Thomas F. Phillips

Geriatric blunt multiple trauma: improved survival with early invasive monitoring.

Geriatric trauma survival rates are reported to approach 85%, but no series to our knowledge has included a predominance of multiply injured patients. In 1985, we treated 60 patients more than 65 years of age who sustained blunt multiple trauma, excluding burns and minor falls. A pedestrian-motor vehicle mechanism, initial BP less than 150 mm Hg, acidosis, multiple fractures, and head injuries all predicted mortality. To investigate this, in 1986, we began invasive monitoring in all patients with any of these risk factors and modified this in 1987 to emergent monitoring, postponing all but the most critical diagnostic studies. All patients included were hemodynamically stable after initial evaluation. Attempts were made to optimize all patients with volume, inotropes, and afterload reduction as needed. There was no difference between 1986 and 1987 in patient age, injury severity, or per cent of patients requiring operation. In 1986, mean time from ED admission to monitoring was 5.5 hours. Eight of 15 patients had an initial cardiac output (CO) less than 3.5 L/M and/or mixed venous saturation (MVO2) less than 50%. All developed progressive pump failure despite therapy and died within 24 hours. The other seven had an initial CO between 3.4-5.5 L/M, but five had an MVO2 less than 50%. All augmented their CO with therapy over 6-12 hours to a mean CO of 6.8 L/M and resolved their MVO2, but six died from MOF. Survival was 7%. In 1987-88, we reduced time to monitoring to 2.2 hours by limiting diagnostic tests. Thirteen of 30 patients treated had an initial CO less than 3.5 L/M.(ABSTRACT TRUNCATED AT 250 WORDS)

Early open reduction and internal fixation of the disrupted pelvic ring.

Early open reduction and internal fixation (ORIF) of extremity fractures in patients with multiple injuries has been demonstrated to be safe, improve survival, and decrease the incidence of respiratory failure. Complications leading to abandonment of planned operative fixation and death in several patients with pelvic fractures led us to initiate a policy of early ORIF of the disrupted pelvic ring. Early ORIF of the pelvis was performed in 15 multiply injured patients between May 1984 and August 1985. Patients ranged in age from 13 to 79 years, their Hospital Trauma Index-ISS scores ranged from 14 to 68, and number of preoperative transfusions ranged from 0 to 42. Types of fractures were A-P compression, two, lateral compression, one, vertical shear, seven, complex, two, and acetabulum with ring disruption, three. All patients were resuscitated, transported in pneumatic antishock garments, and evaluated by abdominal and pelvic CT scan (in two patients following celiotomy). Preoperative angiograms to assess retroperitoneal hemorrhage in eight patients resulted in identification and control of significant bleeding in five. The mean time from injury to pelvic stabilization was 38 hours. Seven patients underwent ORIF within the first 24 hours. In most cases simultaneous anterior and posterior internal fixation was performed with the patient in the lateral decubitus position. Excluding associated procedures, operative time averaged 5.1 hours. Intra-operative transfusions averaged 4 units (range, 0-11). Rigid fixation was achieved in all patients. Most patients were out of bed by the third postoperative day. No patient developed respiratory failure. Two patients developed wound infections. Modification of our technique has avoided this complication in the latter part of this series.(ABSTRACT TRUNCATED AT 250 WORDS)

Vertebral artery injury--diagnosis and management.

The literature on vascular trauma contains little information on the management of vertebral artery injuries. We have reviewed our experience consisting of 23 patients with vertebral artery injuries caused by 19 gunshot wounds, two stab wounds, one shotgun wound, and one blunt injury. Twelve patients sustained unilateral vertebral artery thrombosis, seven patients had vertebral AV fistulae (three jugular vein, four vertebral vein) and four patients sustained mural injury without thrombosis. Six patients (26.1%) developed major neurologic deficits of which five could be directly attributed to CNS missile injury. One patient had transient vertebrobasilar ischemia on the basis of a vertebral AV fistula. Four of the seven vertebral AV fistulae were managed solely by therapeutic embolization and two patients early in the series underwent surgical management alone. One patient had therapeutic embolization of the proximal vertebral artery and operative distal vertebral artery ligation for an AV fistula. The four patients who died (17.4%) did so as a direct result of their CNS missile injury. We conclude that: 1) unilateral vertebral artery occlusion seldom results in a neurologic deficit if there is a normal contralateral vertebral artery and PICA (posterior inferior cerebellar artery) blood supply is preserved; 2) accurate assessment of a vertebral artery injury requires contralateral vertebral arteriogram; 3) management of vertebral artery injury is simplified by proximal, and if possible distal, therapeutic embolization; 4) an anterior approach to the C1-2 vertebral artery is a satisfactory method of obtaining distal surgical control, obviating the need to unroof the bony canal of the vertebral artery; 5) angiography is necessary in penetrating neck trauma to identify occult vascular injuries.

Central venous oxygen saturation: a useful clinical tool in trauma patients.

