[Acute thoracotomy--the life-threatening cases take precedence].
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Emergencies↗
Biomedical subjects
J Pillgram-Larsen
Publications and source records attributed to J Pillgram-Larsen.
[Quality assurance in a surgical department].
The quality of a given service in a surgical department depends on many factors. Most important are adequate resources, training of the surgeons and nurses and time for follow-up and clinical research. Quality standards should be defined in accordance with the international literature and results should be continuously surveyed to ensure that the agreed goals are met. This article describes various general rules and routines which have been established in our department, as well as the specific systems used to measure the quality of our surgical service in three special fields: Care of patients with tumour mammae, care of patients with gallstone disease, and prospective registration of complications for all gastroenterological patients in our surgical department.
Norway↗
[Injuries from mines].
In autumn 1991, 157 patients injured by mine explosions were taken care of by a Norwegian military medical unit attached to the United Nations mission in the demilitarized zone between Iraq and Kuwait. 146 of the patients were seen during a three week period of Iraqi mine harvesting in the desert. The detachment worked according to the principles of a second echelon surgical installation. The patients were operated upon if necessary, stabilized and evacuated to Iraqi hospitals. 20 patients in all (13%) died primarily. Four of 109 patients evacuated to the field hospital died (4%). 68 patients had major amputations, in seven of them two extremities were blown off. One patient had an open chest wound, two had tracheal puncture wounds, and one had penetrating head injury. 27 patients had eye injuries, 13 of which were penetrating. 64 major surgical procedures were performed. When evacuation times are long after mine injuries, approximately six hours, almost only patients with injuries to the extremities can be expected to reach hospital for treatment. The pattern of injury was regular, with crushed extremities, amputations and damaged eyes.
Adult↗
[Not a tourniquet, but compressive dressing. Experience from 68 traumatic amputations after injuries from mines].
In autumn 1991, 68 patients with traumatic amputations after injuries caused by mines were evacuated to the United Nation's field hospital in the demilitarized zone between Iraq and Kuwait. Most were seen during a three week period when civilians harvested mines. During the first days of this period, continuous bleeding distally to applied tourniquets was frequently observed. Orders were issued to remove any tourniquets and cover the wounds with a very tight elastic bandage. Prehospital intravenous infusions were decreased. Three out of 18 patients died prior to the change of routine compared with one out of 50 afterwards. The new directives led to visibly less haemorrhage. Haemoglobin on admission was mean 8.6 g/100 ml during the first part of the observation period compared with mean 10.5 g/100 ml with the new routine. 23 patients received blood transfusions. Fewer patients needed transfusions after the use of tourniquets was discontinued. A tourniquet should not be used in the treatment of bleeding extremity injuries. In extensive crush injuries and traumatic amputations a compressive dressing should be used, applied from the end of the extremity in a proximal direction.
Adult↗
[Traumatic pneumopericardium with cardiac tamponade].
A 20 year old male motorist with multiple injuries, including bilateral lung laceration, developed cardiac tamponade 12 hours after injury. X-ray showed characteristic findings of pneumopericardium with air all around the cardiac silhouette, which was diminished in size. A chest tube was inserted intrapericardially through a subxiphoid incision. Blood pressure increased immediately, and central venous pressure became normal. Cardiac left ventricular stroke work increased by 86% to normal value. The drain was removed after three days. Another patient was a 15 year old male cyclist who had been overrun by a trailer. Left-sided emergency thoracotomy was performed during laparotomy for liver and vena cava injury, in the course of which procedures there was a sudden decrease in blood pressure with marked elevation of the central venous pressure. The pericardium was incised. Air hissed out, leading to normalisation of arterial and venous pressures. Both patients recovered. Pneumopericardium without symptoms may be treated by observation. Tension pneumopericardium is rare and is best treated by open drainage.
Accidents, Traffic↗
[Gunshot wounds and explosion injuries].
The severity of injury inflicted by a missile is determined by the structure hit and retardation of the missile and thus the energy dissipated to the tissue. The injury to tissue depends on the kinetic energy and the construction of the missile, and the density and resilience of the tissue. Devastating, heavily contaminated wounds are inflicted by close-range shotguns and high-energy missiles, and thorough wound debridement and delayed primary closure are required after about four days. In general, it is not necessary to remove the missile unless this can be done easily. Explosions in air can cause burns, shrapnel wounds, acceleration and deceleration injuries. The shock wave dissipates energy on the border between air and fluid. This injuries primarily hollow organs such as lungs and intestines. Casualties from blasts may exhibit no external symptoms or signs of lung or intraabdominal injury. It is necessary to perform serial physical examinations, blood gas analyses, chest X-ray or CT scan.
Blast Injuries↗
[Trauma severity grading and quality control].
