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Biomedical subjects

E E Cornwell

Publications and source records attributed to E E Cornwell.

At least 19 recordsLinked to original sources
PubMed2001

Thoracolumbar immobilization for trauma patients with torso gunshot wounds: is it necessary?

BACKGROUND: Previous studies have suggested that patients transported by emergency medical services (EMS) following major trauma had a longer injury-to-treatment interval and a higher mortality rate than their non-EMS-transported counterparts. HYPOTHESIS: There is little actual benefit of thoracolumbar immobilization for patients with torso gunshot wounds (GSW). DESIGN: Retrospective analysis of prospectively gathered data from the Maryland Institute for Emergency Medical Service Systems State Trauma Registry from July 1, 1995, through June 30, 1998. SETTINGS: All designated trauma centers in Maryland. PATIENTS: All patients with torso GSW. MAIN OUTCOME MEASURES: (1) A patient was considered to have benefited from immobilization if he or she had less than complete neurologic deficits in the presence of an unstable vertebral column, as shown by the need for operative stabilization of the vertebral column; (2) mortality. RESULTS: There were 1000 patients with torso GSW. Among them, 141 patients (14.1%) had vertebral column and/or spinal cord injuries. Two patients (0.2%) (95% confidence interval, -0.077% to 0.48%) required operative vertebral column stabilization, while 6 others required other spinal operations for decompression and/or foreign body removal. The presence of vertebral column injury was actually associated with lower mortality (7.1% vs 14.8%, P<.02). CONCLUSIONS: This study suggests that thoracolumbar immobilization is almost never beneficial in patients with torso GSW, and that a higher mortality rate existed among those GSW patients without vertebral column injury vs those with such injuries. The role of formal thoracolumbar immobilization for patients with torso GSW should be reexamined.

Adult↗
PubMed2001

Healing of traumatic diaphragm injuries: comparison of laparoscopic versus open techniques in an animal model.

BACKGROUND: Minimally invasive surgical techniques have become routinely applied to the evaluation and treatment of patients with isolated diaphragmatic injuries due to penetrating trauma. The objective of the study was to compare the healing of diaphragm injuries as determined by macroscopic inspection, histologic appearance, and tensile strength following repair by open suturing, laparoscopic suturing, and laparoscopic stapling techniques in an animal model. METHODS: Using a pig model, three injuries were created and repaired in each hemidiaphragm of five animals, for a total of 30 lacerations. These injuries were repaired using single-layer open repair, single-layer laparoscopic repair, or laparoscopic stapling. After a 6-week healing period the animals were sacrificed. The gross integrity, histologic appearance using H+E and trichrome satins, and tensile strength of each repair were assessed. RESULTS: All injuries were grossly intact without dehiscence or herniation. Histologic examination revealed no difference in the collagen deposition between the three groups. The tensile strengths of each type of repair were similar. CONCLUSION: Laparoscopic techniques used to repair diaphragmatic injuries allow for adequate healing equivalent to open sutured repairs. Simple approximation of the peritoneum with laparoscopic staples allows full-thickness healing of these injuries.

Animals↗
PubMed2001

Penetrating colon injuries requiring resection: diversion or primary anastomosis? An AAST prospective multicenter study.

