Biomedical subjects

G Velmahos

Publications and source records attributed to G Velmahos.

At least 19 recordsLinked to original sources

PubMed2003

Role of postoperative computed tomography in patients with severe liver injury.

BACKGROUND: The role of postoperative computed tomography (CT) in asymptomatic patients with severe liver injury has not been investigated. The aim of the present study was to investigate the nature and incidence of significant liver-related abnormalities detected by postoperative CT in asymptomatic patients with severe liver injury. METHODS: This was a prospective study of survivors with severe liver injury (grades III-V) who were treated surgically. The patients underwent CT to evaluate the liver after operation, irrespective of symptoms. RESULTS: During the study interval there were 181 patients with severe liver injury, of whom 49 fulfilled the criteria for inclusion. The overall incidence of liver-related complications detected by CT was 49 per cent (necrotic areas in the liver in seven patients, seven bilomas, four abscesses, three perihepatic collections and three false aneurysms). In the subgroup of 17 asymptomatic patients CT revealed four abnormalities: two large bilomas, one false aneurysm and one fluid collection. Two of these patients required therapeutic intervention and the other two remained under observation. CONCLUSION: In view of the incidence of asymptomatic significant liver abnormalities following operative management of severe liver injury, it is recommended that these patients undergo routine postoperative CT.

Adult↗

PubMed2002

Effect on outcome of early intensive management of geriatric trauma patients.

BACKGROUND: Despite significant injuries elderly patients (aged 70 years or more) often do not exhibit any of the standard physiological criteria for trauma team activation (TTA), i.e. hypotension, tachycardia or unresponsiveness to pain. As a result of these findings the authors' TTA criteria were modified to include age 70 years or more, and a protocol of early aggressive monitoring and resuscitation was introduced. The aim of the present study was to assess the effect of the new policy on outcome. METHODS: This trauma registry study included patients aged 70 years or more with an Injury Severity Score (ISS) greater than 15 who were admitted over a period of 8 years and 8 months. The patients were divided into two groups: group 1 included patients admitted before age 70 years and above became a TTA criterion and group 2 included patients admitted during the period when age 70 years or more was a TTA criterion and the new management protocol was in place. The two groups were compared with regard to survival, functional status on discharge and hospital charges. RESULTS: There were 336 trauma patients who met the criteria, 260 in group 1 and 76 in group 2. The two groups were similar with respect to mechanism of injury, age, gender, ISS and body area Abbreviated Injury Score. The mortality rate in group 1 was 53.8 per cent and that in group 2 was 34.2 per cent (P = 0.003) (relative risk (RR) 1.57 (95 per cent confidence interval 1.13 to 2.19)). The incidence of permanent disability in the two groups was 16.7 and 12.0 per cent respectively (P = 0.49) (RR 1.39 (0.59 to 3.25)). In subgroups of patients with an ISS of more than 20 the mortality rate was 68.4 and 46.9 per cent in groups 1 and 2 respectively (P = 0.01) (RR 1.46 (1.06 to 2.00)); 12 of 49 survivors in group 1 and two of 26 in group 2 suffered permanent disability (P = 0.12) (RR 3.18 (0.77 to 13.20)). CONCLUSION: Activation of the trauma team and early intensive monitoring, evaluation and resuscitation of geriatric trauma patients improves survival.

Aged↗

PubMed2001

Technology-driven triage of abdominal trauma: the emerging era of nonoperative management.

Selective nonoperative management of blunt or penetrating abdominal trauma is safe, has eliminated the complications associated with nontherapeutic laparotomies, and is cost-effective. Appropriately selected investigations, such as focused abdominal sonography for trauma, diagnostic peritoneal lavage, spiral computed tomography (CT) scan, diagnostic laparoscopy, or thoracoscopy and angiography, play a critical role in the triage of patients. Future technological advances, such as improvement of the ultrasonic hardware and software that provide automated interpretation and the availability of portable CT scan machines in the emergency room, may improve the speed and accuracy of the initial evaluation. Improvement of the optical system of minilaparoscopes may allow reliable bedside laparoscopy for suspected diaphragmatic injuries.

Abdominal Injuries↗

PubMed2001

Reliable variables in the exsanguinated patient which indicate damage control and predict outcome.

