Wendy Marshall

The role of diagnostic laparoscopy in the management of trauma patients: a preliminary assessment.

This study evaluated the role and advantages of diagnostic laparoscopy (DL) compared with diagnostic peritoneal lavage (DPL) in 75 trauma patients who were prospectively studied with DL followed by DPL. Of these, 59 patients had blunt injuries and 16 stab wounds. Seventy patients (93%) had the procedures performed in the emergency department (ED); 41 (59%) of these were awake and under local anesthesia. Forty-two patients had negative DPL and DL results with no subsequent sequelae. Twenty-three patients had negative DPL results and abnormal DL results. Of these, 20 were managed nonsurgically, and three (DPL < 10,000 RBC) underwent surgery based solely on DL findings of diaphragmatic lacerations from stab wounds. These were repaired. All 23 had an uneventful course. Three patients had positive DPL and insignificant DL findings. Laparotomy and DL findings correlated. A splenectomy for iatrogenic injury unrelated to DL and two nontherapeutic laparotomies were performed. Seven patients demonstrated both positive DPL and significant DL findings, and all had therapeutic laparotomies. Management based on DL rather than DPL would potentially have improved care in 8% of cases (6 of 75). Reliance on DL improved care in 19% (3 of 16) of patients with stab wounds and possibly could have in 3% (2 of 59) of those with blunt injuries. Management using DL would have potentially improved care in 30% (3 of 10) of patients with positive DPL findings and 5% (3 of 65) with negative DPL findings. Diagnostic laparoscopy can be performed safely in stable patients under local anesthesia in the ED. It offers no advantage over DPL as a primary assessment tool in blunt trauma. It does have advantages in the management of stab wounds. Diagnostic laparoscopy has a role in redefining DPL criteria for laparotomy and, in selected patients, as an adjunct to DPL, allowing further diagnosis and potentially the treatment of injuries without laparotomy.

Emergency cricothyroidotomy in trauma victims

The first dictum of trauma care is to establish an airway. Infrequently endotracheal intubation is unsuccessful or contraindicated, and a surgical airway is required. We reviewed 30 emergency cricothyroidotomies among 8320 admissions over a 36-month period at a level I trauma center. Twenty cricothyroidotomies were performed in the emergency room by Trauma Service personnel and 10 during prehospital care by flight nurses. Cricothyroidotomy was the first airway control maneuver performed in 7 patients and 23 cricothyroidotomies were performed after attempts at oral intubation failed. No major complications were identified. Minor complications identified in the hospital included minimal subglottic stenosis (2), local wound infection (1), and nonthreatening hemorrhage (1). Fifteen patients were long-term survivors. We conclude that emergency cricothyroidotomy is a safe and rapid means of obtaining an airway when endotracheal intubation fails or is contraindicated.

Routine pelvic x-ray studies in awake blunt trauma patients: a sensible policy?

To evaluate the usefulness of routine pelvic x-ray films in the resuscitation of blunt trauma victims, 1395 patients were prospectively evaluated over a 13-month period. Of these, 810 (58%) were awake with Glasgow Coma Scale scores greater than or equal to 13 and were enrolled into the study. A history, with directed questions regarding pelvic pain, a clinical examination of the pelvis, and an anterior-posterior pelvic x-ray film (APPX) were obtained for each patient. Thirty-nine patients (5%) had fractures identified on the x-ray films. Of these patients with radiographically identified fractures, 34 (87%) complained of pain and had positive results on clinical examination, two (5%) either complained of pain or had positive results on examination and three (8%) had neither complaint of pain nor positive examination results. Of the 771 patients without fractures 743 (96%) lacked pain complaints or positive examination results. The likelihood of fracture was greatest in patients with complaints of pain and positive examination results (65%) followed by patients with either complaint of pain or positive examination results (16%). Only three (0.4%) of the 743 patients having no complaints of pain and a negative clinical examination had fractures diagnosed roentgenographically. These were minor fractures that did not affect the clinical course. Total charges incurred to diagnose pelvic fractures in this low-yield patient group were

Aortoventricular Fistula Secondary to Blunt Trauma: A Case Report and Review of the Literature

88,028. We conclude that the practice of obtaining a screening APPX is not necessary or cost-effective in the management of awake blunt trauma patients who do not complain of pain and who have normal pelvic physical examination results.

