Robert E. Falcone

Management of Penetrating Neck Injuries: The Controversy Surrounding Zone II Injuries

Penetrating neck injuries present a difficult challenge in management, given the unique anatomy of the neck. Controversy surrounds the approach to zone II injuries; mandatory versus selective exploration. On the basis of an extensive literature review, the authors conclude that neither approach is obviously superior. A selective approach is safe in the asymptomatic and hemodynamically stable patient, provided that accurate invasive diagnostic means are immediately available. The mandatory approach is safe, reliable, and time tested. The greatest problem appears to be the accuracy of detection of cervical esophageal injuries: Radiologic evaluation may be inaccurate, rigid esophagoscopy carries a risk of perforation, and the injury may easily be overlooked during surgical exploration.

Penetrating esophageal injuries: Multicenter study of the American Association for the Surgery of Trauma

OBJECTIVE The purpose of this study was to define the period of time after which delays in management incurred by investigations cause increased morbidity and mortality. The outcome study is intended to correlate time with death from esophageal causes, overall complications, esophageal related complications, and surgical intensive care unit length of stay. METHODS This was a retrospective multicenter study involving 34 trauma centers in the United States, under the auspices of the American Association for the Surgery of Trauma Multi-institutional Trials Committee over a span of 10.5 years. Patients surviving to reach the operating room (OR) were divided into two groups: those that underwent diagnostic studies to identify their injuries (preoperative evaluation group) and those that went immediately to the OR (no preoperative evaluation group). Statistical methods included Fishers exact test, Students T test, and logistic regression analysis. RESULTS The study involved 405 patients: 355 male patients (86.5%) and 50 female patients (13.5%). The mean Revised Trauma Score was 6.3, the mean Injury Severity Score was 28, and the mean time interval to the OR was 6.5 hours. There were associated injuries in 356 patients (88%), and an overall complication rate of 53.5%. Overall mortality was 78 of 405 (19%). Three hundred forty-six patients survived to reach the OR: 171 in the preoperative evaluation group and 175 in the no preoperative evaluation group. No statistically significant differences were noted in the two groups in the following parameters: number of patients, age, Injury Severity Score, admission blood pressure, anatomic location of injury (cervical or thoracic), surgical management (primary repair, resection and anastomosis, resection and diversion, flaps), number of associated injuries, and mortality. Average length of time to the OR was 13 hours in the preoperative evaluation group versus 1 hour in the no preoperative evaluation group (p < 0.001). Overall complications occurred in 134 in the preoperative evaluation group versus 87 in the no preoperative evaluation group (p < 0.001), and 74 (41%) esophageal related complications occurred in the preoperative evaluation group versus 32 (19%) in the no preoperative evaluation group (p = 0.003). Mean surgical intensive care unit length of stay was 11 days in the preoperative evaluation group versus 7 days in the no preoperative evaluation group (p = 0.012). Logistic regression analysis identified as independent risk factors for the development of esophageal related complications included time delays in preoperative evaluation (odds ratio, 3.13), American Association for the Surgery of Trauma Organ Injury Scale grade >2 (odds ratio, 2.62), and resection and diversion (odds ratio, 4.47). CONCLUSION Esophageal injuries carry a high morbidity and mortality. Increased esophageal related morbidity occurs with the diagnostic workup and its inherent delay in operative repair of these injuries. For centers practicing selective management of penetrating neck injuries and transmediastinal gunshot wounds, rapid diagnosis and definitive repair should be made a high priority.

Multiinstitutional Experience With the Management of Superior Mesenteric Artery Injuries.