BACKGROUND: Exsanguination as a syndrome is ill defined. The objectives of this study were to investigate the relationship between survival and patient characteristics--vital signs, factors relating to injury and treatment; determine if threshold levels of pH, temperature, and highest estimated blood loss can predict survival; and identify predictive factors for survival and to initiate damage control. MATERIAL AND METHODS: A retrospective 6-year study was conducted, 1993 to 1998. In all, 548 patients met one or more criteria: (1) estimated blood loss > or =2,000 mL during trauma operation; (2) required > or =1,500 mL packed red blood cells (PRBC) during resuscitation; or (3) diagnosis of exsanguination. Analysis was made in two phases: (1) death versus survival in emergency department (ED); (2) death versus survival in operating room (OR). Statistical methods were Fisher's exact test, Student's t test, and logistic regression. RESULTS: For 548 patients, mean Revised Trauma Score 4.38, mean Injury Severity Score 32. Penetrating injuries 82% versus blunt injuries 18%. Vital statistics in emergency department: mean blood pressure 63 mm Hg, heart rate 78 beats per minute. Mean OR pH 7.15 and temperature 34.3 degrees C. Mortality was 379 of 548 (69%). Predictive factors for mortality (means): pH < or =7.2, temperature <34 degrees C, OR blood replacement >4,000 mL, total OR fluid replacement >10,000 mL, estimated blood loss >15 mL/minute (P <0.001). Analysis 1: death versus survival in ED, logistic regression. Independent risk factors for survival: penetrating trauma, spontaneous ventilation, and no ED thoracotomy (P <0.001; probability of survival 0.99613). Analysis 2: death versus survival in OR, logistic regression. Independent risk factors for survival: ISS < or =20, spontaneous ventilation in ED, OR PRBC replacement <4,000 mL, no ED or OR thoracotomy, absence of abdominal vascular injury (P <0.001, max R(2) 0.55, concordance 89%). CONCLUSIONS: Survival rates can be predicted in exsanguinating patients. "Damage control" should be performed using these criteria. Knowledge of these patterns can be valuable in treatment selection.

Adolescent↗

PubMed2001

Aerodigestive injuries of the neck.

Cervical aerodigestive trauma is rare and most centers have a limited experience with its management. The purpose of this review was to study the epidemiology, diagnosis, and problems related to the early evaluation and management of these injuries. This was a retrospective study based on trauma registry and on chart, operative, radiological, and endoscopic reports. There were 1560 admissions with blunt or penetrating trauma to the neck. The overall incidence of aerodigestive trauma was 4.9 per cent (10.2% for gunshot wounds, 4.6% for stab wounds, and 1.2% for blunt trauma). All patients with aerodigestive trauma had suspicious signs or symptoms on admission. The most common life-threatening problem in the emergency room and directly related to the aerodigestive trauma was airway compromise. Twenty-nine per cent of patients with laryngotracheal trauma required an emergency room airway establishment because of threatened airway loss. Although rapid sequence induction was successful in the majority of cases, in 11.9 per cent there was loss of airway and a cricothyroidotomy was necessary. Overall, 9 per cent of cases with aerodigestive injuries were successfully treated nonoperatively. Thirty-six per cent of patients with laryngotracheal trauma and surgical repair were successfully treated without a protective tracheostomy. There was no mortality due to the aerodigestive injuries. Cervical aerodigestive trauma is rare. In conclusion, all patients with significant aerodigestive injuries requiring treatment had suspicious signs and symptoms. Airway compromise was a common problem in the emergency room. Loss of airway after rapid sequence induction is a potentially lethal complication and the trauma team should be ready for a surgical airway. Repair of laryngotracheal injuries without a protective tracheostomy is safe in selected cases.

Airway Obstruction↗

PubMed2000

Intraabdominal abscess rate after laparoscopic appendectomy.

