Michael M. Badellino

Penetrating cardiac wounds: prospective study of factors influencing initial resuscitation.

A prospective study of 66 consecutive patients with cardiac wounds seen over a 27-month period is reported. No patient was excluded. Patients were stratified by injury mechanism and by physiologic scoring at admission using the cardiovascular-respiratory elements of the Trauma Score (CVRS). Admission cardiac rhythm was obtained in patients with a CVRS of 0 and a Glasgow Coma Scale (GCS) score of 3. Information concerning the anatomic extent of the cardiac wound, the presence or absence of tamponade, and the degree of injury to other structures was also collected prospectively. Seventy percent of the cardiac wounds were caused by gunshots. The probability of successful resuscitation was significantly related to mechanism of injury and physiologic condition on arrival. Among patients arriving with a CVRS of 0 and a GCS score of 3, survival correlated with cardiac rhythm. Pericardial tamponade did not prove to be an independent predictor of early survival. The presence of tamponade was statistically linked to the mechanism of injury. Transport by non-official conveyance was associated with a higher CVRS on arrival. Intoxication with alcohol or cocaine had no evident effect on resuscitation probability.

Hepatic angioembolization in trauma patients: indications and complications.

BACKGROUND Hepatic angiography (HA) and hepatic angioembolization (HAE) are increasingly used to diagnose and treat intrahepatic arterial injuries. This study was performed to review indications, outcomes, and complications of HA/HAE in blunt trauma patients who underwent HAE as adjunct management of hepatic injury. METHODS A retrospective review of consecutive cases of HA/HAE at a Level I trauma center during an 8-year period. Data include demographics, physiologic condition, liver injury grade, HA/HAE indications, outcomes, morbidity, and mortality. RESULTS Seventy-nine patients underwent diagnostic HA; 31 (39%) had subsequent HAE. Fifty-eight hemodynamically stable patients had computerized axial tomographic (CT) scan followed by HA. HA was performed for contrast blush on CT in 30 (52%) of 58 patients, high-grade liver injury in 4 (7%), subsequent hemodynamic instability in 15 (27%), and angiography planned for other purpose in 9 (17%). HA confirmed arterial injury and led to HAE in 50% of patients with contrast blush on CT or high-grade liver injury. HA was negative when performed for hemodynamic instability or for other primary purposes. Twenty-one hemodynamically unstable patients underwent emergent laparotomy followed by postoperative HA with 11 (50%) requiring HAE. Overall mortality in HAE group was 16%, and liver-related morbidity was 29% usually presenting as gallbladder or liver necrosis. CONCLUSION HA/HAE should be used when CT scan suggests associated intrahepatic arterial or high-grade injury in the management of hepatic injuries and should also be considered after laparotomy and perihepatic packing to control inaccessible intrahepatic hemorrhage. Mortality related to HAE is uncommon, but morbidity occurs frequently.

Injuries of the inferior vena cava

Injuries of the IVC, whether caused by blunt or penetrating mechanisms, are usually fatal. Patients who arrive in shock and fail to respond to initial resuscitative measures, those who are still actively bleeding at the time of laparotomy, and those with wounds of the retrohepatic vena cava have a low probability of survival. Death most commonly is caused by intraoperative exsanguination. Knowledge of the anatomy and exposure techniques for the five different segments of the intra-abdominal vena cava is very important to trauma surgeons. Although some wounds of the vena cava, especially those of the retrohepatic vena cava, are best left unexplored, most injuries inferior to this level can be exposed and repaired by lateral suture technique. Preservation of a lumen of at least 25% of normal is probably important in the suprarenal vena cava but is of no provable value inferior to the renal veins. No evidence supports the need to expose and repair vena caval wounds that have spontaneously stopped bleeding. Such wounds, especially in the retrohepatic area, may be managed expectantly provided that there is no strong suspicion of an associated injury to a major artery or hollow viscus.