BACKGROUND: The management of colon injuries that require resection is an unresolved issue because the existing practices are derived mainly from class III evidence. Because of the inability of any single trauma center to accumulate enough cases for meaningful statistical analysis, a multicenter prospective study was performed to compare primary anastomosis with diversion and identify the risk factors for colon-related abdominal complications. METHODS: This was a prospective study from 19 trauma centers and included patients with colon resection because of penetrating trauma, who survived at least 72 hours. Multivariate logistic regression analysis was used to compare outcomes in patients with primary anastomosis or diversion and identify independent risk factors for the development of abdominal complications. RESULTS: Two hundred ninety-seven patients fulfilled the criteria for inclusion and analysis. Overall, 197 patients (66.3%) were managed by primary anastomosis and 100 (33.7%) by diversion. The overall colon-related mortality was 1.3% (four deaths in the diversion group, no deaths in the primary anastomosis group, p = 0.012). Colon-related abdominal complications occurred in 24% of all patients (primary repair, 22%; diversion, 27%; p = 0.373). Multivariate analysis including all potential risk factors with p values < 0.2 identified three independent risk factors for abdominal complications: severe fecal contamination, transfusion of > or = 4 units of blood within the first 24 hours, and single-agent antibiotic prophylaxis. The type of colon management was not found to be a risk factor. Comparison of primary anastomosis with diversion using multivariate analysis adjusting for the above three identified risk factors or the risk factors previously described in the literature (shock at admission, delay > 6 hours to operating room, penetrating abdominal trauma index > 25, severe fecal contamination, and transfusion of > 6 units blood) showed no statistically significant difference in outcome. Similarly, multivariate analysis and comparison of the two methods of colon management in high-risk patients showed no difference in outcome. CONCLUSION: The surgical method of colon management after resection for penetrating trauma does not affect the incidence of abdominal complications, irrespective of associated risk factors. Severe fecal contamination, transfusion of > or = 4 units of blood within the first 24 hours, and single-agent antibiotic prophylaxis are independent risk factors for abdominal complications. In view of these findings, the reduced quality of life, and the need for a subsequent operation in colostomy patients, primary anastomosis should be considered in all such patients.

Adult↗
PubMed2000

Emergency medical services (EMS) vs non-EMS transport of critically injured patients: a prospective evaluation.

BACKGROUND: A previous report of 5,782 trauma patients demonstrated higher mortality among those transported by emergency medical services (EMS) than among their non-EMS-transported counterparts. HYPOTHESIS: Trauma patients who are transported by EMS and those who are not differ in the injury-to-hospital arrival time interval. DESIGN: Prospective cohort-matched observation study. SETTING: Level I trauma center, multidisciplinary study group. PATIENTS: All non-EMS patients were matched with the next appropriate EMS patient by an investigator who was unaware of the outcome and mode of transport. Every 10th EMS patient with an Injury Severity Score (ISS) of 13 or greater was also randomly enrolled. Matching characteristics included age, ISS, mechanism of injury, head Abbreviated Injury Score, and presence of hypotension. An interview protocol was developed to determine the time of injury. Interview responses from patients, witnesses, and friends were combined with data obtained from police, sheriff, and medical examiner reports. MAIN OUTCOME MEASURES: Time to the hospital, mortality, morbidity, and length of stay. RESULTS: A total of 103 patients were enrolled (38 non-EMS, 38 EMS matched, 27 random EMS). Injury time was estimated using all available data made on 100 patients (97%). Independent raters agreed in 81% of cases. Deaths, complications, and length of hospital stay were similar between the EMS- and non-EMS-transported groups. Although time intervals were similar among the groups overall, more critically injured non-EMS patients (ISS > or = 13) got themselves to the trauma center in less time than their EMS counterparts (15 minutes vs 28 minutes; P<.05). CONCLUSIONS: A multidisciplinary approach can be utilized, and an interview protocol created to determine actual time of injury. Critically injured non-EMS-transported patients (ISS > or =13) arrived at the hospital earlier after their injuries.

Adolescent↗
PubMed2000

Endpoints of resuscitation of critically injured patients: normal or supranormal? A prospective randomized trial.