BACKGROUND: Studies suggest increased intraabdominal abscess (IA) rates following laparoscopic appendectomy (LA), especially for perforated appendicitis. Consequently, an open approach has been advocated. The aim of our study is to compare IA rates following LA performed by a laparoscopic surgery and a general surgical service within the same institution. METHODS: Data of LA patients treated at Los Angeles County-University of Southern California (LAC-USC) Medical Center between March 1992 and June 1997 were reviewed. The main outcome measure was postoperative IA. RESULTS: In all, 645 LA were reviewed. A total of 413 LA (285 acute, 61 gangrenous, 67 perforated appendicitis) were performed by three general surgical services (10 attendings). Ten abscesses occurred postoperatively (2.4%), 6 with perforated appendicitis. After the laparoscopic service was introduced, 232 standardized LA (126 acute, 46 gangrenous, 60 perforated) were performed by two attendings. One IA occurred (gangrenous appendicitis). The IA rate for perforated appendicitis was significantly lower on the laparoscopic service (P = 0.025). There was no difference in IA rates for acute and gangrenous appendicitis. There was no mortality in either group. CONCLUSION: IA rate following LA for perforated appendicitis was significantly reduced on the laparoscopic service. Mastery of the learning curve and addition of specific surgical techniques explained this improved result. Therefore, laparoscopic appendectomy for complicated appendicitis may not be contraindicated, even for perforated appendicitis.

Abdominal Abscess↗

PubMed2000

Operative management and outcome of 302 abdominal vascular injuries.

BACKGROUND: Abdominal vascular injuries incur high mortality rates. The purposes of this study are (1) review institutional experience, (2) determine additive effect on mortality of multiple vessel injuries, (3) determine mortality of combined arterial and venous injuries, and (4) correlate mortality with American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS) for abdominal vascular injury. METHODS: A retrospective 6-year study was made at an urban level I trauma center of patients with abdominal vascular injuries. Main outcome measure was survival. RESULTS: (1) There was a total of 302 patients, mean age 28, mean Injury Severity Score (ISS) 25 (range 4 to 75). Mechanism of injury was penetrating in 266 (88%), blunt in 36 (12%). Emergency Department thoracotomy was done in 43 of 302 (14%), 504 vessels were injured: arteries 238(47%), veins 266(53%). Surgical management was ligation 245, primary repair 141, prosthetic interposition grafts 24, autogenous 2. Overall mortality was 162 of 302 (54%). (2) Mortality multiple vessels injured: 1 vessel 160 (45%), 2 vessels 102 (60%), 3 vessels 33 (73%), >4 vessels 5 (100%). Mortality arterial injuries: aorta isolated (I) 78% versus combined with other arterial injuries (C) 82.4%, superior mesenteric artery (SMA) I 47.6% versus C 71.4%, iliac I 53% versus C 72.7%, renal I 37.5% versus C 66.7%. Venous injuries: inferior vena cava (IVC) isolated (I) 70% versus combined with other venous injuries (C) 77.7%, superior mesenteric vein (SMV) I 52.7% versus C 65%, IMV I 16% versus C 50%. (3) Specific mortality combined arterial and venous injuries: aorta plus IVC 93%, SMA plus SMV 43%, iliac artery plus vein 45.5%. (4) Mortality versus AAST-OIS: grade II 25%, grade III 32%, grade IV 65%, grade V 88%. CONCLUSION: Abdominal vascular injuries are highly lethal. Multiple arterial and venous injuries increase mortality. Mortality correlates with AAST-OIS for abdominal vascular injury.

Abdominal Injuries↗

PubMed2000

Approach to the management of complex hepatic injuries.

BACKGROUND: Complex hepatic injuries American Association for the Surgery of Trauma Organ Injury Scale grades IV and V incur high mortality rate ranging from 40 to 80%, respectively. The objective of this study is to assess the clinical experience with an aggressive approach to the management of these, the most complex of hepatic injuries. METHODS: This is a retrospective 6-year study (1992-1997) at an American College of Surgeons urban Level I trauma center of patients sustaining complex hepatic injuries whose interventions included surgery, angiographic embolization, endoscopic retrograde cholangiopancreatography plus biliary stenting and percutaneous computed tomographic-guided drainage. The main outcome measure was survival. RESULTS: A total of 22 patients sustaining complex hepatic injuries; mean age of 26 years (range, 10-52 years), mean Revised Trauma Scale score of 9.9, mean Injury Severity Score of 32 (range, 16-75), American Association for the Surgery of Trauma - Organ Injury Scale grade IV (13 cases); grade V (9 cases). Mean estimated blood loss was 4,600 mL; mean number of units of blood transfused was 15. The patients underwent the following interventions: surgery (n = 22), re-operated (n = 13), mean number of operations 1.6 (range, 1-4), extensive hepatotomy and hepatorrhaphy (n = 17), nonanatomic resection (n = 7), formal hepatectomy (n = 4), packing (n = 10), direct approach to hepatic veins (n = 3); angiographic embolization (n = 15); endoscopic retrograde cholangiopancreatography and stenting (n = 5); computed tomographic guided drainage (n = 6). Mean length of stay in the intensive care unit was 21 days (range, 2-134 days), mean hospital length of stay was 40 days (range, 2-147 days). Overall mortality rate was 14% (3 of 22 cases), hepatic mortality rate was 9% (2 of 22 cases), mortality rate by injury grade was 8% grade IV (1 of 13 cases) and 22% grade V (2 of 9 cases). CONCLUSION: In this select patient population, improvements in mortality rates can be achieved with an aggressive approach to the management of complex hepatic injuries, including surgery, early packing, angiographic embolization, endoscopic retrograde cholangiopancreatography and stenting of biliary leaks, and drainage of hepatic abscesses.

