T. V. Berne

Evaluation of Penetrating Injuries of the Neck: Prospective Study of 223 Patients

Abstract. The objective of this study was to assess the role of clinical examination, angiography, color flow Doppler imaging, and other diagnostic tests in identifying injuries to the vascular or aerodigestive structures in patients with penetrating injuries to the neck. A prospective study was made of patients with penetrating neck injuries. All patients had a careful physical examination according to a written protocol. Stable patients underwent routine four-vessel angiography and color flow Doppler imaging. Esophagography and endoscopy were performed for proximity injuries. The sensitivity, specificity, and predictive values of physical examination, color flow Doppler studies, and other diagnostic tests were assessed during the evaluation of vascular and aerodigestive tract structures in the neck. Altogether 223 patients were entered in the study. After physical examination 176 patients underwent angiography and 99 of them underwent color flow Doppler imaging. Angiographic abnormalities were seen in 34 patients for an incidence of 19.3%, but only 14 (8.0%) required treatment. Color flow Doppler imaging was performed on 99 patients with a sensitivity of 91.7%, specificity 100%, positive predictive value (PPV) 100%, and negative predictive value (NPV) 99%. These values were all 100% when only injuries requiring treatment were considered. None of the 160 patients without clinical signs of vascular injury had serious vascular trauma requiring treatment (NPV 100%), although angiography in 127 showed 11 vascular lesions not requiring treatment. “Hard” signs on clinical examination (large expanding hematomas, severe active bleeding, shock not responding to fluids, diminished radial pulse, bruit) reliably predicted major vascular trauma requiring treatment. Among 34 of the 223 total patients (15.2%) admitted with “soft” signs, 8 had angiographically detected injuries, but only one required treatment. An esophagogram was performed on 98 patients because of proximity injuries (49 patients) or suspicious clinical signs (49 patients), and two of them showed esophageal perforations. None of the 167 patients without clinical signs of esophageal trauma had an esophageal injury requiring treatment. It was concluded that physical examination is reliable for identifying those patients with penetrating injuries of the neck who require vascular or esophageal diagnostic studies. Color flow Doppler imaging is a dependable alternative to angiography. An algorithm for the initial assessment of neck injuries is suggested.

Penetrating Left Thoracoabdominal Trauma: The Incidence and Clinical Presentation of Diaphragm Injuries

OBJECTIVE The objective of this study was to (1) determine the incidence of diaphragmatic injuries in penetrating left thoracoabdominal trauma and (2) evaluate the role of laparoscopy in detecting clinically occult diaphragmatic injuries. PATIENTS AND METHODS One hundred nineteen consecutive patients with penetrating injuries to the left thoracoabdominal region presenting to Los Angeles County-University of Southern California Medical Center were prospectively evaluated during an 8-month period. Either celiotomy (with hemodynamic instability or peritonitis) or laparoscopy was performed. Results of the clinical examination and roentgenographic findings were recorded preoperatively. RESULTS One hundred seven patients were fully evaluated. Fifty patients required emergent celiotomy. Fifty-seven patients underwent laparoscopy. The overall incidence of diaphragmatic injuries was 42% (59% for gunshot wounds, 32% for stab wounds). Among the 45 patients with diaphragmatic injuries, 31% had no abdominal tenderness, 40% had a normal chest roentgenogram, and 49% had an associated hemopneumothorax. Fifteen of the patients undergoing laparoscopy (26%) had occult diaphragm injuries. CONCLUSION (1) The incidence of diaphragmatic injuries in association with penetrating left thoracoabdominal trauma is high. (2) The clinical and roentgenographic findings are unreliable at detecting occult diaphragmatic injuries. (3) Laparoscopy is a vital tool for detecting occult diaphragmatic injuries among patients who have no other indications for formal celiotomy.

Radiographic cervical spine evaluation in the alert asymptomatic blunt trauma victim : much ado about nothing

OBJECTIVE To evaluate the hypothesis that alert nonintoxicated trauma patients with negative clinical examinations are at no risk of cervical spine injury and do not need any radiographic investigation. DESIGN Prospective study. SETTING A university-affiliated teaching county hospital. PATIENTS Five hundred and forty-nine consecutive alert, oriented, and clinically nonintoxicated blunt trauma victims with no neck symptoms. RESULTS All patients had negative clinical neck examinations. After radiographic assessment, no cervical spine injuries were identified. Less than half the patients could be evaluated adequately with the three standard initial views (anteroposterior, lateral, and odontoid). All the rest needed more radiographs and/or computed tomographic scans. A total of 2,27 cervical spine radiographs, 78 computed tomographic scans and magnetic resonance imagings were performed. Seventeen patients stayed one day in the hospital for no other reason but radiographic clearance of an asymptomatic neck. The total cost for x-rays and extra hospital days was

Mortality and prognostic factors in penetrating injuries of the aorta.