OBJECTIVE: To evaluate the effect of early optimization in the survival of severely injured patients. SUMMARY BACKGROUND DATA: It is unclear whether supranormal ("optimal") hemodynamic values should serve as endpoints of resuscitation or simply as markers of the physiologic reserve of critically injured patients. The failure of optimization to produce improved survival in some randomized controlled trials may be associated with delays in starting the attempt to reach optimal goals. There are limited controlled data on trauma patients. METHODS: Seventy-five consecutive severely injured patients with shock resulting from bleeding and without major intracranial or spinal cord trauma were randomized to resuscitation, starting immediately after admission, to either normal values of systolic blood pressure, urine output, base deficit, hemoglobin, and cardiac index (control group, 35 patients) or optimal values (cardiac index >4.5 L/min/m2, ratio of transcutaneous oxygen tension to fractional inspired oxygen >200, oxygen delivery index >600 mL/min/m2, and oxygen consumption index >170 mL/min/m2; optimal group, 40 patients). Initial cardiac output monitoring was done noninvasively by bioimpedance and, subsequently, invasively by thermodilution. Crystalloids, colloids, blood, inotropes, and vasopressors were used by predetermined algorithms. RESULTS: Optimal values were reached intentionally by 70% of the optimal patients and spontaneously by 40% of the control patients. There was no difference in rates of death (15% optimal vs. 11% control), organ failure, sepsis, or the length of intensive care unit or hospital stay between the two groups. Patients from both groups who achieved optimal values had better outcomes than patients who did not. The death rate was 0% among patients who achieved optimal values compared with 30% among patients who did not. Age younger than 40 years was the only independent predictive factor of the ability to reach optimal values. CONCLUSIONS: Severely injured patients who can achieve optimal hemodynamic values are more likely to survive than those who cannot, regardless of the resuscitation technique. In this study, attempts at early optimization did not improve the outcome of the examined subgroup of severely injured patients.

Adult↗
PubMed2000

Traumatic asphyxia complicated by unwitnessed cardiac arrest.

We report a case of traumatic asphyxia complicated by unwitnessed cardiac arrest in which the patient has made a good, functional recovery. Traumatic asphyxia is an uncommon clinical syndrome usually occurring after chest compression. Associated physical findings include subconjunctival hemorrhage and purple-blue neck and face discoloration. These facial changes can mimic those seen with massive closed head injury; however, cerebral injury after traumatic asphyxia usually occurs due to cerebral hypoxia. When such features are observed, the diagnosis of traumatic asphyxia should be considered. Prompt treatment with attention to the reestablishment of oxygenation and perfusion may result in good outcomes.

Adult↗
PubMed1999

Predicting the need for thoracoscopic evacuation of residual traumatic hemothorax: chest radiograph is insufficient.

BACKGROUND: The early removal of large residual posttraumatic hemothorax by videothoracoscopy is increasingly used to avoid the late sequelae of trapped lung and empyema. Plain chest radiography (CXR) is the tool most frequently used to select such cases for operation. Our recent experience has demonstrated that what appears to be a large retained hemothorax on CXR may turn out to be intrapulmonary or extrapleural conditions not amenable to thoracoscopic removal. Our objective was to evaluate the accuracy of CXR in detecting significant residual hemothorax and compare its clinical value to thoracic computed tomography (CT) when used to select patients for thoracoscopic evacuation. METHODS: All patients requiring tube thoracostomy for traumatic hemothorax were prospectively evaluated during a 22-month period (n = 703). Patients who, on the second day after admission, demonstrated opacification on CXR involving more than the costophrenic angle were evaluated by thoracic computed tomography for the presence of undrained fluid. Second-day CXR (CXR2) results were compared with the CT findings. Incorrect interpretation was defined as a difference of more than 300 mL between the two readings. All CXR2 and CT results were reviewed in the same fashion by a radiologist blinded to the surgeon's interpretations. Data on injury mechanism, hemodynamic status, laboratory values, interventions, and outcome were collected prospectively. RESULTS: Fifty-eight patients had clinically significant opacifications on CXR2. The surgeon's and radiologist's CXR2 interpretations were incorrect in 48 and 47% of the cases, respectively. The CT interpretations by the two specialists were in agreement in 97% of the cases. Management that would have been instituted on the basis of CXR2 findings was changed in 18 cases (31%). Twelve patients (21%) required early thoracoscopic evacuation of undrained collections. There was good correlation between the CT estimation and the thoracoscopically retrieved amount of blood. CONCLUSION: Although CXR is useful as a screening tool, it cannot be used to reliably select patients for surgical evacuation of retained traumatic hemothorax. Decision-making should be based on thoracic CT findings.

Adult↗
PubMed1999

Colonic resection in trauma: colostomy versus anastomosis.

