Richardson Jd

Interventional techniques are useful adjuncts in nonoperative management of hepatic injuries.

BACKGROUND Nonoperative management has become the standard of care for hemodynamically stable patients with complex liver trauma. The benefits of such treatment may be obviated, though, by complications such as arteriovenous fistulas, bile leaks, intrahepatic or perihepatic abscesses, and abnormal communications between the vascular system and the biliary tree (hemobilia and bilhemia). METHODS We reviewed the hospital charts of 135 patients with blunt liver trauma who were treated nonoperatively between July 1995 and December 1997. RESULTS Thirty-two patients (24%) developed complications that required additional interventional treatment. Procedures less invasive than celiotomy were often performed, including arteriography and selective embolization in 12 patients (37%), computed tomography-guided drainage of infected collections in 10 patients (31%), endoscopic retrograde cholangiopancreatography with endoscopic sphincterotomy and biliary endostenting in 8 patients (25%), and laparoscopy in 2 patients (7%). Overall, nonoperative interventional procedures were used successfully to treat these complications in 27 patients (85%). CONCLUSION In hemodynamically stable patients with blunt liver trauma, nonoperative management is the current treatment of choice. In patients with severe liver injuries, however, complications are common. Most untoward outcomes can be successfully managed nonoperatively using alternative therapeutic options. Early use of these interventional procedures is advocated in the initial management of the complications of severe blunt liver trauma.

Packing and planned reexploration for hepatic and retroperitoneal hemorrhage : critical refinements of a useful technique

We evaluated 35 consecutive patients treated with temporary intraabdominal packing for control of bleeding to determine factors that could improve hemorrhage control, morbidity from infection, and mortality. Twelve patients could not be resuscitated from hemorrhagic shock and died in the operating or recovery room. Bleeding was controlled in the remaining 23 patients; however, five (22%) died of complications other than hemorrhage. Intra-abdominal abscesses occurred in seven of the 21 patients who survived longer than 5 days and were more frequent in patients who had gastrointestinal perforation (50% versus 27%) and selective hepatic artery ligation (80% versus 19%). Four patients with either retrohepatic vena cava injury, hepatic vein injury, or both, were packed without attempted repair; three underwent delayed repair and survived. Coagulopathy occurred in 55% of patients who received greater than 15 units of blood before packing but in only 17% who received less than 15 units. The abdomens of ten patients were closed with a prosthetic mesh which did not prevent hemorrhage control, and only one patient developed a wound infection compared to 42% of patients with primary suture closure. We therefore conclude: 1) packing is more effective if instituted early (when less than 15 units of blood have been transfused) and is not contraindicated before either repair of retrohepatic vena cava injury, hepatic vein injury, or both; 2) selective hepatic artery ligation should be avoided if packing alone stops bleeding; 3) abdominal closure with a synthetic mesh decreases the incidence of wound infection; and 4) patients should be returned to the operating room for repacking if 24-hour postoperative blood requirements exceed 10 units.

Definitive control of bleeding from severe pelvic fractures.

Forty patients with severe pelvic fracture and extrapcritoncal hemorrhage were reviewed. Eighteen patients seen prior to 1975 (group I) were clinically similar to 22 patients seen subsequently (group II). Major pelvic fracture hemorrhage was defined as bleeding in excess of 2,000 ml over and above initial resuscitation volumes. Ten of 22 group II patients met the criteria for continued extraperitoncal bleeding and were immobilized in an inflatable G-suit after surgically remediable lesions had been excluded. Ventilator support and hemody-namic monitoring were instituted and clinical response recorded. Prompt cessation of bleeding was observed in nine of ten patients. One patient required selective cathetcrization of a bleeding artery with subsequent embolic occlusion. Significant reductions in overall mortality and the frequency of shock related death were observed in group II patients. Sepsis was the leading cause of late death in survivors. Immobilization of pelvic fracture patients in the G-suit is recommended as a means of controlling continuing rctroperitoneal hemorrhage when surgically correctable bleeding points have been dealt with. Failure of patients to respond promptly to the G-suit strongly suggests arterial bleeding amenable to selective catheterization and embolic occlusion.