Blunt Duodenal Rupture: A 6-Year Statewide Experience

OBJECTIVES To characterize the incidence, presentation, diagnostic features, injury pattern, and mortality of blunt duodenal rupture. METHODS The records of 103,864 patients entered into a state-wide trauma registry during a 6-year period were screened for the diagnosis of blunt duodenal injury. The hospital records of all patients meeting diagnostic criteria of blunt duodenal rupture from 28 trauma centers were reviewed. RESULTS Blunt duodenal injury was identified in 206 (0.2%) patients. Thirty (14.5%) of these had full-thickness rupture of the duodenum. Of these 30 patients, 21 had been involved in motor vehicle crashes. Twenty-five presented with either abdominal pain, tenderness, or guarding on physical examination. Diagnostic peritoneal lavage was performed on 12 patients. Three patients were found to have isolated rupture of the duodenum. Computerized tomography was the primary diagnostic investigation in eighteen cases. Extravasation of contrast was noted in only two cases. Four studies were interpreted as normal. The second portion of the duodenum was most commonly injured, and there was a high incidence of associated intra-abdominal injuries. Seven patients underwent operation >12 hours after admission. Twenty-six patients survived to hospital discharge. Two deaths were caused by duodenal injury-related sepsis. CONCLUSION Blunt rupture of the duodenum is rare. Most blunt duodenal injuries do not result in full-thickness injury. The majority of patients with duodenal rupture presented with either a history or a physical examination suggestive of intra-abdominal injury. Computerized tomography results were often negative or nonspecific. Delay in diagnosis of duodenal rupture remains common but does not appear to affect mortality. Overall mortality was lower than previously reported.

Current opinion regarding indications for emergency department thoracotomy.

BACKGROUND Emergency department thoracotomy (EDT) is a dramatic but rarely lifesaving intervention. Clinical variability regarding indications for EDT has yet to be quantified. Members of the Eastern and American Associations for the Surgery of Trauma were questioned by mail to evaluate which clinical and demographic factors influence the decision to perform EDT and whether physicians perform EDT in accordance with current practice guidelines. METHODS A single mailing of an anonymous survey was sent to 1,124 surgeons to collect institutional and physician demographics as well as indications for EDT on the basis of variable mechanisms of trauma, duration of arrest, and signs of life (SOL). Statistical analysis included the Pearson and linear-by-linear association chi(2) tests, independent samples t test, and univariate and multivariate analyses of variance; p values of < 0.05 were considered significant. RESULTS Completed surveys were received from 358 respondents. After 54 surveys were excluded that were incomplete, late, or from noneligible respondents, 304 surveys were analyzed. There were no significant differences in EDT indications among institutions of differing caseload volume, exposure to penetrating trauma, trauma level designation, American College of Surgeons verification status, or residency program affiliation. In addition, neither the respondents position nor whether attendings versus residents performed the majority of EDTs influenced clinical decision-making. Performance criteria for EDT were liberal in comparison with established guidelines, especially for blunt trauma. The presence or recent loss of SOL influenced responses, but respondents varied greatly in their definition of SOL. CONCLUSION A lack of agreement exists regarding the indications for EDT in multiple clinical scenarios as well as in defining SOL. Indications for EDT were liberal, especially for blunt trauma-related indications, and were determined by clinical parameters, not by physician or institutional factors. Our results suggest that clinical practice is at variance with Advanced Trauma Life Support guidelines. We recommend that practice guidelines for EDT be established on the basis of a consensus definition of SOL to allow for a more uniform and selective approach to EDT.

Detection of pulmonary aspiration of gastric contents in an animal model by assay of peptic activity in bronchoalveolar fluid

OBJECTIVE To determine whether peptic activity in bronchoalveolar fluid, due to the presence of the gastric proteolytic enzyme pepsin, could serve as a biochemical marker for pulmonary aspiration of gastric contents. DESIGN Prospective, experimental trial. SETTING A university animal research laboratory. SUBJECTS Thirty-six New Zealand rabbits, weighing 2 to 4 kg. INTERVENTIONS New Zealand rabbits were anesthetized, intubated via tracheostomy, and mechanically ventilated. Pulmonary aspiration was induced by the intratracheal instillation of 2 mL/kg human gastric juice (pH 1.2 +/- 0.2; pepsin activity 0.02 +/- 0.006 microgram/mL; human gastric juice group, n = 24) or normal saline solution (pH 5.2 +/- 0.2; normal saline solution group; n = 12). Mechanical ventilation was continued. Bronchoalveolar lavage was performed at 15 mins (human gastric juice group, n = 8; normal saline solution group, n = 4), 30 mins (human gastric juice group, n = 8; normal saline solution group, n = 4), or 60 mins (human gastric juice group, n = 8; normal saline solution group, n = 4) postaspiration. MEASUREMENTS AND MAIN RESULTS Peak airway pressure and PaO2 values were measured at baseline and 15 and 30 mins after aspiration. The pH of retrieved bronchoalveolar lavage fluid was measured and pepsin activity in sample fluid was determined. Changes from baseline in peak airway pressure and PaO2 were significant in human gastric juice animals at 15 and 30 mins when compared with normal saline solution animals (PaO2 -4% vs. -44%, peak airway pressure 20% vs. 36% at 15 mins; PaO2 -16% vs. -79%, peak airway pressure 28% vs. 69% at 30 mins; normal saline solution group vs. human gastric juice group, p < .02). Bronchoalveolar lavage fluid pH was not significantly different between groups at any time postaspiration (6.6 +/- 0.7 vs. 6.0 +/- 0.4 at 15 mins; 7.4 +/- 0.9 vs. 6.5 +/- 0.4 at 30 mins; 7.2 +/- 0.5 vs. 6.4 +/- 0.4 at 60 mins, normal saline solution group vs. human gastric juice group, p = NS). No peptic activity was present in bronchoalveolar lavage fluid from normal saline solution animals at any time. In the human gastric juice group, peptic activity was detected in postaspiration bronchoalveolar lavage fluid in eight of eight animals at 15 mins, six of eight animals at 30 mins, and five of eight animals at 60 mins (normal saline solution group vs. human gastric juice group; p < .001 at 15 mins, p < .01 at 30 mins, p = NS at 60 mins). Peptic activity of bronchoalveolar lavage fluid varied; mean values were greater at 15 mins than at 30 or 60 mins (pepsin activity: 0.004 +/- 0.002 microgram/mL vs. 0.002 +/- 0.001 microgram/mL vs. 0.0006 +/- 0.0001 microgram/mL, respectively, p < .05). CONCLUSIONS The results of this study suggest that peptic activity in bronchoalveolar lavage fluid can be detected up to 60 mins after induced, experimental gastric juice aspiration and may prove a clinically useful biochemical marker for episodes of occult pulmonary aspiration of gastric contents.