Adolescent↗

PubMed2000

Nonskeletal cervical spine injuries: epidemiology and diagnostic pitfalls.

BACKGROUND: Cervical spine injuries are the most commonly missed severe injuries with serious implications for the patient and physician. The diagnosis of subluxations or spinal cord injuries in the absence of vertebral fractures, especially in unevaluable patients, poses a major challenge. The objective of this study was to study the incidence and type of cervical spine trauma according to mechanism of injury; identify problems and pitfalls in the diagnosis of nonskeletal cervical spine injuries. METHODS: Retrospective study of all C-spine injuries caused by traffic accidents or falls admitted over a 5-year period at a large Level I trauma center. Data were obtained from the trauma registry, review of patient charts, and radiology reports. RESULTS: During the study period, there were 14,755 admissions due to traffic injuries or falls who met trauma center criteria. There were 292 patients with C-spine injuries, for an overall incidence of 2.0% (3.4% in car occupants, 2.8% for pedestrians, 1.9% for motorcycle riders, and 0.9% for falls). The incidence of C-spine injuries in patients with a Glasgow Coma Scale score of 13 to 15 was 1.4%, 9 to 12 was 6.8%, and in < or =8 was 10.2% (p < 0.05). Of C-spine injuries, 85.6% (250 patients) were a vertebral fracture, 10.6% of the injuries (31 patients) were subluxation without fractures, and 3.8% (11 patients) were an isolated spinal cord injury without fracture or subluxation. Of the 31 patients with isolated subluxations, one-third required an early endotracheal intubation before clinical evaluation of the spine, because of associated severe head injury or hypotension. Adequate lateral C-spine films diagnosed or suspected 30 of the 31 subluxations (96.8%). The combination of plain films and computed tomographic (CT) scan diagnosed or suspected all injuries. Of the 11 patients with isolated cord injury, 27.3% required early intubation before clinical evaluation of the spine. The diagnosis of cord injury was made on admission in only five patients (45.5%). In three patients, the neurologic examination on admission was normal and neurologic deficits appeared a few hours later. In the remaining three patients (two intubated, one intoxicated), the diagnosis was missed clinically and radiologically. CONCLUSIONS: Isolated nonskeletal C-spine injuries are rare but potentially catastrophic because of the high incidence of neurologic deficits and missed diagnosis. In subluxations, the combination of an adequate lateral film and CT scan was reliable in diagnosing or highly suspecting the injury. A large prospective study is needed to confirm these findings, before a recommendation is made to remove the cervical collar if the findings of these investigations are normal. However, in isolated cord injuries, the diagnosis was often missed because of associated severe head trauma and the low sensitivity of the plain films and CT scans.

Accidental Falls↗

PubMed2000

Helical computed tomographic scan in the evaluation of mediastinal gunshot wounds.

