Robert L. Fulton

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.

The Role of Thoracoscopy in the Management of Retained Thoracic Collections After Trauma

BACKGROUND Retained hemothorax and infected thoracic collections after trauma can be seen in up to 20% of patients initially treated with tube thoracostomy and have traditionally been treated nonoperatively, often with prolonged hospital stays. METHODS Twenty-five patients with retained thoracic collections were reviewed. They underwent 26 thoracoscopies to evacuate undrained blood with or without infection. RESULTS In 19 patients (76%), the collections were evacuated thoracoscopically. In 4 patients the procedure was converted to an open thoracotomy, and 2 patients required additional procedures to drain these collections. Failure of thoracoscopy correlated with the time between injury and operation and the type of collection, but not with the mechanism of injury. When thoracoscopy was performed in less than 7 days after admission, no cases of empyema were noted at operation. CONCLUSIONS Videothoracoscopy is an accurate, safe, and reliable operative therapy to evacuate retained thoracic collections. In 90% of the patients in whom the procedure was completed, good results were obtained, reducing hospital stay and possible complications. Videothoracoscopy should be the initial treatment in trauma patients with retained thoracic collections and should be used earlier and more frequently in these patients.

A comparison of the pathophysiologic effects of carbon dioxide, nitrous oxide, and helium pneumoperitoneum on intracranial pressure.

BACKGROUND Previous studies have suggested that diagnostic laparoscopy may be contraindicated in multiple trauma patients with closed head injuries because of the detrimental effects of carbon dioxide (CO2) pneumoperitoneum on intracranial pressure (ICP). In this study we compared the effects of two alternative inflation gases, helium (He) and nitrous oxide (N2O), against the standard agent used in most hospitals, CO2. ICP was monitored in experimental animals both with and without a space occupying intracranial lesion designed to simulate a closed head injury. METHODS Twenty-four domestic pigs (mean, 30 kg) were divided into four groups (6 CO2, 6 He, 6 N2O, and 6 control animals without insufflation). All animals were monitored for ICP, intraabdominal pressure, mean arterial pressure, end-tidal CO2 (ETCO2), and arterial blood gases. These parameters were measured for 30 minutes prior to introducing a pneumoperitoneum and then for 80 minutes thereafter. The measurements were repeated after artificially elevating the ICP with a balloon placed in the epidural space. RESULTS The mean ICP increased significantly in all groups during peritoneal insufflation compared with the control group (P < 0.005). The CO2-insufflated animals also showed a significant increase in PaCO2 (P < 0.05) and ETCO2 (P < 0.05), as well as a decrease in pH (P < 0.05). After inflating the epidural balloon the ICP remained significantly higher in animals inflated with CO2 as compared with the He and N2O groups (P < 0.05). CONCLUSIONS Peritoneal insufflation with He and N2O resulted in a significantly less increase in ICP as compared with CO2. That difference was most likely due to a metabolically mediated increase in cerebral perfusion (PaCO2) in the CO2 group. Further studies need to be conducted to determine the safety and efficacy of using He and N2O as inflation agents prior to attempting diagnostic or therapeutic laparoscopy in patients with potential closed head injuries.

Indications for thoracotomy following penetrating thoracic injury.

The treatment of penetrating thoracic injuries has been reviewed in both civilian and military series. Although most surgeons agree that closed that closed thoracostomy drainage is the initial treatment of choice, the timing of early thoracotomy and perhaps cardiorrhaphy upon patients with penetrating thoracic injuries remains controversial. The purpose of this study was to determine which patients will require immediate thoractomy or cardiorrhaphy following penetrating chest injury. Over a two-year period 190 patients with penetrating thoracic injuries were treated. Of 53 patients who required immediate thoracotomy, 31 suffered cardiac wounds. Seventy-nine patients required laparotomy for associated intra-abdominal injuries. The mortality rate was related to exsanguinating hemorrhage or postoperative intra-abdominal sepsis. Cardiopulmonary complications were rare in the absence of intra-abdominal sepsis and could not be attributed to the thoracic injury or thoracotomy. Indications for immediate cardiorrhaphy or thoracotomy are: 1) location of the entrance wound (70% in upper mediastinum); 2) blood pressure on admission less than 90; 3) initial thoracostomy blood loss greater than 800 cc; 4) radiographic evidence of retained hemothorax; and/or 5) clinical evidence of pericardial tamponade.

Principles for the management of penetrating cardiac wounds.