The effect of trauma may be graded by the extent of anatomical injury caused or functional derangement created. The anatomical scoring is useful in determining the trauma load in a hospital and for comparisons between hospitals. It correlates well with the need for resources. Functional scoring may be used to follow the effect of treatment of the individual patient. A combined evaluation of both anatomical injuries, physiological derangements and patient's age is necessary for individual prognostics and is used in evaluation of trauma care. The most widely used system of anatomical scoring is Injury Severity Score based on the Abbreviated Injury Scale. Trauma Score is a widely disseminated functional scoring system. These two may be combined into the TRISS method for assessing probability of survival. Under conditions of war, patients are divided into groups which either have to be operated, which can wait or which have to wait. War wounds are graded according to the extent of soft tissue damage, involvement of deeper structures and whether the wound contains foreign bodies.
Abbreviated Injury Scale↗
[Practical aspects of thoracic injuries].
While mortality is about one per hundred in patients with injuries to the chest wall it is one in five in patients with internal thoracic injuries. The mortality is dependent on the total severity of injuries, and upon age. Closed, blunt thoracic trauma may initially present few signs and symptoms. Internal injuries, such as pneumothorax and haemothorax may be present. Decompression by thoracic drainage improves oxygenation. This may be crucial for the prognosis in multitrauma, particularly in cases of concomitant head injury. Treatment and diagnosis of thoracic injuries have first priority in the multitraumatized patient. A chest X-ray should be obtained early, and should be repeated, possibly supplemented by a CT-scan. When pneumothorax or haemothorax is suspected, and in cases of penetrating injury, chest drainage is widely used. In cases of chest injury and unexplained shock, cardiac tamponade must be excluded by subxiphoidal incision.
Drainage↗
[Multiple trauma--physician's responsibility].
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Health Priorities↗
[Multiple injuries and quality control].
A prospective registration was carried out of all patients with multiple injuries who were admitted to hospital in 1990 during the first 24 hours after the accident. The total number was 441, and included 47 patients with penetrating injuries. Such patients constituted 5% of a total of 9,000 admitted patients, and 19% of a total of 2,266 injured persons. The injuries were scored using the Trauma Score and Injury Severity Score and the probability for survival was calculated by the TRISS method. 148 patients were seriously injured, having an Injury Severity Score 16 or more. Traffic accidents were more common, and were the cause of injury in more than 50% of the patients. 15% of the patients with such injuries were under the influence of alcohol and 5% were drug abusers. The percentage under the influence of alcohol was three times as high, however, among patients injured by violence. Median ISS was 26 for the whole series, and 41 for the 41 patients who died. Mortality was significantly higher in patients older than 54 years of age than among younger patients. No patients were reduced to a vegetative state, but 13% of the surviving patients were considerably disabled. Among the 41 patients who died the main cause of death was haemorrhage in 17, and airway obstruction in five. Estimation of probability of survival showed that the mortality in this series compared well with the mortality in larger series of injured persons in America. None the less, improvement is still feasible.
Adult↗
[Initial evaluation and treatment, selection by priority].
Mortality from severe multitrauma is 25-30%. Haemorrhage is the cause of one third of the deaths, either directly or indirectly as the cause of organ failure. Many trauma victims will not present alarming symptoms shortly after the accident. When high energy trauma is suspected the patient should be admitted to a resource hospital with the relevant expertise for systematic evaluation. Control over the airways and venous access should be obtained within minutes, and it should be established whether the patient is bleeding so much as to warrant emergency operation. The diagnostic work-up should have been completed within two to three hours. All severely injured patients should be treated initially at the same location, following the same routines. Due to risk of overlooking injuries, patients should not be sorted by surgical specialty in the field. Obstructed airways are more acutely life-threatening than inadequate respiration, which is more serious than decreased circulation, which is again more dangerous than impaired consciousness. In general, thoracic injuries take priority over abdominal, cerebral and orthopaedic injuries, in that order.
Emergency Medical Services↗
[Multiple injuries and quality control].
A prospective registration was carried out of all patients with multiple injuries who were admitted to hospital in 1990 during the first 24 hours after the accident. The total number was 441, and included 47 patients with penetrating injuries. Such patients constituted 5 per cent of a total of 9,000 admitted patients, and 19 per cent of a total of 2,266 injured persons. The injuries were scored using the Trauma Score and Injury Severity Score (ISS) and the probability for survival was calculated by the TRISS method. 148 patients were seriously injured, having an Injury Severity Score 16 or more. Traffic accidents were most common, and were the cause of injury in more than 50 per cent of the patients. 15 per cent of the patients with such injuries were under the influence of alcohol and 5 per cent were drug abusers. The percentage under the influence of alcohol was three times as high, however, among patients injured by violence. Median ISS was 26 for the whole series, and 41 for the 41 patients who died. Mortality was significantly higher in patients older than 54 years of age than among younger patients. No patients were reduced to a vegetative state, but 13 per cent of the surviving patients were considerably disabled. Among the 41 patients who died the main cause of death was haemorrhage in 17, and airway obstruction in five. Estimation of probability of survival showed that the mortality in this series compared well with the mortality in larger series of injured persons in America. None the less, improvement is still feasible.
