary to postoperative wound complications (18), trauma (15), cutaneous disease (15), idiopathic causes (10), perirectal abscesses (3), strangulated hernias (2), and subcutaneous injections (2). Necrotizing soft-tissue infections were polymicrobial in 45 patients (69%). S. pyogenes was isolated in only 17% of the NSTIs, but accounted for 53% of monomicrobial infections. Eight of ten idiopathic infections were caused by a single bacterium (p = 0.0005), whereas 82% of postoperative infections were polymicrobial. An average of 3.3 operative debridements per patient and amputation in 12 patients were necessary to control infection. The overall mortality was 29%; mortality from S. pyogenes infection was only 18%. The average time from admission to operation was 90 hours in nonsurvivors versus 25 hours in survivors (p = 0.0002). Other risk factors previously associated with the development of NSTIs did not affect mortality.nnnCONCLUSIONSnEarly debridement of NSTI was associated with a significant decrease in mortality. S. pyogenes infection was the most common cause of monomicrobial NSTI, but was not associated with an increased mortality.

The Effects of Splenic Artery Embolization on Nonoperative Management of Blunt Splenic Injury: A 16-year Experience

INTRODUCTIONnNonoperative management (NOM) of blunt splenic injury has become the preferred treatment for hemodynamically stable patients. The application of splenic artery embolization (SAE) in NOM has been controversial. We hypothesized that incorporation of initial use of SAE into a practice protocol for patients at high risk for NOM failure (contrast extravasation or pseudoaneurysm on computed tomography, grade 3 injury with large hemoperitoneum, grade 4 injuries) would improve patient outcomes.nnnMETHODSnA retrospective analysis of three continuums of practice was performed: group I (January 1991-June 1998), SAE not part of routine NOM; group II (July 1998-December 2001), introduction and discretionary use of SAE; and group III (January 2002-June 2007), standardized use of initial SAE for patients considered at high risk of nonoperative failure. The primary outcome measure was the success of NOM. Failure of NOM was defined as the need for abdominal operation. Secondary outcomes were mortality, length of stay, and splenic salvage.nnnRESULTSnOver 16 years, 815 patients with blunt splenic injury were treated at our level 1 trauma center. There were 222 patients in group I, 195 in group II, and 398 in group III. There was an increase in the use of SAE over time with a significant improvement in the utilization of NOM (61% in group I; 82% in group II; 88% in group III; p < 0.05). This was associated with an increase in successful NOM (77%, group I; 94%, group II; 97%, group III; p < 0.0001 group I vs. group II and III). Mortality, length of stay, and splenic salvage were similar in groups II and III but significantly improved when compared with group I.nnnCONCLUSIONSnThe increased use of initial SAE in high-risk patients expanded the successful use of NOM but was not associated with other incremental improvements.

Delayed operative intervention in the management of traumatic descending thoracic aortic rupture

BACKGROUNDnOutcomes may be improved by purposefully delaying surgical intervention of the traumatically ruptured descending thoracic aorta.nnnMETHODSnFifty-seven patient records identified through the Trauma Registry of a level 1 trauma center between January 1993 and April 2002 were retrospectively analyzed between groups who underwent clamp-and-sew versus partial left heart bypass repair techniques and between emergent versus delayed repair.nnnRESULTSnThirty-two (56%) of 57 patients were male. The mean age among survivors and nonsurvivors was 41 +/- 18 (range 13 to 70) and 52 +/- 23 (range 18 to 92; p = 0.04) years, and Injury Severity Score was 31 +/- 13 (range 17 to 75) and 40 +/- 16 (range 16 to 75; p = 0.04) points, respectively. Thirty-one (54%) underwent surgical intervention, 20 (35%) died during their initial resuscitation, and 6 (11%) were managed nonoperatively. Seventeen (55%) were repaired using partial left heart bypass and 14 (45%) using the clamp technique. Twenty-one (68%) had emergent repair and 10 (32%) had delayed repair. The rates of paraplegia, renal failure, and mortality were 12% (2 of 17), 0%, and 24% (4 of 17) in the bypass group, 0% (p = 0.29), 0%, and 36% (5 of 14, p = 0.36) in the clamp group, 9.5% (2 of 21), 0%, and 38% (8 of 21) in the emergent group (<24 hours after admission), and 0% (p = 0.45), 0%, and 10% (1 of 10, p = 0.12) in the delayed group (>24 hours after admission), respectively. Mean clamp times for the bypass and clamp groups were 44 +/- 18 (21 to 90) and 30 +/- 10 (14 to 52) minutes, respectively (p = 0.02). Overall operative mortality was 29% (9 of 31).nnnCONCLUSIONSnPurposefully delaying surgical intervention in selected cases of descending thoracic aortic rupture and using the clamp technique does not increase mortality or morbidity over immediate operation and use of partial left hear bypass.

