History and current status of trauma scoring systems.
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History, 20th Century↗
Biomedical subjects
D H Wisner
Publications and source records attributed to D H Wisner.
History and current status of scoring systems for critical care.
Scoring systems for quantifying critical illness and predicting outcome are being used increasingly for resource utilization analysis and quality assurance purposes. The history of the development of these systems, the rationale for their use, and the data elements and statistical methods involved in these systems were reviewed. There are obvious advantages of scoring systems for the analysis of large groups of patients. At the same time, there are limitations of such systems in the treatment of individual patients. While improvement and refinement of existing scoring systems is likely to occur with time, these limitations must be kept in mind.
Critical Care↗
Visceral injuries.
Abdominal visceral injuries are encountered by every surgeon who deals with trauma. It is simple and useful to divide abdominal visceral injuries into those caused by penetrating mechanisms of injury and those due to blunt mechanisms. Determination of the need for operative intervention is generally easier after penetrating trauma. Gunshot wounds to the abdomen should be explored, as should stab wounds to the anterior abdomen that penetrate the fascia. A midline incision is the standard approach to abdominal visceral injuries because of its ease and versatility. Abdominal exploration should be consistent and systemic so as not to miss significant injuries. Hollow viscus injury is most common after penetrating injury, while blunt injury most often results in injury to solid viscera. Diagnostic and operative aspects of the treatment of specific visceral injuries are reviewed.
Abdominal Injuries↗
Nuclear magnetic resonance as a measure of cerebral metabolism: effects of hypertonic saline resuscitation.
UNLABELLED: Fears of central nervous system dysfunction from acute hypernatremia and hyperosmolarity with hypertonic saline resuscitation are often cited. We used high-energy phosphate nuclear magnetic resonance to investigate resuscitation effects on cerebral metabolism. Rats were instrumented for hemodynamic monitoring and fluid infusion and a phosphorus surface coil placed on their skulls. After shimming, baseline spectra were obtained. Animals were then bled for one hour to a mean arterial pressure (MAP) of 45 mm Hg, followed by resuscitation for one hour to a MAP of 75 mm Hg with lactated Ringer's (LR, n = 17) or 7.5% hypertonic saline (HS, n = 25). Spectra were obtained again and analyzed for the ratio of high-energy phosphocreatine (PCr) to low-energy inorganic phosphate (Pi). Intracellular hydrogen ion concentration [H+] was calculated from the PCr/Pi shift. [table: see text] CONCLUSIONS: (1) Hypertonic saline results in a decreased intracellular pH compared with LR without associated changes in high-energy phosphate metabolism. (2) Decreases in pH may be the result of cell dehydration rather than metabolic dysfunction.
Animals↗
Neurologic consequences of cerebrovascular injury.
Because of ongoing controversy, the issue of vascular repair or ligation for patients with cerebrovascular injuries and preoperative central neurologic deficits is frequently debated. A total of 133 patients with penetrating cerebrovascular injuries were analyzed. The frequency of preoperative neurologic deficit was 20% (27 patients). The common carotid and internal carotid arteries were the most frequently injured structures, with a 29% and 15% incidence of preoperative neurologic deficits, respectively. The results of carotid repair in all patients whose preoperative deficit was limited to weakness or paralysis were favorable (seven patients normal or improved, two patients unchanged). The results of repair in patients whose preoperative deficit was characterized by obtundation were variable (four patients improved, four patients worsened or died). The results of carotid ligation were also variable (one improved, one unchanged, three worsened or died). Limited numbers of patients with preoperative neurologic deficits and the retrospective nature of this review prohibit definite conclusions. Therefore a multicenter, prospective, randomized trial of ligation or vascular repair for comatose patients with cerebrovascular injuries is proposed.
Carotid Artery Injuries↗
When to save the ruptured spleen.
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Adult↗
The mangled extremity. When to amputate?