Predicting the Need to Pack Early for Severe Intra-abdominal Hemorrhage

OBJECTIVE To determine if the decision to pack for hemorrhage could be refined. MATERIALS AND METHODS Seventy consecutive trauma patients for whom packing was used to control hemorrhage were studied. The patients had liver injuries, abdominal vascular injuries, and bleeding retroperitoneal hematomas. Preoperative variables were analyzed and survivors compared with nonsurvivors. RESULTS Packing controlled hemorrhage in 37 (53%) patients. Significant differences (p < 0.05) between survivors and nonsurvivors were Injury Severity Score (29 vs. 38), initial pH (7.3 vs. 7.1), platelet count (229,000 vs. 179,000/mm3), prothrombin time (14 vs. 22 seconds), partial thromboplastin time (42 vs. 69 seconds), and duration of hypotension (50 vs. 90 minutes). Nonsurvivors received 20 units of packed red blood cells before packing compared to 13 units for survivors. CONCLUSION Patients who suffer severe injury, hypothermia, refractory hypotension, coagulopathy, and acidosis need early packing if they are to survive. Failure to control hemorrhage is related to severity of injury and delay in the use of pack tamponade. A specific protocol that mandates packing when parameters reach a critical limit should be considered.

Is the timing of fracture fixation important for the patient with multiple trauma

Objective The effect of timing of femur fracture fixation for patients with multiple trauma was studied to determine the effect of operative timing on eventual outcome. Methods The relationship between timing of intramedullary rod (IMR) placement, degree of injury, and pulmonary complications was studied in 424 consecutive patients. The authors focused on 105 patients undergoing IMR placement with an Injury Severity score (ISS) of greater than or equal to 18, The effects of timing of IMR placement on various pulmonary complications, organ failure, intensive care unit (ICU) admission, and ventilatory assistance were studied for various time intervals. Results Of the 424 patients, pulmonary complications increased slightly in the more seriously injured group (ISS > 18) but were not influenced by the timing of IMR placement. Of the 105 patients undergoing IMR placement with an ISS ≥ 18, only 2 patients died. Both patients had an IMR placed in less than 24 hours and died later of head injury and delayed hemorrhage. The incidence of organ failure, number of ventilator days, and length of ICU stay did not differ between the groups based on timing of fracture fixation. The incidence of severe head injuries was higher in the group undergoing delayed IMR placement (>48 hours). Conclusions Modest delays in IMR placement did not adversely affect patient outcome. Pulmonary complications were related to the severity of injury rather than to timing of fracture fixation. In a well‐integrated trauma system, clinical judgment regarding the timing of IMR placement was the most important determinant of outcome. Delays that were made to stabilize the patient, treat associated injuries, and plan orthopedic reconstruction did not adversely affect patient outcome.

Blunt carotid artery injuries: difficulties with the diagnosis prior to neurologic event.

OBJECTIVE To evaluate the incidence, timing of diagnosis, clinical factors for adverse outcome, and role of anticoagulant, surgical therapy, or endovascular intervention for patients with blunt carotid artery injury (BCAI). METHODS Retrospective review of the records of patients who sustained BCAI between 1987 and 1997. RESULTS There were 18 men and 12 women, with an average age of 29 years. The diagnosis of BCAI was initially suspected in 15 patients after a major or new neurologic event, and in 15 patients after changes were shown by computed tomography. BCAI was confirmed by arteriography in 29 patients and by magnetic resonance angiography in 1 patient. Treatment consisted of antiplatelet therapy (n = 9), anticoagulation (n = 8), surgical repair (n = 6), observation (n = 4), and endovascular embolization (n = 3). With some type of treatment, 14 patients with no neurologic deficits remained stable; however, treatment improved the final neurologic outcome in 8 patients (20%). Three patients remained with severe deficits, and five patients died. CONCLUSION The consequences of BCAI may be devastating. In our study, there were no reliable means to suspect this injury before neurologic symptoms or abnormalities show on computed tomographic scan. Although external signs are occasionally helpful, most patients have no pattern of injury to suggest BCAI. For patients whose findings after neurologic examination do not correlate with those on the computed tomographic scan, an immediate angiogram is indicated. Occasionally, a proximal injury can be surgically repaired, but in most patients, anticoagulation therapy appears to be the best treatment to avoid or improve neurologic deficits.

Prehospital hypotension as a valid indicator of trauma team activation.