An experience with penetrating cardiac injuries between 1974 and 1977 has permitted designation of particular findings as indications for emergent operations and appropriate therapeutic approaches. Of the 46 patients with cardiac trauma, 28 suffered gunshot wounds. Seventeen patients died, and 14 of the deaths occurred as a result of asystole, ventricular fibrillation or exsanguination during operation. Two patients died of neurologic sequelae following successful cardiac repair, and one died secondary to injury not disclosed by physical examination or roentgenogram. The surviving 29 patients had five major complications. Sepsis, organ system failure and cardiac defects rarely occurred despite rapidly performed thoracotomy and severe shock. Since delayed operation has been uniformly associated with adverse outcome and because postoperative complications of emergent pericardial exploration are mild, the following conclusions have been reached: 1) Mediastinal entrance wounds, severe hypotension and signs of cardiac tamponade arc demonstrative of cardiac trauma. Therefore, virtually any combination of these physical signs mandates pericardial exploration. 2) Subxiphoid or transdiaphragmatic exploration (during laparotomy) of the pericardium has been valuable in diagnosis of suspected heart wounds. 3) Emergent cardiorrhaphy is the treatment of choice. Pericardiocentesis is at best only temporarily effective. Thoracotomies performed in the emergency room were uniformly unsuccessful. If possible, cardiorrhaphy should be done in the operating room. 4) Median sternotomy is the approach of choice. 5) The basic principles of management of cardiac injury are rapid diagnosis, relief of tamponade, control of hemorrhage, repair of cardiac defects and restoration of blood volume.

Impact of trauma attending surgeon case volume on outcome: is more better?

OBJECTIVE To examine the relationship between annual trauma volume per surgeon and years of attending experience with outcome in a Level I trauma center with a large panel of trauma attending surgeons. METHODS The outcomes of trauma patients were examined in 1995 and 1996 in relationship to surgeon annual trauma volume and years of experience. Outcome variables studied included overall mortality, mortality stratified by Trauma and Injury Severity Score, mortality in patients with an Injury Severity Score greater than 15, and preventable or possibly preventable deaths. Morbidity outcomes examined were overall complication rate and length of stay per attending surgeon. Additionally, five difficult problems were evaluated for critical management decisions by the attending surgeons, and these outcomes were correlated to annual volume and experience. RESULTS There was no difference in outcome in either morbidity or mortality that correlated with annual volume of patients treated or years of experience. Critical management errors occurred sporadically and were not related to volume or experience. CONCLUSIONS Outcome after trauma seemed to be related to severity of injury rather than annual volume of cases per surgeon. Although our results may not be applicable to other institutions, they should urge caution in adopting and promulgating volume requirements for individual attending surgeons in trauma centers.

Physiologic effects of fluid therapy after pulmonary contusion

Summary The physiologic effects of fluid infusions given after pulmonary contusion were studied. Rapid infusion of blood, saline, or both produced an impulsive increase in pulmonary blood flow and pressure, particularly in the normal lung. A fall in normal lung resistance allows the pressure to reach the capillaries, resulting in leakage of blood and fluid into the normal lung (congestive atelectasis). Animals given rapid infusions suffered a shunt (Q s /Q t ) fraction larger than that of contused lung blood flow and more severe hypoxemia than did the controls. Hypotension followed by blood and saline administration did not alter lung function compared with saline infusion alone. It was suggested that some of the progression of pulmonary contusion as seen clinically and radiologically is due to damage in the normal lung. Monitoring of the pulmonary artery pressure during fluid administration after pulmonary contusion may be helpful in preventing further lung damage.

Lumbar sympathectomy: A procedure of questionable value in the treatment of arteriosclerosis obliterans of the legs

Abstract A review of the literature concerning lumbar sympathectomy and a study of fifty-four patients upon whom the operation was performed were used to suggest that lumbar sympathectomy is of questionable value in the treatment of arteriosclerosis obliterans of the lower extremities. It is our opinion that lumbar sympathectomy does not alleviate intermittent claudication, that it does not aid in the salvation of gangrenous limbs, that it has no effect on amputation rate or level of amputation, and that it is associated with a finite and significant mortality.

Analysis of factors leading to posttraumatic pulmonary insufficiency.

Abstract Clinical and pathological data on all trauma patients (113) on whom a postmortem examination was performed between January, 1975, and July, 1976, were analyzed to determine the factors leading to posttraumatic pulmonary insufficiency (PTPI) defined as treatment-resistant lung failure. Fifty-nine patients died within 3 days of injury; 28 had suffered hemorrhagic shock and received massive fluid therapy (>10 liters). While mechanical ventilation was used more often in those patients suffering from shock ( p p > 0.08). The three factors associated with late PTPI were sepsis ( p p p Most patients suffering from shock do not have pulmonary failure, and modern ventilatory support is adequate treatment for the usually mild respiratory dysfunction they experience. The combination of mild pulmonary edema and mechanical ventilation may lead to gram-negative pulmonary infection manifest as PTPI.

Cardiac function during hemorrhagic shock and crystalloid resuscitation

Abstract It is concluded that (1) myocardial failure develops during hypovolemic shock; (2) inadequate coronary perfusion contributes to the decrease in myocardial function; (3) inadequate resuscitation prolongs myocardial dysfunction and decreased coronary blood flow and may lead to terminal arrhythmias; (4) crystalloid resuscitation relieves heart failure and corrects myocardial ischemia; and (5) no evidence exists for cardiac overload with use of large volumes of crystalloid.