Virginia A. Eddy

The staged celiotomy for trauma. Issues in unpacking and reconstruction.

OBJECTIVE This article describes the important clinical events and decisions surrounding the reconstruction/unpacking portion of the staged celiotomy for trauma. METHODS Of 13,817 consecutive trauma admissions, 1175 received trauma celiotomies. Of these, 107 patients (9.1%) underwent staged celiotomy with abdominal packing. The authors examined medical records to identify and characterize: (1) indications and timing of reconstruction, (2) criteria for emergency return to the operating room, (3) complications after reconstruction, and (4) abdominal compartment syndrome (ACS). RESULTS Fifty-eight patients (54.2%) survived to reconstruction, 43 (74.1%) survived to discharge; 9 patients (15.5%) were returned to the operating room for bleeding; 13 patients required multiple packing procedures. There were 117 complications; 8 patients had positive blood cultures, abdominal abscesses developed in 6 patients, and ACS developed in 16 patients. CONCLUSIONS 1. Reconstruction should occur after temperature, coagulopathy, and acidosis are corrected, usually within 36 hours after the damage control procedure. 2. Emergent reoperation should occur in any normothermic patient with unabated bleeding (greater than 2 U packed cells/hr). 3. ACS occurs in 15% of patients and is characterized by high peak inspiratory pressure, CO2 retention, and oliguria. Lethal reperfusion syndrome is common but preventable.

Prospective Comparison of Admission Computed Tomographic Scan and Plain Films of the Upper Cervical Spine in Trauma Patients with Altered Mental Status

OBJECTIVE The accurate evaluation of patients with multiple injuries is logistically complex and time sensitive, and must be cost-effective. We hypothesize that computed tomographic (CT) scan of the upper cervical spine (occiput to C3 [Co-C3]) would add little to the initial evaluation of patients with multiple injuries who have altered mental status. METHODS The study consisted of a prospective, unblinded, consecutive series. Patients met entry criteria if they had sustained a blunt mechanism of injury and had an altered mental status requiring CT scan of two or more body systems. All patients received CT scan of Co-C3 with 2-mm cuts and subsequent reconstructions as well as five-view cervical spine plain films. Cervical spine injury was defined as any radiographically identified fracture or subluxation that required treatment. Patients were excluded if they died or were cleared clinically before plain film series were obtained. CT scan of Co-C3 and cervical spine films were reviewed by two different attending radiologists. RESULTS Of the 2,690 consecutive admissions between December 1998 and November 1999, 1,356 patients met entry criteria. Seventy patients (5.2%) had a total of 95 injuries to the upper cervical spine. CT scan of Co-C3 identified 67 of 70 patients and plain films identified 38 of 70 patients with injuries to the upper cervical spine. Twelve patients (17%) had neurologic deficits attributable to Co-C3 injuries. Three patients had false-negative CT scans of Co-C3, and one patient was quadriplegic. There were 32 patients with false-negative plain films, including four patients with motor deficits (one with quadriplegia). Use of the guidelines developed by the Eastern Association for the Surgery of Trauma identified all patients with upper cervical spine injuries; to date, no patient in the study group was readmitted or has initiated a lawsuit for missed injury of the upper cervical spine. CONCLUSION CT scan of Co-C3 was superior to plain films in the early identification of upper cervical spine injury. Plain films failed to identify 45% of upper cervical spine injuries; four of these missed injuries resulted in motor deficits. Our study supports the practice guidelines developed by the Eastern Association for the Surgery of Trauma for clearance of the upper cervical spine in patients with altered mental status, as all patients with injuries were identified using these guidelines.

HYPOTHERMIA, COAGULOPATHY, AND ACIDOSIS

The management of patients requiring a damage control approach taxes the abilities of the best equipped trauma center. These patients present with severe metabolic abnormalities, most notably characterized by a deadly triad of hypothermia, coagulopathy, and acidosis. Using volumetric, oxymetric pulmonary artery catheters, hypothermia and any ongoing cardiovascular abnormalities can be identified quickly and treatment can be monitored. External, forced air rewarming is a valuable technique in treating the patient with hypothermia, as are more invasive modalities, including body cavity lavage. Although there is no shotgun approach to blood component transfusion therapy, the coagulopathy shown by these patients has a time course that is more rapid than stat laboratories can presently keep up with. Given the fulminant nature of this coagulopathy, the authors feel justified in empirically initiating platelet and plasma or cryoprecipitate transfusion on identification of visible coagulopathy. The willingness of trauma surgeons to push the envelope in treating these most severely afflicted patients has allowed patients who once would have certainly died to lead meaningful lives.