BACKGROUND Criteria for trauma team activation are continually being evaluated to ensure proper utilization of resources. We examined the impact of prehospital (PH) hypotension (systolic blood pressure < or = 90) on outcome (operative intervention and mortality) and its usefulness as an indicator for trauma team activation. METHODS A database was created by using the trauma registry for all nonburned, injured patients from July of 1993 through October of 1998 at our Level I trauma center. RESULTS Of 6,976 patients (83% blunt injury) in the database, 4,437 had a PH blood pressure recorded. Documented PH hypotension was present in 791 patients. Hypotension persisted in the emergency department (ED) in 299 patients, but 193 of them showed minimal or no signs of life on arrival. Four hundred ninety-two patients had PH hypotension but normal ED systolic blood pressure, and 130 patients developed ED hypotension after normal PH systolic blood pressure. Nearly half of the patients with hypotension were taken from the ED directly to the operating room primarily for hemorrhage control procedures. The early and late mortality rates of patients with PH and ED hypotension were 12% and 32%, respectively. Other PH interventions had minimal effect on mortality in the hypotensive patient. CONCLUSION Prehospital hypotension remains a valid indicator for trauma team activation. Even though most of the non-DOA patients (492 of 598) were stable on arrival to the ED, nearly 50% required operative intervention, and an additional 25% required intensive care unit admission. The trauma team should be activated and involved with these patients early.

Transpyloric passage of feeding tubes in patients with head injuries does not decrease complications.

Early enteral nutrition is reported to improve outcome of patients with severe closed head injuries (CHI). The efficacy and safety of nasoenteric tube (NET) feeds, however, has been questioned; the risk of aspiration is the major concern. Our purpose was to determine the rate of transpyloric migration, the efficacy of adjunctive measures to promote passage, and the effect on pulmonary complications. Seventy-four consecutive patients with moderate to severe CHI received enteral nutrition. Glasgow Coma Scale (GSC) score was 5.2 on admission and 6.9 at 48 hours. NETs were placed an average of 5.6 days after admission; an average of three abdominal films per patient were used to assess tube position. No patients had endoscopic NET placement during this period. Ten patients required fluoroscopic placement after failure to pass spontaneously by 5 days. Overall, transpyloric passage was achieved in 32 patients (43%), whereas 42 (57%) remained intragastric. There were no differences between the postpyloric and intragastric groups in days to full feeding (5 vs. 7 days), ventilator days (11.9 vs. 12.5), intensive care unit length of stay (15.5 vs. 15.1), or incidence of pneumonia (81 vs. 69%) or aspiration (6 vs 7%). Sixty-two patients (83%) were transferred to extended care facilities and 50 (68%) were still receiving NET feedings. Spontaneous transpyloric passage of NET occurred in less than one-half of patients with severe CHI. The routine use of adjunctive measures to promote transpyloric passage was not particularly successful, had no obvious benefit, and therefore may not be necessary.

Delayed laparoscopy facilitates the management of biliary peritonitis in patients with complex liver injuries.

BackgroundNonoperative management is now regarded as the best alternative for the treatment of patients with complex blunt liver injuries. However, some patients still require surgical treatment for complications that were formerly managed with laparotomy and a combination of image-guided studies.MethodsWe reviewed the medical records of 15 patients who had complex blunt liver injuries that were managed nonoperatively and in which biliary peritonitis developed.ResultsDelayed laparoscopy was performed 2–9 days after admission in patients with extensive liver injuries. All 15 patients had developed local signs of peritonitis or a systemic inflammatory response. Laparoscopy was indicated to drain a large retained hemoperitoneum (eight patients), bile peritonitis (four patients), or an infected perihepatic collection (three patients). Laparoscopy was successful in all patients, and there was no need for further interventions.ConclusionThe data indicate that as more patients with complex liver injuries are treated nonoperatively and the criteria for nonoperative management continue to expand, more patients will need some type of interventional procedure to treat complications that historically were managed by laparotomy. At this point, laparoscopy is an excellent alternative that should become part of the armamentarium of the trauma surgeons who treat these patients.

Common and external iliac artery injuries associated with pelvic fractures.

BACKGROUND Common and external iliac artery injuries associated with pelvic fractures are uncommon. The diagnosis of such injuries is based on clinical findings and confirmed by arteriography. DESIGN Retrospective chart review. SETTING University Level I trauma center. PATIENTS Five men and three women, aged seventeen to seventy-six years, with injuries to the common and external iliac arteries associated with pelvic fractures. RESULTS All patients sustained complex pelvic fractures associated with multiple blunt injuries. Five injuries occurred on the right side. Two patients had an associated right vertical shear pelvic fracture. In five patients, vascular injury was diagnosed in the first six hours after admission. One patient presented with an aneurysm of the right common iliac artery two months after his initial injury. All patients underwent surgical repair with an interposition graft, which failed in two patients, who underwent vascular reconstruction ten hours after the injury. One patient died of associated injuries. CONCLUSIONS Arterial hyperextension with intimal damage seems to be the most likely cause of this injury. Ideally, an extraperitoneal approach should be attempted to minimize blood losses and, due to the size of the iliac vessels, an interposition graft should be used for reconstruction.