An accurate method of estimating acute blood loss is essential in the evaluation of injured patients. Central venous oxygen (CVO2) saturation has been shown to be a sensitive and reliable correlate of blood loss in an animal model but its clinical validity is unproven. We evaluated 26 consecutive patients with an injury mechanism suggesting blood loss but who were deemed stable after initial evaluation. Vital signs (pulse, blood pressure, pulse pressure, urine output, CVP) and CVO2 saturation were serially measured. Blood loss was estimated by direct intracavitary collection or serial hematocrits and acute transfusion requirements. Despite stable vital signs, ten patients (39%) had CVO2 saturations under 65%. These patients had more serious injuries, significantly larger estimated blood losses, and required more transfusions than those patients with CVO2 saturation greater than 65%. Linear regression analysis demonstrated the superiority of CVO2 saturation to predict blood loss with a p value less than 0.005 relative to any of the normally followed parameters. CVO2 saturation is a reliable and sensitive method for detecting blood loss. It is a useful tool in the evaluation of acutely injured patients.

Outcome of massive transfusion exceeding two blood volumes in trauma and emergency surgery.

Our experience with 56 patients who sustained massive transfusion exceeding two times their estimated blood volume is reviewed. Survival was 39% for the entire group, which included six cases of blunt multiple trauma and seven nontraumatic surgical emergencies, and 51% for the subgroup who sustained penetrating trauma. Six patients arrived without detectable vital signs, but half of them left the hospital alive. Three subgroups sustained 100% mortality: cirrhotics, nontraumatic surgical emergencies, and victims of blunt trauma. Thirty-eight per cent of the noncirrhotics developed a post-transfusion bleeding disorder, but the specific patients who would develop coagulopathy could not be predicted on the basis of any clinical parameter scrutinized, including lowest measured platelet count. Pulmonary morbidity was rare among penetrating trauma patients in spite of an average of 35 units of blood transfusion. Acute respiratory failure developed in a subgroup with penetrating trauma who received an average of 59 units of blood; blunt trauma patients developed acute respiratory failure at an average transfusion volume of 35 units. The 77% mortality among patients who developed coagulopathy, and our inability to predict in advance which patients will develop serious clinical bleeding, argue strongly in favor of an aggressive approach toward prophylaxis in these patients in spite of the theoretical risk of disease transmission from the additional units of platelets and frozen plasma required.

Central venous blood oxygen saturation: an early, accurate measurement of volume during hemorrhage.

Accurate and relatively simple monitoring is essential in managing patients with multiple injuries, and becomes particularly important when there is substantial occult blood loss. Tachycardia, said to occur following a 15% blood loss, is generally regarded as the first reliable sign of hemorrhage. However, heart rate is a nonspecific parameter which is affected by factors other than changing intravascular volume. The purpose of this study was to evaluate available means of monitoring volume status and to identify the parameter which is the earliest and most reliable indication of blood loss. Sixteen mongrel dogs were anesthetized and bled by increments of 3% of their total blood volume until the onset of sustained hypotension or a 25% blood loss. All dogs were monitored with a Swan-Ganz catheter and an arterial line. Vital signs, full hemodynamic parameters, and arterial and mixed venous blood gases were measured after each 3% blood loss. Statistical analysis of the data demonstrated that only Cardiac Index and Mixed Venous Oxygen Saturation showed linearity as function of measure blood loss. Linear regression analysis generated r values that ranged from 0.85-0.99 with a mean of 0.95 for Mixed Venous Oxygen Saturation; r values for Cardiac Index ranged from 0.39-0.98 with a mean of 0.85. Furthermore, all dogs had increased tissue oxygen extraction after 3-6% blood loss. Because Central Venous Blood Oxygen Saturation mirrors Mixed Venous Oxygen Saturation and is easily and rapidly measured, we extended our study by repeating all of the previously measured parameters, with the addition of CVP blood gases in an unanesthetized animal model.(ABSTRACT TRUNCATED AT 250 WORDS)

An Analysis of 161 Falls from a Height: The ‘jumper Syndrome’

Vertical deceleration injuries represent a distinct form of urban blunt trauma. We reviewed 161 adult patients, admitted over 36 months, who jumped or fell from a height of one to seven stories and survived emergency department resuscitation. Charts and radiographs were analyzed to identify common injuries, complications, and causes of death. Those who fell five or more stories had a mean ISS of 41, for a predicted survival of 50% but actual survival of 83%. Virtually all these patients had multiple fractures. Sixty per cent of them presented in shock, yet more than two thirds had angiographically demonstrated retroperitoneal hemorrhage as their major source of bleeding. Thirteen patients had significant intra-abdominal injuries, with only one associated with major hemorrhage. Utilizing early diagnostic peritoneal lavage, ten of 13 patients explored had a therapeutic laparotomy. Hollow viscus perforations accounted for about one half of the abdominal injuries, including three duodenal injuries. Conclusions. 1) Patients who present in shock after falls from height are much more likely to be bleeding from retroperitoneal than intraperitoneal sources. 2) Early tap and lavage followed by emergency angiography and transcatheter embolization is the treatment of choice in this group of patients. 3) Although these patients often have multiple complex injuries, the prognosis for long-term survival is good. Therefore, we advocate early aggressive operation stabilization of fractures to permit patient mobilization, facilitate pulmonary toilet and nursing care, and to decrease long-term disability.