OBJECTIVES: The management of colonic trauma is well established for simple injuries with primary repair, and ileocolostomy for right-sided injuries that undergo colonic resection. Segmental colon resection for injuries to the left colon can be managed with either an end colostomy or primary anastomosis. A retrospective review was performed to evaluate the outcome and complications associated with colonic resection for trauma to determine the risk factors associated with anastomotic leakage. METHODS: A retrospective review included patients undergoing colonic resection for trauma. The patients were stratified into colostomy, ileocolostomy, and colocolostomy groups. Patient demographics and colon-related complications were collected. Comparison between the colostomy and colocolostomy groups was performed to determine the difference in outcome. The outcome of right-sided colon injuries managed by either an ileocolonic or colocolonic anastomosis was compared. Analysis was performed to identify the factors associated with an increased risk of anastomotic leakage. RESULTS: One hundred forty patients over a 66-month period were included in the analysis. Overall, 41% (57 of 140) of patients developed a colon-related complication; 28% (39 of 140) of patients developed an abscess. Overall, the anastomotic leak rate was 13% (7 of 56) in the colocolostomy group, 4% (2 of 56) in the ileocolostomy group. Right-sided colon injuries managed with a colocolonic anastomosis had a higher incidence of anastomotic leakage than ileocolonic anastomosis, i.e., 14 versus 4% respectively. Of the seven patients who developed a leak from a colocolonic anastomosis, two patients died (29%). Univariate analysis identified an Abdominal Trauma Index Score > or = 25 (p = 0.03) or hypotension in the emergency department (p = 0.001) to be associated with increased risk of developing an anastomotic leak from a colocolonic anastomosis. CONCLUSION: Colonic injuries that are managed with resection are associated with a high complication rate regardless of whether an anastomosis or colostomy is performed. Colonic resection and anastomosis can be performed safely in the majority of patients with severe colonic injury, including injuries to the left colon. For injuries of the right colon, an ileocolostomy has a lower incidence of leakage than a colocolonic anastomosis. For injuries to the left colon, there remains a role for colostomy specifically in the subgroups of patients with a high ATI or hypotension, because these patients are at greater risk for an anastomotic leak. The role of resection and primary anastomosis versus colostomy in colonic trauma requires further investigation.

Adult↗
PubMed1999

Value of complete cervical helical computed tomographic scanning in identifying cervical spine injury in the unevaluable blunt trauma patient with multiple injuries: a prospective study.

OBJECTIVE: To evaluate the role of routine helical computed tomographic (CT) scan of the entire cervical spine in high-risk patients with multiple injuries. METHODS: Prospective study of patients with severe blunt multiple injuries, requiring intensive care unit admission and CT scan of another body area besides the cervical spine. All patients were evaluated by means of standard cervical spine radiography. A complete cervical spine CT scan was performed during the same trip to the scanner in which other body areas were evaluated. The plain films and the CT scans were read by a radiologist in a blinded manner. RESULTS: Fifty-eight patients fulfilled the criteria for inclusion in the study. The mean Glasgow Coma Scale score was 8.9 and the mean Injury Severity Score was 24.1. Twenty patients (34.4%) had cervical spine injuries (12 stable and 8 unstable injuries). Plain radiography missed eight injuries (including three unstable) and its sensitivity was 60%, specificity 100%, positive predictive value 100%, and negative predictive value 85.1%. The helical CT scan missed two spinal injuries (both stable) and its sensitivity was 90%, specificity was 100%, positive predictive value = 100%, negative predictive value = 95%. CONCLUSION: There is a high incidence of cervical spine injuries in the severe, blunt, multiple-injury, unevaluable patients requiring intensive care unit admission. Plain radiography alone is not reliable in diagnosing many cervical spine injuries. Complete cervical spiral computed tomography is superior to plain radiography. It is suggested that in this selected group of patients, both plain radiography and spiral computed tomography should be performed.

Adolescent↗
PubMed1999

High-frequency percussive ventilation improves oxygenation in patients with ARDS.