To determine indications for immediate or delayed amputation of the mangled lower extremity, we reviewed the cases of 80 patients. Vascular, neurologic, bone, and soft-tissue status were reviewed, as were postoperative complications, requirements for mechanical ventilation, fluid balance, delayed amputation, and survival. Although neurologic, bone, and soft-tissue status did influence decisions regarding immediate amputation, they had little to do with delayed loss of limb or life. The circulation, as determined by the presence or absence of a palpable or Doppler-detected pulse, however, was critical. Of six patients in whom salvage was attempted and in whom fluid balances of greater than 3 L were detected in the first 24 hours post-operatively, five eventually required amputation. Salvage should usually be attempted if a distal pulse is present. If no distal pulse is present, the decision for immediate amputation should be based on functional prognosis. In cases in which salvage is attempted, amputation should be performed at 24 hours if the patient's condition, including a markedly positive fluid balance, indicates systemic compromise. In the absence of a distal pulse on presentation, the eventual amputation rate is high.
Adult↗
Can nurses perform surgical cricothyrotomy with acceptable success and complication rates?
STUDY OBJECTIVE: This study was undertaken to determine whether flight nurses can perform surgical cricothyrotomies with acceptable success and complication rates. METHODS: This case series examined the survival, success, and complication rates of surgical cricothyrotomy. A specially trained flight nurse retrospectively reviewed all prehospital, emergency department, inpatient, autopsy, and outpatient follow-up records. RESULTS: Fifty-five consecutive patients in whom surgical cricothyrotomy was attempted by a flight nurse during a two-and-one-half-year period were studied. Patients ranged in age from 9 to 76 years. The airway was not cannulated successfully by a flight nurse in two patients. In two patients, the tube was not in the cricothyroid space (one in the upper tracheal rings, and the other in the larynx). In three patients, packing was insufficient to stop bleeding from around the operative site; and in three the tube became occluded by blood in the emergency department. Finally, two patients developed subglottic stenosis. CONCLUSION: Surgical cricothyrotomy in the field can be performed reliably by specially trained nurses. Because only the most critically ill or injured patients with unmanageable airways are subjected to this procedure, a significant complication rate can be anticipated.
Adolescent↗
Multiple vessel injury to branches of the aortic arch: case report.
A case of multiple injuries to the branches of the aortic arch following blunt trauma is reported. Prompt diagnosis and early operation resulted in a favorable outcome.
Accidents, Traffic↗
Combined hemorrhagic shock and head injury: effects of hypertonic saline (7.5%) resuscitation.
Hypertonic saline resuscitation was compared to isotonic fluid resuscitation in a large animal model combining hemorrhagic shock with head injury. Sheep were subjected to a freeze injury of one cerebral hemisphere as well as 2 hours of hypotension at a mean arterial pressure (MAP) of 40 mm Hg. Resuscitation was then carried out (MAP = 80 mm Hg) for 1 hour with either lactated Ringer's (LR, n = 6) or 7.5% hypertonic saline (HS, n = 6). Hemodynamic parameters and intracranial pressure (ICP) were followed. At the end of resuscitation brain water content was determined in injured and uninjured hemispheres. No differences were detected in cardiovascular parameters; however, ICPs were lower in animals resuscitated with HS (4.2 +/- 1.5 mm Hg) compared to LR (15.2 +/- 2.2 mm Hg, p less than 0.05). Additionally, brain water content (ml H2O/gm dry weight) in uninjured brain hemispheres was lower after HS resuscitation (HS = 3.3 +/- 0.1; LR = 4.0 +/- 0.1; p less than 0.05). No differences were detected in the injured hemispheres. We conclude that hypertonic saline abolishes increases in ICP seen during resuscitation in a model combining hemorrhagic shock with brain injury by dehydrating areas where the blood-brain barrier is still intact. Hypertonic saline may prove useful in the early management of multiple trauma patients.
Animals↗
2-D echocardiography: emergent use in the evaluation of penetrating precordial trauma.