BACKGROUND: The standard evaluation of mediastinal gunshot wounds usually requires angiography and either esophagoscopy or esophagography. In the present study, we have evaluated the role of helical computed tomographic (CT) scanning in reducing the need for angiographic and esophageal studies. METHODS: This was a prospective study of patients with mediastinal gunshot wounds who were hemodynamically stable and would otherwise require angiography and esophageal evaluation. All patients underwent CT scan of the chest with intravenous contrast to delineate the missile trajectory. If the missile tract was in close proximity to the aorta, great vessels, or esophagus, then traditional evaluation with angiographic or esophageal evaluation was pursued. RESULTS: A total of 24 patients met the inclusion criteria and underwent CT scan evaluation of their mediastinal gunshot wounds. One patient was taken for sternotomy to remove a missile embedded in the myocardium solely on the basis of the result of the CT scan. Because of proximity of the bullet tract, 12 patients required additional evaluation with eight angiograms and nine esophageal studies. One of these patients had a positive angiogram (bullet resting against the ascending aorta) and underwent sternotomy for missile removal; all other studies were negative. The remaining 11 patients were found to have well-defined missile tracts that approached neither the aorta nor the esophagus, and no additional evaluation was pursued. There were no missed mediastinal injuries in this group. Overall, 12 of 24 patients (50%) had a change in management (either received an operation or avoided additional radiographic or endoscopic evaluation) on the basis of the CT scan. CONCLUSION: The helical CT scan provides a rapid, readily available, noninvasive means to evaluate missile trajectories. This permits accurate assessment of potential mediastinal injury and reduces the need for routine angiographic and esophageal studies.

Adolescent↗

PubMed1999

Hemodynamic patterns of survivors and nonsurvivors during high risk elective surgical operations.

Postoperative survivors' and nonsurvivors' hemodynamic and oxygen transport patterns have been extensively studied, and the early postoperative circulatory events leading to organ failures and death have been documented. Outcome was improved when potentially lethal circulatory patterns were treated during the early (the first 8-12 hours) postoperative period; but after the appearance of organ failure, reversal of nonsurvival patterns did not improve the outcome. The purpose of this study was to describe prospectively intraoperative circulatory deficiencies that precede shock, organ failures, and death. The ultimate aim was to elucidate nonsurvivor patterns at the earliest possible time to develop more effective preventive strategies for lethal organ failures. This approach is based on the assumption that it is easier and more effective to prevent the initiators of shock, such as hypovolemia, hypoxemia, poor tissue perfusion, and tissue hypoxia, than to treat the mediators of organ failure, such as cytokines, antigens, eicosinoids, and heat shock proteins. We monitored 356 high risk elective surgical patients with preoperative and intraoperative hemodynamic monitoring by the pulmonary artery (PA) thermodilution catheter. The conventionally monitored mean arterial pressure and heart rate remained in the normal range in both groups; the nonsurvivor pattern included decreased cardiac index, stroke index, stroke work, oxygen delivery, and oxygen consumption. Low oxygen consumption was partly compensated by increased oxygen extraction rates, and arterial pressures were maintained by increasing systemic vascular resistance. The early temporal pattern of nonsurvivors' changes were similar to those described during the postoperative period that preceded development of organ failure and death. This suggests that lethal circulatory dysfunctions may begin during the intraoperative period but become more apparent before and after organs fail during later postoperative stages.

Catheterization, Central Venous↗

PubMed1999

Penetrating injuries to the subclavian and axillary vessels.

BACKGROUND: Subclavian and axillary vascular injuries are notorious for their mortality and their difficult surgical exposure. In the present study we analyze our experience with 79 patients and describe the techniques used for surgical access to these vessels. STUDY DESIGN: Retrospective review of the medical records of all patients with penetrating injuries to the subclavian or axillary vessels who had been admitted to 2 Los Angeles trauma centers during a 4-year, 3-month period. RESULTS: Seventy-nine patients were admitted during the study period January 1993 to March 1997 (58 gunshot injuries, 21 other penetrating injuries). The artery was injured in 59 patients and the vein in 40 (20 patients had both arterial and venous injuries). Eighteen patients (23%) were admitted with no signs of life or were in extremis and underwent an emergency room thoracotomy without any survivors. Fifty-eight patients underwent exploration in the operating room, 1 patient with an arteriovenous subclavian fistula was successfully managed with a radiologically placed endovascular stent, and 2 patients with minimal subclavian artery injuries were managed nonoperatively. Overall mortality was 34.2%. Excluding the ER thoracotomies the overall mortality was 14.8%. The mortality for isolated arterial injuries was 20.5%, for isolated venous injuries 50%, and for both vessels 45.0%. The mortality in venous injuries was significantly higher than in arterial injuries (p < 0.05). The standard clavicular incision provided adequate exposure in 32 (50.0%) of the operating room cases. In the other 50% of operating room cases a combination of a clavicular incision with a median sternotomy or thoracotomy was necessary. Proximal subclavian injuries may be accessed through a clavicular incision combined with a median sternotomy irrespective of left or right site location. CONCLUSIONS: Subclavian and axillary vascular injuries remain lethal. A clavicular incision provides satisfactory surgical exposure in about half the patients. In patients with proximal injuries addition of a median sternotomy provides adequate surgical access in both right and left subclavian vessels.