Direct cardiac massage without major thoracotomy: feasibility and systemic blood flow.

BACKGROUND Open-chest cardiac massage (OC-CM) provides higher blood pressure and flow than closed-chest compression and may improve the probability of successful resuscitation from cardiac arrest. Its clinical use has been limited by its requirement for a major thoracotomy. The present pilot study tested the technical feasibility of performing effective direct cardiac massage without a major thoracic incision, by using a simple, manually-powered plunger-like device, inserted through a small thoracic incision, to cyclically compress the cardiac ventricles. The method was termed minimally-invasive direct cardiac massage (MID-CM). Systemic blood flow using MID-CM was compared to that with OC-CM, by both direct systemic hemodynamic measurements, cumulative metabolic indicators of the ratio of whole body oxygen delivery and oxygen consumption, and a metabolic index of pulmonary blood flow. METHODS In 12 large swine, baseline systemic and pulmonary hemodynamic measurements were performed. Arterial and mixed venous blood gases and metabolic indicators of systemic blood flow were measured. Ventricular fibrillation was induced and after 4 min, animals underwent either bimanual OC-CM (N = 6) or MID-CM (N = 6). At 10, 20 and 30 min, hemodynamic and metabolic measurements were repeated. RESULTS Systemic Blood Pressure: Aortic systolic and diastolic blood pressures were reduced from baseline levels with both OC-CM and MID-CM. No difference in pressure was noted between OC-CM and MID-CM groups. Pulmonary Artery Pressure: Pulmonary artery systolic pressure was elevated from baseline during OC-CM and MID-CM. Pulmonary artery diastolic pressures remained constant throughout the resuscitation period in both groups. No differences in pulmonary systolic or diastolic pressure were noted between OC-CM and MID-CM groups. A trend towards higher pulmonary systolic pressures appeared with MID-CM. Thermodilution Blood Flow: Cardiac index fell from baseline levels with OC-CM and MID-CM. No difference in cardiac index was noted between OC-CM and MID-CM groups. Metabolic Indices: Mixed venous O2 saturation decreased from baseline levels during resuscitation in both experimental groups, with a further decrease at 30 min compared to 10- and 20-min levels. No difference was noted between OC-CM and MID-CM groups at any point. Arterial pH was reduced from baseline levels at 30 min in both groups compared to baseline but no difference was noted between groups.(ABSTRACT TRUNCATED AT 400 WORDS)

Impact of age and anticoagulation: need for neurosurgical intervention in trauma patients with mild traumatic brain injury.

