Raymond P. Bynoe

Prospective Study of Blunt Aortic Injury: Multicenter Trial of the American Association for the Surgery of Trauma

BACKGROUND Blunt aortic injury is a major cause of death from blunt trauma. Evolution of diagnostic techniques and methods of operative repair have altered the management and posed new questions in recent years. METHODS This study was a prospectively conducted multi-center trial involving 50 trauma centers in North America under the direction of the Multi-institutional Trial Committee of the American Association for the Surgery of Trauma. RESULTS There were 274 blunt aortic injury cases studied over 2.5 years, of which 81% were caused by automobile crashes. Chest computed tomography and transesophageal echocardiography were applied in 88 and 30 cases, respectively, and were 75 and 80% diagnostic, respectively. Two hundred seven stable patients underwent planned thoracotomy and repair. Clamp and sew technique was used in 73 (35%) and bypass techniques in 134 (65%). Overall mortality was 31%, with 63% of deaths being attributable to aortic rupture; mortality was not affected by method of repair. Paraplegia occurred postoperatively in 8.7%. Logistic regression analysis demonstrated clamp and sew (p = 0.002) and aortic cross clamp time of > or = 30 minutes (p = 0.01) to be associated with development of postoperative paraplegia. CONCLUSIONS Rupture after hospital admission remains a major problem. Although newer diagnostic techniques are being applied, at this time aortography remains the diagnostic standard. Aortic cross clamp time beyond 30 minutes was associated with paraplegia; bypass techniques, which provide distal aortic perfusion, produced significantly lower paraplegia rates than the clamp and sew approach.

Noninvasive diagnosis of vascular trauma by duplex ultrasonography.

Duplex ultrasonography was used prospectively in the initial evaluation of 198 patients with 319 potential vascular injuries of the neck and extremities. Patients who were unstable or who had obvious arterial trauma were excluded. Injury was caused by gunshot in 104 (53%), blunt trauma in 42 (21%), stab wound in 34 (17%), and shotgun in 18 (9%). Duplex ultrasonography correctly characterized and localized vascular injuries in 23 patients: arterial disruptions (13), intimal flaps (4), acute pseudoaneurysms (3), arteriovenous fistulas (2), and shotgun pellet arteriopuncture (1). Nineteen other patients had vasospasm (13) or external compression (6) without evidence of intrinsic vessel injury, these 42 studies had true-positive results. Twenty patients underwent arterial repair (13 on the basis of duplex ultrasonography alone), one had primary amputation, three required fasciotomy, and 18 were observed. Two patients with false-negative results had minor shotgun pellet arteriopunctures that were missed by duplex ultrasonography, but neither needed repair. One hundred fifty-three patients had true-negative results on duplex ultrasonography: all clinically had only proximity injuries and easily palpable distal pulses. The result of one duplex ultrasonography study was found to be false-positive on arteriography. The sensitivity of duplex ultrasonography was 95%, the specificity was 99%, and the overall accuracy was 98%. These results closely approximate those reported with the use of exclusion arteriography in the evaluation of similar vascular trauma patients. Furthermore, duplex ultrasonography has no interventional risks and is more cost-effective for screening such injuries than arteriography or exploration. Duplex ultrasonography is a reliable method of diagnosis in patients with potential peripheral vascular injuries.

Liberalized screening for blunt carotid and vertebral artery injuries is justified

BACKGROUND Current literature suggests that blunt carotid injuries (BCIs) and vertebral artery injuries (BVIs) are more common than once appreciated. Screening criteria have been suggested, but only one previous study has attempted to identify factors that predict the presence of BCI/BVI. This current study was conducted for two reasons. First, we wanted to determine the incidence of BCI/BVI in our institution. Second, we wanted to determine the incidence of abnormal four-vessel cerebral angiograms ordered for injuries and signs believed to be associated with BCI/BVI and thus to determine whether the screening protocol developed was appropriate. METHODS From August 1998, we used liberalized screening criteria for patients who were prospectively identified and suspected to be at high risk for BCI/BVI if any of the following were present: anisocoria, unexplained mono-/hemiparesis, unexplained neurologic exam, basilar skull fracture through or near the carotid canal, fracture through the foramen transversarium, cerebrovascular accident or transient ischemic attack, massive epistaxis, severe flexion or extension cervical spine fracture, massive facial fractures, or neck hematoma. Four-vessel cerebral angiograms were used for screening for BCI/BVI. RESULTS Over the 18-month study period, 48 patients were angiographically screened, with 21 patients (44%) being identified as having a total of 19 BCIs and 10 BVIs. Nine patients had unilateral carotid artery injuries and three patients had bilateral carotid artery injuries. Vertebral artery injuries were unilateral in six patients. One patient had bilateral carotid artery injuries and a unilateral vertebral artery injury. One patient had a unilateral carotid artery injury and a unilateral vertebral artery injury, and one patient had a unilateral carotid artery injury and bilateral vertebral artery injuries. During the same study period, 2,331 trauma patients were admitted, with 1,941 (83%) secondary to blunt trauma. The overall incidence of BCI/BVI was 1.1%. The frequency of abnormal angiograms ordered for cerebrovascular accident or transient ischemic attack, massive epistaxis, or severe cervical spine fractures was 100%. The frequency of abnormal angiograms ordered for the other indications was as follows: fracture through foramen transversarium, 60%; unexplained mono- or hemiparesis, 44%; basilar skull fracture, 42%; unexplained neurologic examination, 38%; anisocoria, 33%; and severe facial fractures, 0%. CONCLUSION The liberalized screening criteria used in this study were appropriate to identify patients with BCI/BVI. This study suggests BCI/BVI to be more common than previously believed and justifies that screening should be liberalized.