242,000. These patients stayed in the collar for an average of 3.3 hours (range, 0.5-72 hours). There was never an injury missed. CONCLUSIONS Clinical examination alone can reliably assess all blunt trauma patients who are alert, nonintoxicated, and report no neck symptoms. In the absence of any palpation or motion neck tenderness during examination, the patient may be released from cervical spine precautions without any radiographic investigations.

Transcervical gunshot injuries: mandatory operation is not necessary.

PURPOSE This study was designed to investigate the epidemiology and prognostic factors determining survival in penetrating injuries of the aorta. PATIENTS AND METHODS This was a retrospective analysis of all patients with penetrating aortic injuries, admitted to a large, level I trauma center. The following factors were analyzed for their role in determining survival: mechanism of injury, anatomical site of the aortic injury, initial blood pressure on admission, need for emergency room thoracotomy, and the introduction of a dedicated trauma program with an attending surgeon in-house. RESULTS There were 93 patients with penetrating aortic injuries over a 5-year period. The abdominal aorta was injured in 67 patients (72%) and the thoracic aorta in 26 (28%). Most of the victims (82.5%) were admitted in shock and 41% had an unrecordable blood pressure on admission. Victims with injury to the thoracic aorta were more likely to have an unrecordable blood pressure on admission than patients with abdominal aortic injuries (73% vs 28.4%), and more likely to require an emergency room thoracotomy (76.9% vs 20.9%). Thirty-four patients (36.6%) required an emergency room thoracotomy and there were no survivors. The overall mortality was 80.6% (87.5% for gunshot injuries, 64.7 % for knife injuries). Patients with abdominal aortic injuries were three times more likely to survive than those with thoracic aortic injuries (23.9% vs 7.7%). The introduction of a dedicated trauma program, which resulted in significant reduction of mortality in other types of severe trauma, had no effect on the outcome in aortic injuries. CONCLUSIONS Penetrating aortic injuries still have a very high mortality rate with no improvement in survival despite improved trauma services. Injury to the thoracic aorta, gunshot wounds, unrecordable blood pressure on admission, and the need for emergency room thoracotomy, are important predictors of high mortality.

Complications and Nonclosure Rates of Fasciotomy for Trauma and Related Risk Factors

BACKGROUND It has been suggested that all transcervical gunshot wounds should be explored surgically because of the high incidence of injuries to vital structures. The present prospective study investigated the clinical presentation, the role of various diagnostic investigations, and the need for surgery in patients with transcervical gunshot injuries. METHODS Ninety-seven patients sustained gunshot injuries to the neck and 33 of them (34%) were transcervical. All victims were assessed clinically according to a written protocol and subsequently were evaluated angiographically, and, in the appropriate case, by means of endoscopy and esophagography. RESULTS Overall, 24 (73%) of the 33 patients with transcervical gunshot wounds had injuries to cervical structures. Vascular injuries were found in 48%, spinal cord injuries in 24%, and aerodigestive tract injuries in 6% of patients with transcervical injuries. In the 64 patients without midline crossing, the incidence of cervical structure injuries was 31%. Despite the high incidence of injuries to cervical structures in transcervical wounds, only 21% of the patients had a therapeutic operation. The overall mortality was 3%. There were no in-hospital deaths or local complications in the nonoperatively managed group. CONCLUSIONS The results of the present study do not support the current recommendations of mandatory operation for all transcervical gunshot wounds. A careful clinical examination combined with the appropriate diagnostic investigations should determine the treatment modality. About 80% of these patients can safely be managed nonoperatively.

Timing of fracture fixation in blunt trauma patients with severe head injuries

Abstract. The objective of this study was to identify risk factors for the development of complications and unsatisfactory skin closure following fasciotomy for trauma. Risk factors included in the study are prolonged time from injury to fasciotomy, type of fasciotomy, site of injury, and kind of underlying injury. The study was a retrospective analysis of 100 consecutive fasciotomies done for trauma over a period of 38 months (December 1991 to January 1995) in a “level I” trauma center at a university-affiliated county teaching hospital. Ninety-four patients were eligible for analysis, 29 of whom (31%) developed complications at the fasciotomy site. The risk was increased for lower extremity versus upper extremity (34.3% versus 20.8%), prophylactic versus therapeutic (42.0% versus 24.6%), late (>8 hours) versus early (37% versus 25%), and vascular versus musculoskeletal (38.8% versus 22.2%) trauma cases. The same risk factors negatively influenced the ability to close the skin primarily. The four subgroups defined by vascular/nonvascular injury and upper/lower extremity site had significantly different nonclosure rates (p = 0.043). The rate was highest among the vascular/lower extremity group (60.5%) and lowest among the nonvascular/upper extremity group (15.4%). We concluded that fasciotomies in lower extremities, the presence of underlying vascular injuries, fasciotomies performed prophylactically, and a time between the injury and fasciotomy of more than 8 hours are associated with an increased risk for local complications. The same factors are associated with an increased need for skin grafting the wound.