Adult↗

PubMed1999

Gunshot injuries to the liver: the role of selective nonoperative management.

BACKGROUND: Selective nonoperative management of blunt liver injuries has become standard practice in most trauma centers. We evaluated the role of selective nonoperative management of gunshot wounds to the liver. STUDY DESIGN: This was a retrospective review of gunshot wounds to the liver treated in a level I trauma center. Patients with peritoneal signs or hemodynamic instability were operated on without delay. Patients with a soft, nontender abdomen and no signs of heavy bleeding were selected for nonoperative management. Liver injury was diagnosed by CT scan. If peritonitis or signs of substantial internal bleeding developed, an operation was performed; otherwise the patient was discharged within a few days of admission. Analysis was restricted to the group of patients with isolated liver injuries. RESULTS: During a 42-month period, 928 patients were admitted with abdominal gunshot injuries, 152 of whom (16%) had a liver injury. In 52 patients (34% of all liver injuries), the liver was the only injured intraabdominal organ (4 patients had associated kidney or splenic injuries that did not require surgical repair). Thirty-six of the patients (69%) with isolated liver injuries had an emergent operation because of signs of peritonitis or hemodynamic instability. The remaining 16 patients (31%) were selected for nonoperative management (3 patients had associated right kidney injury). Five patients in the observed group required delayed operation because of development of signs of peritonitis (4 patients) or abdominal compartment syndrome (1 patient). The remaining 11 patients (7% of all liver injuries or 21% of isolated liver injuries) were managed successfully without operation. One patient with delayed operation developed multiple complications from abdominal compartment syndrome, and 1 patient in the nonoperative group had a biloma, which was treated with percutaneous drainage. CONCLUSIONS: Selected patients with isolated grades I and II gunshot wounds to the liver can be managed nonoperatively.

Humans↗

PubMed1998

Penetrating cardiac injuries: a prospective study of variables predicting outcomes.

BACKGROUND: Penetrating cardiac injuries are one of the leading causes of death from urban violence. STUDY DESIGN: This is a prospective, 1-year study in a Level I Trauma Center with the objective of analyzing: (1) the parameters measuring the physiologic condition of patients sustaining penetrating cardiac injuries in the field during transport and on arrival, (2) the cardiovascular-respiratory score (CVRS) component of the trauma score, (3) the mechanism and anatomic site of injury, (4) the presence or absence of tamponade, and (5) the cardiac rhythm as a predictor of outcomes. We attempted to correlate cardiac injury grade (AAST-OIS) with mortality. Our main intervention was thoracotomy for resuscitation and definitive repair of cardiac injury. Main outcomes measures were all parameters measuring the physiologic condition of patients, CVRS, mechanism and anatomic site of injury, operative findings and maneuvers, mortality, and grade of injury. RESULTS: The study consisted of 60 patients sustaining penetrating cardiac injuries, 35 gunshot wound (58%) and 25 stab wounds (42%). The injury severity score (ISS) was > 30 in 22 patients; overall survival was 22 of 60 (36.6%); gunshot wound (GSW) survival, 5 of 35 (14%); and stab wound (SW) survival, 17 of 25 (68%). An emergency department thoracotomy was performed in 37 of 60 (61.7%) with 6 of 37 survivors (16%). CVRS: 96% mortality (25 of 26) when CVRS = 0; 67% mortality (6 of 9) when CVRS = 1-3; and 25% mortality (7 of 25) when CVRS > 4 (p < 0.001). Mechanism of injury, and presence of sinus rhythm when pericardium opened predict outcomes (p < 0.001). Anatomic site of injury and tamponade do not predict outcomes (not significant). AAST-OIS injury grade and mortality: grade IV, 31 of 60 (52%); grade V, 20 of 60 (75%), and grade VI, 6 of 60 (100%). CONCLUSIONS: Parameters measuring physiologic condition, CVRS, and mechanism of injury plus initial rhythm are significant predictors of outcomes in penetrating cardiac injuries. The need for aortic crossclamping and the inability to restore an organized rhythm or blood pressure after thoracotomy were also predictors of outcomes. The presence of pericardial tamponade was not.