Maxillofacial injuries and life-threatening hemorrhage: Treatment with transcatheter arterial embolization

BACKGROUND There are many reasons for hypotension in trauma patients with multiple injuries; one uncommon source is facial fractures. The treatment algorithm is volume replacement and local control of the bleeding. A retrospective study was undertaken to evaluate the treatment of patients with life-threatening hemorrhage secondary to facial fractures, and to develop a treatment algorithm. METHODS A retrospective chart review was undertaken to determine the incidence of hemorrhagic shock in patients with facial fractures exclusive of others sources, and the use of transcatheter arterial embolization to control the bleeding was evaluated. RESULTS Over a 4-year period, 7562 patients were treated at Palmetto Richland Memorial Hospital, a Level I trauma center. There were 912 patients with facial injuries, with 11 of these patients presenting with life-threatening hemorrhage secondary to facial fractures. The incidence of life-threatening hemorrhage from facial fracture was 1.2%. The mechanism of injury was blunt in 10 patients and penetrating in 1. The blunt injuries resulted from six motor vehicles crashes, three motorcycle crashes, and one plane crash. The one penetrating injury was a shotgun blast. There were six patients with Le Fort III fractures, two patients with Le Fort II fractures, and three patients with a combination of Le Fort II and III fractures bilaterally. The average volume infused before the embolization was 7 L; this included blood and crystalloid. There were four complications: two minor groin hematomas, one partial necrosis of the tongue, and one facial nerve palsy. There were two deaths, both secondary to concomitant intracranial injury as a result of blunt trauma. CONCLUSION The incidence of severe hemorrhage secondary to facial fractures is rare; however, it can be life threatening. When common modalities of treatment such as pressure, packing, and correction of coagulopathy fail to control the hemorrhage, transcatheter arterial embolization offers a safe alternative to surgical control.

Complications of nonoperative management of blunt hepatic injuries.

Few, if any, complications have been reported with the nonoperative management of selected hepatic injuries diagnosed by computed tomographic (CT) scan in hemodynamically stable patients. This retrospective study was designed to evaluate complications associated with this form of management. Twenty-six patients (21%) of 128 patients with blunt hepatic injuries were treated nonoperatively over a 3-year period. All patients were hemodynamically stable at the time of admission and had hepatic injuries identified by CT scans of the abdomen. Five patients (19%) developed complications associated with nonoperative therapy. Of these, two patients had minor hepatic injuries (grades 1-2) and three had major (grades 3-5) hepatic injuries. Two patients (one with minor and one with major hepatic injury), developed free intraperitoneal biliary leaks and required operative repair. Three patients (one with minor and two with major hepatic injuries) developed large subcapsular bilomas with resultant hepatic dysfunction. These patients were successfully managed with percutaneous CT-guided drainage. There were no deaths in our study population with nonoperative therapy. The complications of hepatic injuries initially managed by expectant observation were treated operatively or by percutaneous CT-guided drainage. Repeated CT evaluation to follow the progress of liver fracture and the occasional use of hepatobiliary scans for the identification of biliary leaks have proven useful in our experience.

Two-dimensional echocardiography in the evaluation of penetrating intrapericardial injuries.

Patients with penetrating pericardial trauma whose vital signs stabilize after fluid administration may present a therapeutic dilemma. Two-dimensional echocardiography has emerged as a diagnostic technique to help determine whether surgical intervention may be required. We present 5 patients with penetrating pericardial trauma whose vital signs stabilized after fluid administration and who had minimal clinical findings. In 3 of these patients, a small effusion was seen; in 2 others, no abnormalities were noted. All 5 underwent surgical exploration and had major intrapericardial injuries. We conclude that a normal echocardiographic study does not rule out major intrapericardial injury in patients with penetrating chest trauma. Furthermore, small areas of effusion seen on echocardiography in these patients represent indications for surgical exploration.