STUDY OBJECTIVES: To evaluate changes in respiratory and hemodynamic function of patients with ARDS and requiring high-frequency percussive ventilation (HFPV) after failure of conventional ventilation (CV). DESIGN: Retrospective case series. SETTING: Surgical ICU (SICU) and medical ICU (MICU) of an academic county facility. MEASUREMENTS AND RESULTS: Thirty-two consecutive patients with ARDS (20 from SICU, 12 from MICU) who were unresponsive to at least 48 h of CV and were switched to HFPV were studied. Data on respiratory and hemodynamic parameters were collected during the 48 h preceding and the 48 h after institution of HFPV and compared. Between the period of CV and the period of HFPV, the ratio of PaO2 to the fraction of inspired oxygen (F(IO2)) increased ([mean+/-SE] 130+/-8 vs. 172+/-17; p = 0.027), peak inspiratory pressure (PIP) decreased (39.5+/-1.7 vs. 32.5+/-1.9 mm Hg; p = 0.002), and mean airway pressure(MAP) increased (19.2+/-1.2 vs. 27.5+/-1.4 mm Hg; p<0.001). The rate of change of PaO2/F(IO2) per hour was also significantly improved between the two periods. The same changes in PaO2/F(IO2), PIP, and MAP were observed when the last value recorded while the patients were on CV was compared with the first value recorded after 1 h of HFPV. This improvement was sustained but not amplified during the hours of HFPV. The patterns of improvement in these three parameters were similar in SICU and MICU patients as well as in volume-control and pressure-control patients. There were no changes in hemodynamic parameters. CONCLUSION: The HFPV improves oxygenation by increasing MAP and decreasing PIP. This improvement is achieved soon after institution of HFPV and is maintained without affecting hemodynamics.

Adult↗
PubMed1999

CT cystography versus conventional cystography in evaluation of bladder injury.

OBJECTIVE: The objective of this study was to evaluate prospectively the use of CT cystography, using retrograde filling of the bladder with diluted iodinated contrast material, versus conventional cystography to identify bladder injury in patients with hematuria after blunt abdominal trauma. SUBJECTS AND METHODS: Inclusion criteria consisted of the adult hemodynamically stable abdominal trauma patient with hematuria referred for abdominopelvic CT and also being considered for cystography. An initial abdominopelvic CT scan using IV iodinated contrast material was obtained, as would have been done routinely in the trauma victim. A second CT scan through the pelvis was obtained after retrograde distention of the bladder with dilute iodinated contrast material. CT cystography revealing bladder injury was followed with appropriate therapy. CT cystograms not revealing injury were followed by conventional cystography. Results of patient outcome were evaluated. RESULTS: Over a 21-month period from January 1995 through September 1996, CT cystography was performed on 55 patients who presented with hematuria after blunt abdominal trauma. Five of the 55 patients had bladder injury on CT cystography. The injury in each of these five patients was confirmed intraoperatively. In the remaining 50 patients, both CT and conventional cystography did not reveal bladder injury. CONCLUSION: CT cystography is an accurate method for evaluating bladder injury in the blunt abdominal trauma victim with hematuria. CT cystography, performed in conjunction with routine CT of the abdomen and pelvis for evaluating traumatic hematuria, would therefore preclude conventional cystograms in these patients.

Abdominal Injuries↗
PubMed1998

Routine helical computed tomographic evaluation of the mediastinum in high-risk blunt trauma patients.