BACKGROUND Superior mesenteric artery (SMA) injuries are rare and often lethal injuries incurring very high morbidity and mortality. The purposes of this study are to review a multiinstitutional experience with these injuries; to analyze Fullens classification based on anatomic zone and ischemia grade for its predictive value; to correlate the American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS) for abdominal vascular injury with mortality; and to identify independent risk factors predictive of mortality, describing current trends for the management of this injury in America. DESIGN We performed a retrospective multiinstitutional study of patients sustaining SMA injuries involving 34 trauma centers in the US over 10 years. Outcomes variables, both continuous and dichotomous, were analyzed initially with univariate methods. For the subsequent multivariate analysis, stepwise logistic regression was used to identify a set of risk factors significantly associated with mortality. RESULTS There were 250 patients enrolled, with a mean Revised Trauma Score (RTS) of 6.44 and a mean Injury Severity Score (ISS) of 25. Surgical management consisted of ligation in 175 of 244 patients (72%), primary [corrected] repair in 53 of 244 patients (22%), autogenous grafts were used in 10 of 244 (4%), and prosthetic grafts of PTFE in 6 of 244 patients (2%). Overall mortality was 97 of 250 patients (39%). Mortality versus Fullens zones: zone I, 39 of 51 (76.5%); zone II, 15 of 34 (44.1%); zone III, 11 of 40 (27.5%); and zone IV, 25 of 108 (23.1%). Mortality versus Fullens ischemia grade: grade 1, 22 of 34 (64.7%). Mortality versus AAST-OIS for abdominal vascular injury: grade I, 9 of 55 (16.4%); grade II, 13 of 51 (25.5%); grade III, 8 of 20 (40%); grade IV, 37 of 69 (53.6%); and grade V, 17 of 19 (89.5%). Logistic regression analysis identified as independent risk factors for mortality the following: transfusion of greater than 10 units of packed RBCs, intraoperative acidosis, dysrhythmias, injury to Fullens zone I or II, and multisystem organ failure. CONCLUSION SMA injuries are highly lethal. Fullens anatomic zones, ischemia grade, and AAST-OIS abdominal vascular injuries correlate well with mortality. Injuries to Fullens zones I and II, Fullens maximal ischemia grade, and AAST-OIS injury grades IV and V, high-intraoperative transfusion requirements, and presence of acidosis and disrhythmias are significant predictors of mortality. All of these predictive factors for mortality must be taken into account in the surgical management of these injuries.

Occurrence of nosocomial pneumonia in mechanically ventilated trauma patients: a comparison of sucralfate and ranitidine.

To determine if there is a difference in nosocomial pneumonia frequency rate in mechanically ventilated trauma patients treated with sucralfate vs. ranitidine for stress ulcer prophylaxis. Design:Prospective, randomized trial. Setting:A 640-bed urban teaching hospital and trauma center. Patients:Ninety-two mechanically ventilated trauma patients. Interventions:Thirty-nine patients received sucralfate and 44 patients received intravenous ranitidine for stress ulcer prophylaxis; nine patients were excluded from the study for protocol breaks. Measurements and Main Results:The study population was severely injured and critically ill. The Trauma Score averaged 11.3, the Injury Severity Score averaged 27.7, and the Acute Physiology and Chronic Health Evaluation (APACHE) score averaged 18.1. There were no significant differences in demographics, mechanisms of injury, Trauma Score, Injury Severity Score, APACHE score, length of hospital stay, length of surgical intensive care unit stay, or duration of endotracheal intubation between the sucralfate and ranitidine groups. Eleven (13.2%) patients developed nosocomial pneumonia: six (15.4%) of 39 patients in the sucralfate group and five (11.4%) of 44 patients in the ranitidine group; these numbers were not significantly different (x2 = 0.0226, p = .8805). There were no episodes of significant upper gastrointestinal bleeding. Six patients died during hospitalization, all secondary to severe head injury and none with pneumonia. Conclusions:There was no statistically significant difference in pneumonia rate in mechanically ventilated trauma patients receiving stress ulcer prophylaxis with sucralfate vs. ranitidine. (Crit Care Med 1993; 21:1856–1862)

Breast reduction for symptomatic macromastia: can objective predictors for operative success be identified?

The purpose of this paper is to assess symptomatic macromastia, the relief of symptoms by operation, and predictors of symptom relief. The methods used have been retrospective chart review and a self-assessment patient questionnaire. One-hundred and thirty-three patients underwent an average 1660-gm reduction. Ninety-three percent reported a postoperative decrease in symptoms such as shoulder grooves and shoulder, neck, and back pain. Correlation between breast size and sign or symptom severity achieved significance only for the preoperative submammary rash (r = 0.33, p < 0.001). Patients lost an average of 8.9 lb postoperatively and were less overweight (49 versus 40 percent). Activity level increased postoperatively in 63 percent. Postoperative chest size correlated inversely with activity level (r = 0.35, p < 0.001). Thirty-nine percent of patients who took pain medications preoperatively were able to eliminate these postoperatively. The quantity of tissue removed did not correlate with outcome. A model predictive of symptom relief could not be developed (total R2 = 0.03). Reduction mammaplasty promoted relief of signs and symptoms of macromastia, but a predictive model of successful operation could not be developed.