The misapplication of the term spinal cord injury without radiographic abnormality (SCIWORA) in adults.

BACKGROUND Spinal cord injury without radiographic abnormality (SCIWORA) is generally considered a disease of children; however, it is commonly used when referring to adults who have spinal cord injury without computed tomography evidence of trauma (SCIWOCTET). The purpose of this study was to describe characteristics of patients with both adult and pediatric cervical SCIWOCTET admitted to hospitals in our region. METHODS A retrospective review of all patients admitted to our two ACS-verified trauma centers with cervical spinal cord injury from January 2005 to December 2009 was performed. All patients with vertebral or ligamentous injury identified on computed tomographic (CT) scan of the cervical spine were excluded. Data gathered on the remaining patients included demographics, injury mechanism, Injury Severity Score, neurologic level and severity of spinal cord injury, magnetic resonance imaging results, and mortality rates. RESULTS During the 5-year period of this study, 11,644 adult patients and 3,458 pediatric trauma patients were admitted. Of these, 313 patients were thought to have cervical spinal cord injury based on International Classification of Diseases, Ninth Revision (ICD-9) codes, 279 (89.1%) were excluded due to injury noted on CT cervical spine, and 9 were excluded as they were found to not truly have cervical spinal cord injury after review of the medical record. The remaining 25 patients were identified as having cervical SCIWOCTET. Twenty-three patients (92%) were male. The patient ages ranged from 10 to 83 years with a median age of 56 years. The mean Injury Severity Score was 22.6. Sixty-eight percent had a mechanism of fall. Degenerative changes were found on the CT scan of the cervical spine in 96% of all patients and in all 24 adult patients. There was only one pediatric patient with SCIWORA, a 10-year-old boy who had a normal CT scan of the cervical spine but had a persistent neurologic deficit. CONCLUSION SCIWOCTET is mainly a disease of adults, and its subset SCIWORA, a disease of children, is much less common. Adults with this disease have CT scans showing canal stenosis and significant degenerative changes in the cervical spine; thus, it is not accurate to state that they have SCIWORA. The characteristics of this patient population are important as SCIWOCTET is the concern when clearing the cervical spines of trauma patients with a CT scan of the cervical spine negative for injury. LEVEL OF EVIDENCE Epidemiologic study, level III.

Analysis of deaths within 24 hours of injury: Cost-benefit implications for organ and tissue donations

OBJECTIVEnTo determine useful predictors of successful organ donation in patients who die within 24 hours of injury (early deaths).nnnDESIGNnRetrospective review of a 3-year experience at a Metropolitan Level I Trauma Center.nnnMATERIALS AND METHODSnAll 223 early deaths among 5,719 trauma patients in a 3-year period were reviewed. This group represented 62% of all trauma deaths.nnnRESULTSnForty-six patients (21%) donated 102 vascularized organs and made 66 donations of tissues. Patients with isolated severe head injuries had the highest rate of successful donation (33%). Those with severe head injury and another severe organ injury had a lower rate of donation (13%), and donation was rare (1%) among patients with severe organ injury in the absence of head injury (p < 0.001). There were no organ donors among victims >65 years old or in 64 of 65 patients with a Revised Trauma Score of <2.2. The Revised Trauma Score was significantly higher in organ donors (3.39 vs. 3.07, p < 0.05). The cost-benefit ratio for early deaths was

Is it better to be injured when you are pregnant

6,512 per organ/tissue recovered.nnnCONCLUSIONSnDecisions regarding the resuscitation of trauma patients who have characteristics associated with a recognized low rate of organ donation should be made exclusive of the potential for organ recovery.

American Surgical Association Blue Ribbon Committee Report on Surgical Education: 2004

THERE HAS BEEN MUCH INVESTIGATION into the differential effects of sex hormones on the response to injury and hemorrhage. The preponderance of experimental reports have demonstrated that the hormonal milieu, in particular, increased levels of 17b-estradiol and decreased testosterone, affects cell-mediated immunity and organ system tolerance of shock through complex receptor-mediated and cell-specific interactions. In contrast, clinical studies of this phenomenon cannot confirm these experimental results. John et al investigate this hypothesis by analyzing injured pregnant women who were entered in the National Trauma Data Bank (NTDB) from 2001 to 2005. By comparing pregnant and nonpregnant women using a multiple regression analysis with computer matching for covariates, these authors demonstrate that pregnant women were 40% less likely to die after an injury. Importantly, no differences in outcome were observed between pregnant and nonpregnant women who had an Injury Severity Score (ISS) more than 15, severe head or abdominal injury, or hypotension on admission. This group of patients is expected to be at greatest risk for death after injury. The authors conclude, perhaps speciously, that hormonal and physiologic differences during the gestation period may impact outcomes after trauma in pregnant women. Although these results will not resolve the debate about the impact of sex hormones on mortality after