Adolescent↗

PubMed1998

TRISS methodology in trauma: the need for alternatives.

BACKGROUND: Trauma and Injury Severity Score (TRISS) methodology has become a standard tool for evaluating the performance of trauma centres and identifying cases for critical review. Recent work has identified several limitations and questioned the validity of the methodology in certain types of trauma. METHODS: The usefulness and limitations of the TRISS methodology were evaluated in an urban trauma centre. Trauma registry data of 5445 patients with major trauma were analysed with respect to 30 demographic, prehospital, injury severity and hospitalization attributes. The performance of TRISS was measured primarily by the percentage of misclassifications, including false positives and false negatives, comparing the survival status predicted by TRISS with the true status. Sensitivity, specificity, and positive and negative predictive values were also measured for subgroups defined by the 30 attributes. Logistic regression analysis was used to identify significant independent factors related to the performance of TRISS. RESULTS: The overall misclassification rate was 4.3 per cent. However, in many subgroups of patients with severe trauma the misclassification rate was very high: 34 per cent in patients older than 54 years with Injury Severity Score (ISS) greater than 20; 29 per cent in those with fall injuries and ISS above 20; 29 per cent in patients with injuries involving four or more body areas and ISS greater than 20; 28.6 per cent in patients with injuries needing admission to the intensive care unit (ICU) and ISS greater than 20; 26.4 per cent in patients in severe distress before reaching hospital with ISS greater than 20; and 26.1 per cent in patients whose ISS score was above 20 and who had complications in hospital. CONCLUSION: The TRISS methodology has major limitations in many subgroups of patients, especially in severe trauma. In its present form TRISS has no useful role in major urban trauma centres. Its use should be seriously reconsidered, if not abandoned.

Aged↗

PubMed1998

One hundred five penetrating cardiac injuries: a 2-year prospective evaluation.

OBJECTIVES: To analyze the parameters measured in the field, during transport, and upon arrival of the physiologic condition of patients sustaining penetrating cardiac injuries, along with the Cardiovascular Respiratory Score (CVRS) component of the Trauma Score, the mechanism and anatomical site of injury, operative characteristics, and cardiac rhythm as predictors of outcome. We also set out to identify a set of patient characteristics that best predict mortality outcome and to correlate cardiac injury grade as determined by the American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS) with mortality. METHODS: This report was a prospective study at American College of Surgeons Level I urban trauma center. Interventions included thoracotomy, sternotomy, or both, for resuscitation and definitive repair of cardiac injury. The main outcome measures used were those parameters measuring physiologic condition of patients, CVRS, mechanism and anatomical site of injury, mortality, and grade of injury. RESULTS: A total of 105 patients sustained penetrating cardiac injuries: 68 injuries (65%) were gunshot wounds and 37 injuries (35%) were stab wounds. The mean Injury Severity Score was 36. Of the 105 wounds, 23 wounds (22%) involved multiple-chamber injuries. The overall survival was 35 of 105 patients (33%): survival of gunshot wound victims was 11 of 68 patients (16%); survival of stab wound victims was 24 of 37 patients (65%). Emergency department thoracotomy was performed in 71 of the 105 patients (68%) with 10 survivors (14%). CVRS: 94% mortality (50 of 53) when CVRS = 0, 89% mortality (57 of 64) when CVRS = 0 to 3, and 31% mortality (12 of 39) when CVRS 4 to 11 (p < 0.001). The presence of sinus rhythm when pericardium was opened predicted survival (p < 0.001). Anatomical site of injury (injured chamber) and the presence of tamponade did not predict survival. Stepwise logistic regression analysis identified gunshot wound, exsanguination, and restoration of blood pressure as most predictive variables of mortality. AAST-OIS injury grade and mortality: grade I, 0 of 1 (0%); grade II, 1 of 2 (50%); grade III, 2 of 3 (66%); grade IV, 28 of 50 (56%); grade V, 29 of 38 (76%); grade VI, 10 of 11 (91%). Overall incidence: grades IV-VI, 99 of 105 (94%). CONCLUSIONS: Parameters measuring physiologic condition, CVRS, and mechanism of injury are significant predictors of outcome in penetrating cardiac injuries. AAST-OIS injury grades I-III are rare in penetrating cardiac trauma. AAST-OIS Injury grades IV-VI are common in penetrating cardiac trauma and accurately predict outcome.