ABDOMINAL COMPARTMENT SYNDROME: The Nashville Experience

Intra-abdominal hypertension is an unusual and often lethal syndrome. It is most often seen in critically ill surgical patients. The most important component of therapy is reduction of intra-abdominal pressure. Unfortunately, even with appropriate treatment, mortality is still high.

Elective bedside surgery in critically injured patients is safe and cost-effective.

OBJECTIVE The success of elective minimally invasive surgery suggested that this concept could be adapted to the intensive care unit. We hypothesized that minimally invasive surgery could be done safely and cost-effectively at the bedside in critically injured patients. SUMMARY BACKGROUND DATA This case series, conducted between October 1991 and June 1997 at a Level I trauma center, examined bedside dilatational tracheostomy (BDT), percutaneous endoscopic gastrostomy (PEG), and inferior vena cava (IVC) filter placement. All procedures had been performed in the operating room (OR) before initiation of this study. METHODS All BDTs and PEGs were performed with intravenous general anesthesia (fentanyl, diazepam, and pancuronium) administered by the surgical team. IVC filters were placed using local anesthesia and conscious sedation. BDTs were done using a Ciaglia set, PEGs were done using a 20 Fr Flexiflow Inverta-PEG kit, and IVC filters were placed percutaneously under ultrasound guidance. Cost difference (delta cost) was defined as the difference in hospital cost and physician charges incurred in the OR as compared to the bedside. RESULTS Of 16,417 trauma admissions, 379 patients (2%) underwent 472 minimally invasive procedures (272 BDTs, 129 PEGs, 71 IVC filters). There were four major complications (0.8%). Two patients had loss of airway requiring reintubation. Two patients had an intraperitoneal leak from the gastrostomy requiring operative repair. No patient had a major complication after IVC filter placement. Total delta cost was

Is Routine Arteriography Mandatory for Penetrating Injuries to Zone 1 of the Neck

611,994. When examined independently, the cost was

Children's Traffic Safety Program: Influence of Early Elementary School Safety Education on Family Seat Belt Use

324,224 for BDT,

Anterior ischemic optic neuropathy: a complication after systemic inflammatory response syndrome.

164,088 for PEG, and

The position of the Eastern Association for the Surgery of Trauma on the future of trauma surgery.

123,682 for IVC filter. OR use was reduced by 506 hours. CONCLUSIONS These bedside procedures have minimal complications, eliminate the risk associated with patient transport, reduce cost, improve OR utilization, and should be considered for routine use in the general surgery population.

The trauma celiotomy: The evolving concepts of damage control

Objective: Surgical dogma dictates that the evaluation of all penetrating zone 1 neck injuries must include arteriography to reliably exclude arterial injury requiring operation. This study was done to determine whether patients with normal findings at physical examination (PE) and on chest radiographs (CXR) really do require arteriography to identify occult, surgically important arterial injuries. Methods: All penetrating zone 1 neck injuries in five Level I trauma centers over a 10-year period were reviewed retrospectively. Data collected included demographics, results of PE, CXR findings, other diagnostic studies done, injuries identified, need for operation, and operative findings. Arterial injury was defined as any injury to the aorta or brachiocephalic, subclavian, vertebral, or carotid arteries found on arteriography, duplex, or at operation. Results: Of 138 patients studied, there were 28 arterial injuries. Of the total group of 138 patients, 36 patients had normal findings at PE and on CXR. None of these 36 patients had an arterial injury. The negative predictive value of normal PE and CXR together is 100% in this series. Conclusions: Patients with penetrating wounds to zone I who have no evidence of vascular injury on PE and who have normal findings on CXR may not require routine arteriography. Further study is needed to confirm these findings.