Introduction of pulse oximetry in the air medical setting.

An aorto-right ventricular fistula secondary to nonpenetrating trauma is described. Review of the literature is reported. Ascending aortic injuries present as either traumatic pseudoaneurysms or, less commonly, as aortocardiac fistulas. Blunt cardiac injury is a frequent concomitant injury and contributes to the high mortality of this lesion. Prompt surgical intervention is required for survival.

Air medical response to the 1990 Will County, Illinois, Tornado

The importance of adequate oxygenation in critically ill patients is widely recognized. Pulse oximetry (PO) is a non-invasive, rapid technique of arterial hemoglobin oxygen saturation (SaO2) measurement. This report is a review of our experience using the PO during air medical transport. A chart review was conducted on patients who used air medical transport between October 1988 and March 1989. Types of patients included trauma and ICU patients who were transported from either accident scenes or outlying hospitals. SaO2 and vital sign (VS) measurements were obtained pre and postflight, and inflight interventions were documented. Four groups of patients were identified: Group 1: PO used, inflight intervention employed; Group II: PO used, no inflight intervention employed; Group III: no PO used, inflight intervention employed; Group IV: no PO used, no inflight intervention employed. A dependent, paired-t-test was used to compare pre and postflight SaO2 and VS measurements. The mean difference between pre and postflight measurements of SaO2, systolic blood pressure, and pulse rate were calculated within each group. Then, an ANOVA with post-hoc Newman-Keuls Test compared the means between the four groups. Of the 137 patients reviewed, 82 used PO and 55 patients did not due to technical or anatomic problems. Of the 82 patients who used PO, 19 received an inflight intervention.(ABSTRACT TRUNCATED AT 250 WORDS)

Endotracheal tube stabilization in the air medical setting

At least 29 people were killed and over 300 injured on August 28, 1990, when a powerful tornado cut a path of destruction through the outskirts of Chicago. The tornados destructive force began a mammoth rescue effort from over 50 emergency medical service agencies, 80 ambulances, 1,000 rescue personnel, and Chicagos two air medical helicopters. The EMS effort was supplemented by an equally large response from police, fire, heavy rescue, K-9, and other emergency teams across north and central Illinois. Medical mass casualty incident procedures were activated and coordinated through the Will-Grundy Emergency Medical Services System, located at Silver Cross Hospital in Joliet. The towns of Crest Hill, Plainfield, and Joliet were the hardest hit, with more than

A comparison study of chest tube thoracostomy: Air medical crew and in-hospital trauma service

200 million in damages. The tornado strained not only the ground-based EMS and rescue systems, but taxed the resources of the citys air medical programs as well. This paper reviews the response by critical care air medical transport teams to this natural disaster.

THE ROLE OF DIAGNOSTIC LAPAROSCOPY IN TRAUMA PATIENTS: A PRELIMINARY ASSESSMENT

Abstract Airway control is critical to the preparation and transport of patients by air medical services. Our experience with an endotracheal tube stabilization device employed in all adult orally intubated patients is described. Details of application, types of injury, and characteristics of patient management were reviewed. The stability of the device was determined on the face and the stability of the endotracheal tube was evaluated. Sixty-three intubated, adult patients transported via our air medical team were included in this study. Indications for intubation included burns, inhalation injury, maxillofacial trauma, upper airway obstruction and thoracic trauma. Maxillofacial injuries included scalp/facial lacerations, craniofacial asymmetry, Le Fort III fractures and electrical burns. Maxillofacial injuries and secretions did not compromise device stability. The device could be placed on all patients regardless of condition or climate at time of device application. Use of a standard endotracheal tube stabilization device is recommended in the air medical setting. It protects against accidental extubation, provides stability regardless of craniofacial trauma or secretions, and allows for easy application and consistent positioning of the endotracheal tube relative to holder.