Diagnosis of cardiac injury in stable patients suffering penetrating precordial trauma has relied on observation, subxiphoid window, or exploratory thoracotomy. Previous reports have stressed the need for an alternative noninvasive diagnostic test. Although the use of echocardiography (ECHO) in this patient population has been suggested, to our knowledge no report thus far has presented extensive experience with this technique. We present our experience over 3 years with 36 patients in whom emergent ECHO was used as part of their initial work-up. Injuries included single stab wounds (17), multiple stab wounds (14), and gunshot wounds (5). Four patients (11%) had jugular venous distention, and 12 (33%) were tachycardic. None had a systolic blood pressure below 90 mm Hg. Four ECHOs (11%) were positive for pericardial effusion. No valvular abnormalities were detected. Three of the effusions were small and these patients were triaged to monitored beds and observed. All three effusions resolved on serial echocardiography. The fourth patient underwent an uneventful operative repair of a left ventricular laceration. Although the yield is low, emergent 2-D ECHO is a valuable tool in the triage of stable penetrating trauma patients when cardiac injury is suspected. Patients without effusion can be discharged or triaged to a ward bed. Small effusions can be observed in a monitored setting with serial examinations, while large effusions should be treated surgically. Echocardiography is less expensive than ICU admission and less invasive than either subxiphoid window or thoracotomy. There are no known complications associated with the procedure and it is recommended for emergent use when available.
Adult↗
Diagnosis and treatment of pancreatic injuries. An analysis of management principles.
Ninety-one pancreatic injuries, 47 from blunt trauma, were reviewed with respect to management principles stressed in qi previous reviews. The pancreatic complication rate was 25%. Blunt injury was suspected preoperatively in only 30%. Even short-term observation led to morbidity. Operations done more than 6 hours after admission had a higher complication rate (45%) than those done less than 6 hours after admission (18%). Penrose drainage without a sump was not associated with increased complications. Distal pancreatectomy was done 32 times; splenectomy was done in only 18 patients. Individual duct ligation was rarely done and did not result in a high fistula rate. Pancreatic stump oversew with nonabsorbable suture was associated with a higher rate of pancreatic complications than absorbable suture (58% vs 30%). Only 56% of patients receiving distal pancreatectomy required hyperalimentation. Postoperative serum amylase values were not useful, and amylase values from drainage fluid predicted complications only when they were above 100,000 U/L. Details of pancreatic trauma management are less important than early operation in minimizing morbidity.
Adult↗
Blunt intestinal injury. Keys to diagnosis and management.
Fifty-six patients with blunt intestinal injury seen during 39 months were reviewed for keys to diagnosis and treatment. Motor vehicle accidents were involved in 80% of the cases and seat/lap belts were in use 69% of the time. Blunt intestinal injury was the only abdominal injury in 70% of the cases. There were 42 perforations and 20 devascularizations; multiple injuries were common (27%). Abdominal tenderness was present on admission in 43 of 44 patients in whom a reliable examination was possible. Peritoneal lavage was positive in 13 (93%) of 14 patients. Computed tomography was falsely negative in three of four instances in which it was used. Perforations were most common in the upper and lower ends of the small bowel and in the sigmoid colon; devascularizations were most common in the distal ileum and sigmoid colon. Resection/anastomosis was performed in 38% of small-bowel perforations and in all small-bowel devascularizations. Resection/diversion was required in most colonic perforations (five of six patients) and devascularizations (four of six patients). There were five deaths (9%), none due to intestinal injury. There were seven complications related to intestinal injury. Diagnostic delay occurred in two patients; both had resultant morbidity. Blunt intestinal injury is associated with physical findings in conscious patients. Peritoneal lavage should be used when tenderness cannot be evaluated. Timely operative intervention minimizes morbidity and hospital stay.
Abdominal Injuries↗
Suspected myocardial contusion. Triage and indications for monitoring.
Although many different tests are used to diagnose myocardial contusion, the clinical implications of the diagnosis are unclear. This makes it difficult to decide which patients require admission to a monitored bed. During 16 months, 3010 patients with blunt trauma were reviewed for evidence of sequelae attributable to myocardial contusion. None of 2204 admissions to unmonitored beds had evidence of serious arrhythmias or heart failure. No patient who died after admission had myocardial contusion at autopsy. Of the 644 admissions to monitored beds, 95 had workups for suspected contusion. Heart failure not obvious on admission did not occur and there were only four arrhythmias that required treatment. Conduction abnormalities on admission electrocardiogram predicted serious arrhythmias. Echocardiography and creatine phosphokinase isoenzyme levels, although frequently positive, did not predict morbidity. Clinically significant myocardial contusions are rare. Patients who will develop life-threatening complications from blunt cardiac injury can be identified in an emergency room setting.