TOTAL HIP REPLACEMENT IN RENAL TRANSPLANT RECIPIENTS WITH ASEPTIC NECROSIS OF THE FEMORAL HEAD

BACKGROUND Early fracture fixation in blunt trauma patients is suggested to decrease postoperative morbidity by allowing early mobilization and reducing the release of harmful inflammatory mediators. Some studies have challenged this concept in the presence of severe associated injuries, and especially head trauma. METHODS The records of 47 consecutive blunt trauma patients with severe head injuries, as defined by a Glasgow Coma Score (GCS) < or =8 and a head Abbreviated Injury Score (AIS) > or =3, and long bone fractures requiring surgical fixation were reviewed. The study population was divided into the early fixation (EF) group, consisting of 22 patients who underwent fracture fixation within 24 hours of admission (mean time 17 +/- 8.5 hours); and the late fixation (LF) group, consisting of 25 patients, who had orthopedic repair at a later time (mean 143 +/- 178 hours). RESULTS The two groups were similar in terms of overall injury severity, neurologic injuries, hemodynamic and neurologic status on admission, and operations received. Patients in the EF group had a higher injury severity of extremity fractures (extremity AIS: 2.9 +/- 0.2 versus 2.4 +/- 0.5, P = 0.0002) and a higher incidence of open fractures (72% versus 36%, P = 0.02). There was no difference in intraoperative and postoperative hypoxic and hypotensive episodes. Neurologic, orthopedic, and general complications were the same between the two groups. The mean GCS on discharge was 12 +/- 3 for both groups with equal distribution among patients. Although there was a trend toward longer hospital stay (25 +/- 17 versus 17 +/- 10 days, P = 0.057) among LF patients, mechanical ventilation days, length of stay, and mortality were not different. CONCLUSIONS Timing of fracture fixation in this group of blunt trauma patients with severe head injuries did not influence morbidity, mortality, or neurologic outcome.

Occult Injuries to the Diaphragm: Prospective Evaluation of Laparoscopy in Penetrating Injuries to the Left Lower Chest

Aseptic necrosis of the femoral head is a complication of renal transplantation which seriously delays the rehabilitation of the patient despite otherwise successful transplantation. Of 187 renal allograft recipients, 8 underwent 14 total hip replacements. The most severe postoperative problem was an easily reducible dislocation. All patients were relieved of their severe preoperative pains and all were greatly improved in mobility and strength. Renal function was not altered in any patient. It is therefore suggested that total hip replacement be recommended in such cases at an early stage so that the patient may be spared prolonged suffering and may be returned to a programme of post-transplant rehabilitation.

Effect on outcome of early intensive management of geriatric trauma patients

BACKGROUND To evaluate the incidence of occult diaphragmatic injuries and investigate the role of laparoscopy in patients with penetrating trauma to the left lower chest who lack indications for exploratory celiotomy other than the potential for a diaphragm injury. STUDY DESIGN Patients with penetrating injuries to the left lower chest who were hemodynamically stable and without indications for a celiotomy were prospectively evaluated with diagnostic laparoscopy to determine the presence of an injury to the left hemidiaphragm. Diagnostic laparoscopy was performed in the operating room under general anesthesia. RESULTS One-hundred-ten patients (94 stab wounds, 16 gunshot wounds) were evaluated with laparoscopy. Twenty-six (24%) diaphragmatic injuries were identified (26% for stab wounds and 13% for gunshot wounds). Comparison of patients with diaphragmatic injuries with those without diaphragmatic injuries demonstrated a slightly greater incidence of hemo/pneumothoraces (35% versus 24%, NS). The incidence of diaphragmatic injuries in patients with a normal chest x-ray was 21% versus 31% for patients with a hemo/pneumothorax. An elevated left hemidiaphragm was associated with a diaphragmatic injuries in only 1 of 7 patients (14%). The incidence of diaphragmatic injuries was similar for anterior, lateral, and posterior injuries (22%, 27%, and 22% respectively). CONCLUSIONS The incidence of occult diaphragmatic injuries in penetrating trauma to the left lower chest is high, 24%. These injuries are associated with a lack of clinical and radiographic findings, and would have been missed had laparoscopy not been performed. Patients with penetrating trauma to the left lower chest who do not have any other indication for a celiotomy should undergo videoscopic evaluation of the left hemidiaphragm to exclude an occult injury.