Michael D. McGonigal

Urban firearm deaths: a five-year perspective

Firearm violence is an ever-increasing element in the lives of the U.S. urban population. This study examined the trends in firearm violence and victims during a 5-year period in the city of Philadelphia. Medical Examiner records of all deaths in Philadelphia County in 1985 and 1990 were reviewed. Demographic, autopsy, and criminal record information was analyzed. There were 145 firearm homicide victims in 1985 versus 324 in 1990, a 123% increase. This was primarily because of deaths among young (age 15-24 years), black male victims. Handguns were involved in at least 90% of firearm homicides in both study years. The use of semiautomatic handguns increased from 24% to 39% during the study period. In 1985, 42% of revolver homicides died at the scene, versus 18% in 1990. However, 5% of victims of semiautomatic weapons fire died at the scene in 1985 versus 34% in 1990. The decrease in survival of semiautomatic weapon victims occurred despite the implementation of six trauma centers within the county, and probably reflects a shift toward high-velocity, high-caliber ammunition. Antemortem drug use and criminal history was common. A total of 54% of victims were intoxicated in 1985 and 61% were in 1990. Cocaine became the most common intoxicant in 1990, with 39% of victims using it during the antemortem period. The percentage of victims with a criminal record increased from 44% to 67%. Although the duration of criminal history decreased from 14 to 6 years, the number of patients with previous drug offenses increased from 33% to 84%..(ABSTRACT TRUNCATED AT 250 WORDS)

Urgent paralysis and intubation of trauma patients : is it safe ?

Physicians, fearful of an increase in the incidence of intubation mishaps (IMs) and pulmonary complications (PUCs), have been reluctant to use paralysis and intubation (PI) outside the OR. This study examines the correlations between PI, IM, and PUC. Since 1987, we have used PI when complex injury or combative behavior warranted. From January through December 1989, 851 patients meeting major trauma triage guidelines were evaluated. The medical records of 231 patients (27%) who underwent PI within 8 hours of admission were reviewed; 27 patients were eliminated because of incomplete records. The indications for PI were emergency surgery (131), airway control (30), combativeness (24), and hyperventilation (19). The location was the OR (121), ED (82), other (1). Presence or absence of IM was documented in 198 of 204 charts: Twenty-four IMs (12%) occurred--14 multiple attempts, seven aspirations, three esophageal intubations. Frequency of IM was not statistically related to PI location (Fishers exact test), AIS, or ISS. In 194 of 204 patients who survived at least 24 hours, there were 15 PUCs (8%): eight pneumonia, five persistent infiltrates, two severe atelectases. No deaths were related to IM or PUC. There was no statistical relationship between IM and PUC (Fishers exact test). However, patients with PUCs had a significantly higher AIS-chest score (2.9 +/- 1.7 vs. 0.9 +/- 1.5) (p < 0.0005, Students t test) and ISS (27.3 +/- 9.6 vs. 14.5 +/- 10.8) (p < 0.0005, Students t test). In our hands, PI is associated with low morbidity, no mortality, and can be safely used to facilitate injury management or to control combative behavior.

On the nature of things still going bang in the night: an analysis of residency training in trauma.

In the 1982 Presidential Address to the Society of University Surgeons, Trunkey reported on the inadequacy of surgical education in trauma care. His conclusions were based on American Board of Surgery operative experience data compiled from residents completing surgical training in 1980. The purpose of this study was to compare current resident operative experience in trauma surgery with the American Board of Surgery data from 1980. Yearly resident operative experience data obtained from the Residency Review Committee from 1987 through 1991 were analyzed. The relationship between the percentile rank and the number of operative cases was defined using linear regression. The percentile rank of residents performing a specified number of operative cases was computed using a linear regression coefficient. The results were then compared with previously published 1980 American Board of Surgery summary data. Resident operative experience in trauma surgery was stable over the 5-year period investigated and no significant trends were identified. Comparison of the data from 1980 to 1991 revealed that the percentage of residents performing less than ten cases decreased markedly, from 18% to 9%. Moreover, the percentage of residents claiming fewer than 50 cases declined from 86% to 29%. Based on this analysis, it appears that resident operative experience dramatically increased from 1980 to 1987 and has since remained stable. The reasons for this are unclear but undoubtedly involve the accuracy of reporting operative experience, Residency Review Committee operative trauma definitions, and the actual number of trauma surgery cases available for trainees.(ABSTRACT TRUNCATED AT 250 WORDS)

Role of Fluosol-DA 20% in prehospital resuscitation.

Fluosol-DA 20% (FDA-20) resuscitation has been proposed for prehospital therapy of hemorrhagic shock (HS). Acute HS (mean arterial pressure 60 mm Hg X 90 min, then 40 mm Hg X 30 min) in 24 splenectomized dogs was treated with 50 ml/kg of lactated Ringers solution (RL) plus a volume equal to 105% of shed blood volume of FDA-20 (group 1), FDA-20 carrier Annex solution (group 2), or RL (group 3). Cardiopulmonary, hemopoietic, hemodynamic, and organ function parameters were measured preshock, at the end of shock, and at 30 and 60 min, and 24 h after resuscitation. FDA-20 produced effective volume expansion, oxygen delivery, and oxygen consumption. The FDA-20 appeared to affect organ function and cells adversely as reflected by a fall in red cell mass and platelet levels and by a rise in liver enzymes, BUN, and serum creatinine. Both the FDA-20 and Annex solution led to a reduction in serum proteins including serum albumin, serum globulin, immunoglobulin-G, and fibrinogen. These reductions are probably due to an oncotically driven factor which appears to maintain an optimal lymph to plasma oncotic ratio. The hydroxyethyl starch in the FDA-20 and the Annex solution, thus, would drive the plasma proteins into the interstitial space. The prolonged prothrombin times and the activated partial thromboplastin times after FDA-20 may be due, in part, to a reduction in the coagulation proteins, although these were not measured. Pending further studies designed to assess the effects of FDA-20 on possible cellular and multiple organ toxicity, clinical studies are premature and unwarranted.

Gluteal gunshot wounds: who warrants exploration?

It is difficult to determine which stable patients with gluteal gunshot wounds warrant exploration since 22% to 36% will have injuries requiring operative intervention. The ability of preoperative studies to identify major injuries was evaluated to determine which studies could accurately triage patients into a high-risk group that would warrant laparotomy and a low-risk group that could be managed with observation. The findings of abdominal tenderness or gross blood in the urine or rectum were each highly predictive of major injury. The determination of an extrapelvic versus transpelvic bullet trajectory allowed accurate triage of 94% of patients. Nearly 85% of patients with a transpelvic trajectory had injuries that required operative intervention. No patients with an extrapelvic trajectory required laparotomy. Given the density of vital structures above and below the peritoneum in the pelvis, we conclude that any patient with a transpelvic bullet trajectory warrants exploration.