Adolescent↗
Hypertonic saline resuscitation of head injury: effects on cerebral water content.
UNLABELLED: Ideal resuscitation would simultaneously replete intravascular volume and minimize cerebral edema. We assessed the effects of hypertonic saline (HS) shock resuscitation on cerebral edema after head injury. Rats were subjected to hemorrhagic shock (40 mm Hg for 1 hour) in the presence or absence of mechanical brain injury, followed by 1 hour of resuscitation with either hypertonic saline (6.5%) or lactated Ringer's (LR). After resuscitation, animals were sacrificed and brain water contents determined. RESULTS: Less HS than LR was needed for resuscitation both in animals without brain injury (7 +/- 2 ml/kg vs. 97 +/- 16 ml/kg; p less than 0.0003) and with brain injury (10 +/- 1 ml/kg vs. 68 +/- 6 ml/kg; p less than 0.0001). Brain water content (ml H2O/gm dry wt) after HS resuscitation was decreased compared to LR resuscitation in animals without brain injury (3.36 +/- 0.12 vs. 3.74 +/- 0.08; p less than 0.025) and in the uninjured hemisphere of head-injured animals (3.29 +/- 0.11 vs. 3.78 +/- 0.09; p less than 0.025). Brain water content was increased in injured brain in both resuscitation groups, but the increase was the same (HS 4.10 +/- 0.13; LR 4.25 +/- 0.17; p greater than 0.05). CONCLUSIONS: HS resuscitation of hemorrhagic shock decreases brain water content in uninjured but not injured brain. HS may be useful in resuscitation of combined hemorrhagic shock and head injury.
Animals↗
A stepwise logistic regression analysis of factors affecting morbidity and mortality after thoracic trauma: effect of epidural analgesia.
Rib fractures and other chest wall injuries can lead to weak ventilation, atelectasis, and even death. Whereas such injuries in young patients are usually well tolerated, relatively minor chest wall trauma can be serious in elderly patients. Epidural analgesia, by improving pain control and ventilatory function, might improve morbidity and mortality rates compared to other forms of analgesia. Stepwise logistic regression was used to compare thoracic trauma patients more than 60 years of age treated with either epidural or parenteral (IV/IM) analgesia. In spite of more severe thoracic trauma in epidural patients as measured by the Abbreviated Injury Score for the chest (epidural = 3.3 +/- 0.1, IV/IM = 2.8 +/- 0.1; p less than 0.05) the use of epidural analgesia was an independent predictor of both decreased mortality (p = 0.0035) and a decreased incidence of pulmonary complications (p = 0.0088). Epidural analgesia has a positive effect on outcome in elderly trauma victims with chest wall injury and is useful in high-risk patients. Increased costs associated with epidural analgesia are minimal and are justified by improvements in outcome.
Age Factors↗
Controversies in the fluid management of post-traumatic lung disease.
The appropriate intravenous therapy for injured patients is controversial. Use of colloid-containing solutions has been advocated in an attempt to maintain intravascular colloid osmotic pressure, minimize pulmonary oedema and draw fluid out of areas of contused lung. Studies of animals with lymph fistulas in the lung do not support such therapy and there is no difference between lung water volumes in animals resuscitated for 3 hours with colloid as opposed to crystalloid solutions after a standardized traumatic insult (colloid = 8.4 + 0.8 ml/kg; crystalloid = 7.5 + 0.6 ml/kg). Increased pulmonary capillary permeability makes such therapeutic attempts to 'dry out' the lungs even less effective. Studies in human patients of the rate of extravasation of labelled albumin from the pulmonary intravascular space indicate that increased permeability of pulmonary capillaries occurs early after injury and remains elevated in many severely injured patients. Low plasma colloid osmotic pressures do not correlate with increases in extravascular lung water. A shift to the use of vigorous crystalloid resuscitation of injured patients at our institution has resulted in decreases in both mortality rate (1976-1979, 35 per cent; 1979-1981, 28 per cent) and the rate of dialysis-dependent renal failure (1976-1979, 6 per cent; 1979-1981, 2 per cent). Current evidence supports the use of crystalloid solutions together with blood for resuscitation after injury.
Albumins↗