BACKGROUND Of the 500,000 brain injuries in the United States annually, 80% are considered mild (mild traumatic brain injury). Unfortunately, 2% to 3% of them will subsequently deteriorate and result in severe neurologic dysfunction. Intracerebral changes in the elderly, chronic oral anticoagulation, and platelet inhibition may contribute to the development of intracranial bleeding after minor head injury. We sought to investigate the association of age and the use of anticoagulation and antiplatelet therapy with neurologic deterioration and the need for neurosurgical intervention in patients presenting with mild traumatic brain injury. METHODS A retrospective review of all adult (>14 years) patients admitted to our Level I trauma service with a Glasgow Coma Scale (GCS) score of 14 to 15 who underwent neurosurgical intervention during their hospital stay was performed. Patients were stratified into two groups, age <65 years and age ≥65 years. Each group was then further stratified by the use of anticoagulants: warfarin, aspirin, clopidogrel, or a combination. Mechanism of injury, prehospital complaints, admission GCS, type of neurosurgical intervention, intensive care unit length of stay, hospital length of stay, and discharge disposition were evaluated. Z test and logistic regression were used to compare proportions or percentages from different groups. RESULTS Of the 7,678 patients evaluated during the study period, 101 (1.3%) required neurosurgical intervention. The ≥65 years population underwent significantly more interventions as did those patients on anticoagulants. CONCLUSION All patients aged 65 years or older who present with a GCS score of >13 after head trauma should undergo a screening computed tomography of the head regardless of prehospital use of anticoagulation. Patients younger than 65 years can be selectively screened based on presenting complaints and mechanism of injury provided they are not on anticoagulation. (J Trauma Acute Care Surg. 2012;73: 126–130. Copyright

Open-chest cardiac massage without major thoracotomy: metabolic indicators of coronary and cerebral perfusion.

OBJECTIVE To compare the coronary and cerebral perfusion achieved using a novel method of minimally-invasive, direct cardiac massage to that obtained using bimanual, open-chest cardiac massage. DESIGN Prospective, controlled animal study with repeated measures. SETTING University research laboratory. SUBJECTS Large domestic swine. INTERVENTIONS Aortic, coronary sinus, jugular venous and pulmonary artery catheters were placed. Following an equilibration period, ventricular fibrillation was induced. After 4 min of untreated ventricular fibrillation, animals underwent bimanual, open-chest cardiac massage (N = 6) or minimally-invasive, direct cardiac massage using a novel device for direct cardiac compression (N = 6). Adrenaline was administered at a dose of 1 mg intravenously every 5 min. MEASUREMENTS Systemic metabolic parameters, (arterial PO2, PCO2 and lactate concentration) and coronary sinus and jugular venous metabolic parameters (pH, PVO2, SVO2, PVCO2 and lactate concentration) were measured and calculated (coronary sinus/jugular-arterial SVO2, coronary sinus/jugular-arterial PCO2 and lactate differences) at baseline and at 10, 20 and 30 min following induction of ventricular fibrillation. Animals were euthanised after 30 min with no attempt at defibrillation. MAIN RESULTS Oxygen tension and oxygen saturation of coronary sinus blood declined significantly during the experimental period, but no differences were noted between treatment groups. The coronary sinus-arterial oxygen saturation difference increased during the study with no significant differences between groups. Coronary sinus PCO2 and the coronary sinus-arterial PCO2 difference increased significantly in both experimental groups during cardiac massage. No inter-group differences were noted. A similar relationship was noted in coronary sinus lactate values. The coronary sinus-arterial lactate difference displayed a positive balance at all intervals with no differences noted between group values. The oxygen tension and oxygen saturation of jugular venous blood, were reduced from baseline levels with both treatments. The jugular-arterial oxygen saturation difference increased in both groups compared to baseline values. Between group values were significantly different only at the 20 min interval. Both the jugular venous PCO2 and the jugular-arterial PCO2 gradient were elevated at all intervals, but no inter-group differences were noted. Jugular venous lactate concentration rose steadily with time in both groups. No significant increase in the jugular-arterial lactate gradient was noted at any time point. CONCLUSIONS Minimally-invasive, direct cardiac massage provides coronary and cerebral perfusion similar to that achieved using standard open-chest cardiac massage. This method may provide a more effective substitute for standard, closed-chest cardiac massage in cases of refractory cardiac arrest.

Portal vein injuries.

Wounds of the portal vein are caused most commonly by penetrating trauma and carry a very high mortality rate. Most deaths are caused by exsanguination, occurring intraoperatively as surgeons struggle to control the hemorrhage from the portal vein and associated vascular injuries. A thorough knowledge of the anatomy of the area and of the likely patterns of wounding is important. At surgery, surgeons must be prepared to deal with multiple vessel wounding. Although most investigators have advocated lateral repair of the portal vein when it can be accomplished, portal ligation seems to be a safe alternative. Complex repairs are justified only when a contraindication to ligation exists. Postoperative care must recognize the need for extraordinary fluid replacement and the small risk for postoperative bowel infarction after repair or ligation of the portal vein.