Analysis of septic morbidity following gunshot wounds to the colon: the missile is an adjuvant for abscess

Over a 7-year period, 151 patients with gunshot wounds to the colon surviving beyond 24 hours were managed. The bullet was retained in the body in 66% and exited in 34%. Thirty-four (23%) developed major septic complications (diffuse peritonitis, 21%; intraperitoneal abscesses 24%; and extraperitoneal abdominal abscesses, 56%). The septic complication rate was 26% in the bullet-present group compared with 16% in the remainder (p less than 0.15). The increased septic rate in those with bullets present was the result of abscesses developing around the retained missile. That group with missile abscesses had a lesser degree of injury as measured by the abdominal trauma index compared with the other patients with septic complications (p less than 0.001). Fifteen (79%) of the 19 patients with missile and missile track abscesses had them develop in the psoas muscle. These abscesses occur by fecal contamination of the muscle following inoculation by the bullet, which passes through the large bowel. Computed tomography-guided and operative drainage tend to fail if the foreign body is not removed. Computed tomography-guided or operative drainage should be successful in draining missile track abscesses when the bullet has exited the patient.

Post-traumatic sinusitis.

Septic complications following traumatic injury continue to be a contributing factor to morbidity and mortality. Paranasal sinusitis is being recognized as an often occult etiology of fever and sepsis in multiply injured patients. Our series of 11 patients who developed clinically important maxillary sinusitis is presented. Common features of the patients include: 1) nasal instrumentation; 2) craniofacial trauma; 3) concomitant use of steroids; and 4) severe multisystem injury (mean I.S.S., 45.5; T.S., 10.6). A high index of suspicion in patients with nasal tubes who develop unexplained fever or signs of systemic sepsis should prompt appropriate investigation of the paranasal sinuses. Removal of the tubes, antral puncture for irrigation and aspiration for microbiologic culture, topical nasal decongestants, systemic antibiotics based on sensitivity studies, and occasionally, formal surgical sinus drainage contribute to effective therapy.

Swallowing dysfunction in trauma patients with cervical spine fractures treated with halo-vest fixation.

UNLABELLED ACKGROUND:: Cervical spine fractures are common in traumatically injured patients. The halo-vest brace is a common treatment used for these fractures. We hypothesize that the use of halo-vest fixation is associated with a high incidence of dysphagia in trauma patients. METHODS All trauma patients at our Level I Trauma Center from August 2005 to August 2007 were analyzed retrospectively via the trauma registry (N=3,702). Included were adult patients with cervical spine fractures treated with halo-vests and evaluated formally by speech-language pathologists for dysphagia and aspiration. Patients were categorized into mild, moderate, and severe dysphagia. RESULTS Of the 3,702 patients, 369 (10%) had cervical spine fractures from blunt trauma and 56 met inclusion criteria. Of these, 19 (34%) had no evidence of swallowing dysfunction and the remaining 37 (66%) had evidence of dysphagia. Thirteen (23%) exhibited symptoms of aspiration. There were no significant differences in age, gender, Injury Severity Score, arrival Revised Trauma Score, or arrival Glasgow Coma Scale score on presentation. Dysphagia is associated with longer intensive care unit stays (p=0.019) and trends toward a longer hospital stay (p=0.083). In trauma patients with halo-vests, increasing severity of dysphagia from mild to moderate is associated with longer ventilator days (p=0.005), intensive care unit days (p=0.001), and hospital length of stay (p=0.015). CONCLUSIONS Patients with cervical fractures treated with halo-vest fixation have a significantly high incidence of dysphagia and aspiration. Dysphagia in trauma patients treated with halo-vests for c-spine fractures is common, associated with worse outcomes, and difficult to predict. Therefore, all of these patients should be formally evaluated for dysphagia.

Effect of isolated hepatic ischemia on organic anion clearance and oxidative metabolism.

Hepatic failure is frequently seen following severe hemorrhagic shock, sepsis, and trauma. Clearance of various drugs has been used to evaluate hepatocellular dysfunction, including indocyanine green (ICG), an organic anionic dye that is transported similarly to bilirubin, and antipyrine (AP), a marker of oxidative phosphorylation. Previous investigators have noted a decrease in ICG excretion following systemic hemorrhage. The effect of isolated hepatic ischemia on the clearances of ICG and AP was studied in 16 pigs after 90 minutes of vascular occlusion to the liver. Antipyrine clearance decreased almost 50% from baseline values at 24 and 72 hours after the ischemia procedure, indicating a significant depression in the cytochrome P-450 system. On the other hand, ICG clearance did not change significantly. In conclusion, ICG clearance is not depressed after isolated hepatic ischemia in pigs. Changes in organic anion clearance after systemic hemorrhage may be because of release of toxic products from ischemic peripheral tissue.