Adolescent↗
[Emergency thoracotomy. Aortic clamping in major bleeding].
Emergency room thoracotomy was performed in 22 cases. 19 of the patients were admitted following injury. Four of the injured patients survived. Two of the survivors had penetrating injury above the diaphragm, one had penetrating injury below the diaphragm. One survivor had blunt injury to the abdominal vena cava and the liver. There was no difference between the group of patients that survived and the group that died as regards probability of survival estimated by the TRISS method, trauma score and injury severity score. Internal heart compression was performed in nine cases. Emergency room thoracotomy is a life-saving procedure in critically unstable patients.
Adolescent↗
[The curse of the computer tomograph].
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Adult↗
[Diaphragmatic injuries].
Diaphragmatic injuries are serious, since they can lead to herniation of abdominal organs into the thorax. The injury is simple to treat when diagnosed early. The operation can then be performed with direct suturing. Concomitant injuries are common, however, and complicate diagnosis and treatment in an acute situation. During the period 1980-90, 30 patients with diaphragmatic injuries where treated in Ullevål hospital, 18 after closed and 12 after penetrating trauma. 28 of the 30 patients also had associated injuries. In four patients the diagnosis was initially missed. The majority of the patients were treated by laparotomy. Four patients died during the primary admission to the hospital, one of them suddenly in delirium tremens, two from massive bleeding from a pelvic fracture and one from septicemia and multiorgan failure. One patient died four years later from pneumococcal septicemia. No patient died because of the diaphragmatic injury, and traumatic diaphragmatic hernia due to earlier injuries was not registered during the study period.
Abdominal Injuries↗
[Ambulatory evaluation and treatment of blunt thoracic injuries].
307 patients with chest injuries were treated in an outpatient clinic during a three month period. Ten patients developed complications such as hemothorax, pneumothorax and lung contusion, or late complications such as atelectases and pneumonia. 21 patients were hospitalized after initial evaluation. Two patients died. Pain was a symptom in 306 of the 307 patients. Other symptoms were coughing, hempoptysis, fever, nausea. Complications increased in 40 patients, with other symptoms or signs in addition to pain. These other symptoms had a 40% positive and 95% negative predictive value as regards complications. 45 out of 114 patients had a pathological chest x-ray. Positive chest x-ray had a 40% positive and 94% negative predictive value as regards complications. In four patients (1.3%) complicating injuries were not identified initially. Five of 24 patients (21%) were hospitalized unnecessarily. Chest x-ray should be performed in patients with additional symptoms and signs. Patients with no signs in addition to chest wall tenderness can be observed at home.
Adolescent↗
[Blunt thoracic injuries in Oslo].
All 327 patients treated in Oslo City Hospital for blunt chest injuries during a period of three months were registered prospectively. 274 were treated outside hospital. Traffic accidents accounted for 10% of the total number of patients, but 40% of the hospitalized patients. Accidents in the home were most numerous, with many complications and admissions to hospital. 20% of the hospitalizations, were for injuries due to violence. The registration indicates more than 1,300 patients with chest injuries per year, of whom more than 40 are severely multitraumatized. The chest injury was serious in 21 patients, moderate in 306. 13.5% of the cases were complicated by pneumo-hemothorax and lung contusion, or by late complications such as pneumonia and atelectases. Seven patients (2.1%) died. These were old, physically disabled or multitraumatized. 100 patients had extrathoracic injuries, of whom 15 had intrathoracic injuries as well. In 227 patients with thoracic injuries only, the injuries were intrathoracic in six of them. The mortality in patients with chest wall injuries only was 0.7%, as compared with 20% in patients with intrathoracic injuries.
Accidents↗
[Accidental hypothermia. Risk factors in 29 patients with body temperature of 30 degrees C and below].
29 patients with a body temperature below 30 degrees C (mean 26.4 degrees C) were treated during the period 1982-88, both years inclusive. Eight patients were severely hypotensive (systolic blood pressure less than 60 mm Hg) and two had ventricular fibrillation on admission. Bradycardia (less than 60 beats per minute) was noted in ten patients. 12 patients were rewarmed by surface warming, 17 by extracorporeal circulation with femoral cannulation. 22 patients (76%) were discharged alive. Age, sex, body temperature, method and rate of rewarming, serum electrolytes, acidosis and the use of blood components did not influence the outcome. Renal failure was the only complication associated with a fatal outcome. Severe hypotension on admission tended to increase mortality, but logistic regression analysis identified the mode of cooling as the only independent risk factor for death. A patient cooled indoors had an odd risk of 10.6 of hospital mortality compared to one found outdoors. For the sake of convenience, in hospitals with the available resources rewarming by extracorporeal circulation may be used in patients with circulatory arrest, since this is the easiest way to control and support failing circulation. In all other cases carefully monitored surface rewarming should be used as this necessitates less use of hospital resources and produces equally good results.
Accidents↗