Blood Pressure↗

PubMed1998

Initial evaluation and management of gunshot wounds to the face.

BACKGROUND: The literature on early management of gunshot wounds (GSWs) to the face is scant, with only six series reported in the English-language literature in the last 12 years. In the current study, we present a large series from a busy trauma center in an effort to identify early diagnostic and therapeutic problems and recommend management guidelines. METHODS: Retrospective analysis was done for all GSWs of the face during a 4-year period. Data were obtained from the Trauma Registry and Trauma Patient Summary hard copies. RESULTS: During the study period, there were 4,139 admissions for GSWs, with 247 (6%) involving the face. An associated brain trauma was found in 42 patients (17.0%), and cervical spine fracture was found in 20 patients (8.1%) with GSWs to the face. In 43 patients (17.4%), there was a need for emergency airway control because of local hematoma or edema. Angiography was performed in 70 patients (28.3%) for evaluation of a large hematoma or continuous bleeding, and in 10 of these patients successful embolization of bleeders was achieved. No patient required operative control of bleeding from facial structures. Overall, only 96 patients (38.9%) underwent operation for soft-tissue repair or reduction of facial bone fractures. There were 36 deaths (14.5%) from severe brain injury or severe bleeding from associated chest or abdominal injuries. No death occurred in isolated GSWs to the face. CONCLUSION: Most civilian GSWs can safely be managed nonoperatively. Airway control is required in a significant number of patients and should be established very early. Bleeding from the face is best controlled angiographically. The brain and cervical spine should be aggressively assessed radiologically because of the high incidence of associated trauma.

Adolescent↗

PubMed1998

Relative bradycardia in patients with traumatic hypotension.

BACKGROUND: Tachycardia is considered a physiologic response to traumatic hypotension. The inability of the heart to respond to shock with tachycardia has been described as paradoxical bradycardia or relative bradycardia. The incidence and clinical significance of this condition in major trauma is not known. The objective of this study was to examine the incidence and prognostic significance of tachycardia and relative bradycardia in patients with traumatic hypotension. Relative bradycardia is defined as a systolic pressure < or = 90 mm Hg and a pulse rate < or = 90 beats per minute. METHODS: This is a retrospective study conducted at a large Level I academic trauma center during a 4-year period. Seventeen demographic and injury severity factors were analyzed for their possible role in tachycardic or bradycardic response in hypotensive patients. Incidence and mortality were derived for each subpopulation. Bivariate analysis of the association of incidence and mortality with each risk factor was performed. Factors with p values < 0.2 were included in stepwise logistic regression analyses that identified significant risk factors and derived adjusted relative mortality risks between tachycardic and bradycardic hypotensive patients. RESULTS: Excluding transfers and patients dead on arrival, 10,833 major trauma patients were seen during the study period. Seven hundred fifty patients (6.9%) had systolic blood pressure < or = 90 mm Hg; 533 patients had tachycardia (overall incidence of 4.9%, or 71.1% of hypotensive patients), and 217 patients had bradycardia (overall incidence of 2.0%, or 28.9% of hypotensive patients). The overall crude mortality was 29.2% among tachycardia patients and 21.7% among bradycardia patients (crude relative risk = 1.34; 95% confidence interval = 1.00-1.81; p = 0.047). The adjusted relative mortality risk between the two groups was 1.23 (95% confidence interval = 0.84-1.73; p = 0.284). Multivariate analysis showed that patients with relative bradycardia in the subgroups with Injury Severity Scores > or = 16, chest Abbreviated Injury Scale scores > or = 3, or abdominal Abbreviated Injury Scale scores > or = 3 had significantly better survival than patients with similar injuries presenting with tachycardia. CONCLUSION: Relative bradycardia in hypotensive trauma patients is a common hemodynamic finding. Mortality among tachycardic patients was more predictable than among bradycardic patients using commonly used demographic and injury indicators. The presence of relative bradycardia in some subgroups of patients with severe injuries seems to be associated with better prognosis than the presence of tachycardia.

Adult↗