Use of the contrast-enhanced CT enema in the management of penetrating trauma to the flank and back

There have been few innovations in the management of penetrating trauma of the flank and back since that reported by Peck and Berne in 1981. During 1984-1985 our Trauma Service treated 119 patients with injuries in these areas. In 56 patients management was based on the results of the contrast-enhanced CT enema (CECTE), a computerized tomographic technique designed to delineate all of the retroperitoneal viscera by simultaneously opacifying the small bowel, duodenum, colon, GU tract, and major vessels. Specific radiographic findings were present on 44 scans. Twelve scans were negative. Six scans were considered indications for angiography because of the proximity of the identified missile wounds or their hematomas to major vascular structures. One of these arteriograms revealed a renal artery pseudoaneurysm which would otherwise have remained undiagnosed. In 30 cases the penetrating wounds were well delineated by CECTE, and their nature and location were considered appropriate for nonoperative management. None required subsequent exploration. In eight cases CECTE demonstrated that the wounds were located so as to place specific viscera at risk for significant injury, but no definite injury was identified. Five of these patients were successfully managed by further evaluation and close observation, two were explored, and one signed out of the hospital. No scan demonstrated extravasation from a hollow viscus. Overall, 52 of our 56 patients (92%) were successfully managed nonoperatively on the basis of the interpretation of their CECTE findings. CECTE can be useful in the management of stable patients with penetrating trauma to the back and flank by identifying the nature and location of the resulting retroperitoneal injuries.(ABSTRACT TRUNCATED AT 250 WORDS)

The Management of Arterial Injuries Caused by Penetration of Zone III of the Neck

Penetrating trauma of the neck has been divided into three anatomic locations. Zone III, the subject of this paper, is defined as the area between the base of the skull and the lower border of the mandible. Management of these injuries remains problematic. Clinical assessment may be misleading, exploration may damage surrounding neurovascular structures, and injuries may go undetected. This has led us and others to advocate mandatory angiography before any surgical exploration. This report reviews 46 patients with Zone III injuries with respect to types of injuries, therapy and outcome. Angiography was normal in 22 patients who were treated conservatively with no complications. The remaining 24 patients sustained 39 arterial injuries diagnosed by contrast studies. Eighteen internal carotid injuries were identified in 16 patients. At operation ligation was performed in four patients and revascularization in two patients. One of the repairs subsequently thrombosed. Ten patients were managed nonoperatively by observation (seven patients) or angiographic embolization (three patients). Catheter embolization of the external carotid or its branches was performed to control bleeding (eight vessels) or close arteriovenous fistulas (two patients). Seven nonbleeding external vessels were successfully managed by observation. Two vertebral artery injuries were diagnosed. One required proximal embolization and distal ligation via occipital craniectomy to control a fistula between the vertebral artery and the jugular vein. Overall mortality was 8.6%. Three of the four deaths were in patients with neurologic deficit on admission. Another died of respiratory arrest. An air embolism resulting in hemiparesis was the only complication of the angiographic studies. We conclude that angiography is essential in Zone III neck wounds. It facilitates triage decisions and, combined with transcatheter embolization, enables the majority of these injuries to be managed without surgical exploration.

Evaluation of Occult Cardiac Injuries Using Subxiphoid Pericardial Window

During 1987, we performed diagnostic subxiphoid pericardial windows on all stable patients with juxta-cardiac penetrating injuries. This excluded any patient with clinically diagnosed tamponade or shock. Fifty-one patients underwent subxiphoid diagnostic pericardiotomy for suspected cardiac injuries. Forty patients were normotensive on presentation and 11 experienced transient hypotension. All patients were easily resuscitated in the Emergency Department. The time from admission to operation ranged from 20 minutes to 6 hours (average, 2.5 hours). Twelve patients (23.5%) had hemopericardium at the time of subxiphoid diagnostic pericardiotomy (SDP), and cardiac injury was confirmed at sternotomy in all. Two patients (16%) in the positive group were admitted with systolic blood pressures less than 100 mm Hg compared to nine (23%) in the negative group. One patient had a systolic to diastolic pressure gradient less than 30. Central venous pressures in this group of patients ranged from 8 to 23 cm H2O. Nine patients who had pericardial window solely on the basis of location of the injury had positive findings. All nine patients were normotensive on admission, had CVPs less than 12, and had no other overt clinical signs of injury. This represents an overall occult injury rate of 17.6%. At sternotomy, there were eight ventricular, two pulmonary artery, one aortic root, and one atrial injury, all repaired. Two patients in this group had associated abdominal injuries as did 11 in the negative group, all of whom required operation, and may have explained the hypotension in negative patients. There were no complications of SDP and all negative patients were discharged on the second hospital day.(ABSTRACT TRUNCATED AT 250 WORDS)