BACKGROUND: The indications and method of evaluation of the mediastinum in blunt deceleration trauma are controversial and vary among centers. Most centers practice a policy of angiographic evaluation only in the presence of an abnormal mediastinum on chest radiography. Routine aortography in the absence of any mediastinal abnormality is not widely practiced. Helical computed tomographic (CT) scan has been successfully used in recent studies in the evaluation of the thoracic aorta. OBJECTIVE: To determine the role of routine helical CT scan evaluation of the mediastinum in patients involved in high-speed deceleration injuries, irrespective of chest radiographic findings. DESIGN: A prospective study over a 1-year period. Included in the study were patients with high-speed deceleration injuries who required CT evaluation of the head or abdomen. This group of patients underwent routine helical CT evaluation of the mediastinum irrespective of chest radiographic findings. SETTING: Large, urban, academic level I trauma center. RESULTS: A total of 112 trauma patients fulfilled the criteria for study inclusion. Overall, there were 9 patients (8.0%) with aortic rupture. Four (44.4%) of these patients had a normal mediastinum on the initial chest x-ray film and the diagnosis was made by CT scan. The CT scan was diagnostic in 8 of the aortic ruptures (intimal tear or pseudoaneurysm) and was suggestive of aortic injury but not diagnostic in 1 patient with brachiocephalic artery injury. In 42 patients (37.5%), there was a widened mediastinum: an aortic rupture was diagnosed in 5 of them (11.9%) and a spinal fracture in 9 (21.4%). One patient had both aortic rupture and spinal injury. CONCLUSIONS: The incidence of aortic injury in patients with high-speed deceleration injury is high. A significant proportion of patients with aortic injury have a normal mediastinum on the initial chest radiograph. There is a high incidence of spinal injuries in the presence of a widened mediastinum. We recommend that all trauma patients with high-risk deceleration injuries undergo routine helical CT evaluation of the mediastinum irrespective of chest radiographic findings.

Accidental Falls↗
PubMed1998

Is there a limit to massive blood transfusion after severe trauma?

OBJECTIVE: To examine the hypothesis that the futility of short-term care for trauma patients requiring emergency operation can be determined based on the number of units of blood transfused and associated risk factors. DESIGN: A 4-year retrospective review of a cohort of critically injured patients who underwent an emergency operation. SETTING: A large-volume, academic level I, urban trauma center. PATIENTS: One hundred forty-one consecutive patients received massive blood transfusions of 20 U or more of blood during preoperative and intraoperative resuscitation (highest, 68 U). There were 43 survivors (30.5%) and 98 nonsurvivors (69.5%). MAIN OUTCOME MEASURES: Mortality. RESULTS: The number of blood units transfused did not differ between survivors and nonsurvivors (mean +/- SD, 31 +/- 11 vs 32 +/- 10; P = .52). Stepwise multiple regression analysis identified 3 independent variables associated with mortality: need for aortic clamping, intraoperative use of inotropes, and intraoperative time with a systolic blood pressure of 90 mm Hg or less. However, blood usage was not different among the subgroups of patients who had 1 or more of these risk factors. When patients were stratified according to the amount of massive blood transfusion (20-29, 30-39, 40-49, and 50-68 U), the incidence of risk factors was not different across the 4 subgroups. Survival in the presence of risk factors was not affected by the amount of blood transfused. CONCLUSIONS: Although mortality among critically injured patients requiring operation and massive blood transfusion can be correlated with independent risk factors, discontinuation of short-term care cannot be justified based on the need for massive blood transfusion of up to 68 units.

Adult↗
PubMed1998

Transpelvic gunshot wounds: routine laparotomy or selective management?

Mandatory exploration is the standard method for managing patients with gunshot wounds to the abdomen and back. This policy is associated with a high incidence of unnecessary laparotomies and significant morbidity. Reports from our center have shown that a policy of selective management, based on clinical findings, is safe in such patients. Patients with bullet trajectories that carry a high likelihood for intraabdominal organ injury may constitute a subgroup at particular risk. The need for routine or selective exploration in similar patients must be assessed. Therefore we decided to analyze patients with transpelvic gunshot wounds. The objective of the study was to examine if a policy of selective management of patients with transpelvic gunshot wounds is safe. This prospective study was conducted at an academic level I trauma center. We admitted 37 patients with transpelvic gunshot wounds over a 12-month period. All patients were managed according to a protocol that dictated laparotomy in the presence of significant clinical findings (peritoneal signs, hemodynamic instability, gross hematuria, rectal bleeding) and observation in the absence of the above. Additional diagnostic workup was performed only in appropriate cases rather than routinely. Nineteen (51.3%) patients were immediately operated on the basis of clinical findings. Sixteen of these laparotomies were therapeutic. Eighteen (48.6%) patients were initially observed. Subsequently, three of them underwent exploration for development of abdominal tenderness. All three laparotomies were nontherapeutic. The remaining 15 (40.5%) patients were successfully managed nonoperatively. There were no delays in diagnosis or missed injuries. Clinical examination had a sensitivity of 100% and specificity of 71.4% in detecting the need for laparotomy. A policy of selective management is thus safe, even for patients who suffer gunshot wounds with a high likelihood for intraabdominal organ injury. Clinical examination, supported by additional studies in appropriate cases, is the main method of selecting patients for operation or nonoperative treatment.