Emergency scene endotracheal intubation before and after the introduction of a rapid sequence induction protocol.

INTRODUCTION A change in airway management protocol provided the opportunity to evaluate scene airway management by air medical crew before and after the introduction of a rapid sequence induction protocol. METHODS A retrospective chart review and a descriptive study of scene trauma patients whose airway was established primarily by an air medical crew during two study periods: April 1994 through March 1995 (group 1, before rapid sequence induction) and April 1995 through March 1996 (group 2, after rapid sequence induction). Data collected included demographics, type of airway, Glasgow Coma Scale score, scene time, and outcome. The setting included a four helicopter air medical transport program using nurse/paramedic crews with a service area of 25,000 square miles in central, southeastern, and northeastern Ohio. RESULTS Group 1 patients (n = 148) averaged 31.6 years of age and were primarily male (79.7%) with blunt injuries (92.6%) with an average Glasgow Coma Scale score of 7.7. Group 2 (n = 95) was similar, averaging 31.1 years of age, primarily male (77.9%) with blunt injuries (94.7%) and a Glasgow Coma Scale score of 8.6. Groups 1 and 2 differed in oral endotracheal intubation rate (19/118 versus 36/95 [p = 0.03]) and in scene time (15.7 minutes versus 20.1 minutes [p = 0.0012]). The groups did not differ in rate of successful intubation or the rate of subsequent cricothyrotomy. CONCLUSION Rapid sequence induction added significantly to ground time without significantly increasing intubation success rate or decreasing cricothyrotomy rate. Its use at the scene of injury may not be appropriate.

Colorectal trauma : primary repair or anastomosis with intracolonic bypass vs. ostomy

This prospective, randomized, controlled study was undertaken to compare primary repair or anastomosis with intracolonic bypassvs.ostomy in severe colon and intraperitoneal rectal injury. Patients were randomized at surgery following confirmation of injury. Data collected included demographics, mechanism and location of injury, trauma score (TS), injury severity score (ISS), penetrating abdominal trauma index (PATI), complications, length of hospital stay, and hospital charges. Twenty-two patients were studied: 11 with intracolonic bypass and 11 controls. The experimental and control groups were statistically similar in demographics and mechanism of injury, severity of injury (TS=13.8vs.12.8; ISS=27.5vs.24.2; PATI=40.5vs.35.0), and complication rate. Length of stay (12.2 daysvs.20.7 days) and charges

Percutaneous Endoscopic vs Surgical Gastrostomy

27,885vs.

Accidental Pneumothorax from a Nasogastric Tube

53,599) tended to be greater in controls, and the comparison did not include subsequent colostomy closure. This study supports intracolonic bypass as a safe alternative to ostomy in severe colon and intraperitoneal rectal trauma.

Air medical transport of the injured patient: scene versus referring hospital.

The percutaneous endoscopic gastrostomy (PEG) has replaced the surgical gastrostomy (GT) on our service. We reviewed our data in an effort to determine relative efficacy and cost effectiveness of the two techniques. Thirty-five patients with PEGs were matched for age and diagnosis with 35 patients with GTs done by the same surgical service. PEGs were done in the endoscopy suite; GTs were done in the operating room: both under local anesthesia. Patients in PEG and GT groups were comparable in sex, diagnosis, and age. The PEG took less time to insert (15.3 vs 25.4 min, p less than 0.001). Major postoperative morbidity was similar with 10 systemic complications for each group and 11 deaths for the PEG vs 12 deaths for the GT group (at 90 days). Minor morbidity was higher for the PEG group with nine complications vs 1. Estimated cost for PEG was half the cost of GT. Hospital stay for the two groups was similar (36 vs 45 days, p greater than 0.1), but postop stay for the PEG group tended to be shorter (17 vs 24 days, p less than 0.08). The PEG is faster and cheaper to insert than the GT, however major morbidity and mortality are the same.