Abdominal Injuries↗
PubMed1998

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

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.

Adolescent↗
PubMed1998

The fate of colonic suture lines in high-risk trauma patients: a prospective analysis.

BACKGROUND: Some authors have stated that virtually all patients with penetrating colon injuries can be safely managed with primary repair. The purpose of this study is to test the applicability of this statement to all trauma patients by evaluating a protocol of liberal primary repair applied to a group of patients at high risk of septic complications. STUDY DESIGN: We performed a prospective analysis of a liberal policy of primary repair applied to patients at high risk of developing postoperative septic complications admitted to a Level I urban trauma center. Inclusion criteria were full-thickness colon injury and at least one of three additional risk factors: 1) Penetrating Abdominal Trauma Index (PATI) of 25 or more; 2) 6 U or more of blood transfused; and 3) 6 hours or longer elapsed between injury and surgery. RESULTS: Of 56 patients studied (55 male, 1 female, average age 28.8 years, mean PATI 35.3), the vast majority had gunshot wounds as the mechanism of injury (89%), PATI 25 or more (95%), multiple blood transfusions (77%), an Injury Severity Score greater than 15 (66%), and a need for postoperative ventilatory support in the surgical intensive care unit (61%). Of 56 patients, 49 (88%) had at least one colonic suture line, and 25 patients (45%) had destructive colon injuries requiring resection. Intraabdominal infections occurred in 15 (27%) of 56 patients and colon suture line disruption occurred in 3 (6%) of 49. Two of these patients developed multisystem organ failure, and death was directly related to breakdown of their colonic anastomosis. CONCLUSIONS: On the basis of these data and the relative infrequency of patients in prospective randomized trials with destructive colon injuries, we believe there is still room for consideration of fecal diversion in patients in high-risk categories with destructive colon injuries requiring resection.

Adolescent↗
PubMed1998

Lethal abdominal gunshot wounds at a level I trauma center: analysis of TRISS (Revised Trauma Score and Injury Severity Score) fallouts.

BACKGROUND: The TRISS methodology (composite index of the Revised Trauma Score and the Injury Severity Score) has become widely used by trauma centers to assess quality of care. The American College of Surgeons recommends including negative TRISS fallouts (fatally injured patients predicted to survive by the TRISS methodology) as a filter to select patients for peer review. The purpose of this study was to analyze the TRISS fallouts among patients with lethal abdominal gunshot wounds admitted to a level I trauma center. STUDY DESIGN: All patients categorized as TRISS fallouts admitted from January 1995 through December 1996 were analyzed. RESULTS: During the study period, 848 patients with abdominal gunshot wounds were admitted. Of the 108 patients with any sign of life on admission who subsequently died, 39 (36%) were TRISS fallouts. The patients were largely young (mean age, 29 years) and male (87%), received rapid transport (mean scene time, 11 minutes), and had an attending-led trauma-team response (<5 minutes, 87%). Major vascular (80%) and multiple intraabdominal injuries (90%) predominated. The mean Penetrating Abdominal Trauma Index was 40.3. The mean TRISS probability of survival was 89%. The peer-review process deemed the deaths to be nonpreventable in 38 patients (97%) and potentially preventable in one patient (3%). CONCLUSIONS: "TRISS fallouts" were predominantly patients who died despite receiving rapid prehospital transport, rapid senior-level trauma-team response, and surgical intervention for a serious complex of injuries. We conclude that without regional adjustment of coefficients used to predict the probability of survival, the TRISS methodology is of limited use in patients with abdominal gunshot wounds.

Abdominal Injuries↗