Factors affecting mortality rates in patients with abdominal vascular injuries

Level I Verification Is Associated with a Decreased Mortality Rate after Major Torso Vascular Injuries

Major torso vascular injuries (MTVIs) are frequently fatal. Our purpose was to determine whether the American College of Surgeons’ (ACS) trauma center level of verification was associated with reduced mortality rates in a rural population-based community trauma center. Patients with blunt and penetrating MTVIs were retrospectively reviewed. Mortality rates were compared between Level II and Level I verification time periods. The primary outcome measured was death from MTVIs. Two hundred seventy-four patients (blunt, 167 [61%]; penetrating, 107 [39%]) representing 1.5 per cent of all trauma admissions were studied. Mortality decreased from 41 of 80 (51%) (Level II) to 60 of 194 (31%) (Level I) ( P = 0.002) for the entire group. Mortality reduction occurred primarily in the subgroup with blunt and penetrating thoracic injuries (Level II, 24 of 33 [73%] vs Level I, 25 of 82 [30%]; P < 0.001). A significant reduction was not observed in patients with major abdominal vascular injuries (Level II, 17 of 47 [36%] vs Level I, 35 of 112 [31%]; P = 0.581). Level I status was associated with an overall decreased mortality rate from MTVIs despite low patient numbers. The commitment of hospital resources that are required to achieve Level I ACS verification in a community hospital improves survival, particularly in patients with blunt and penetrating thoracic injuries.

Existing trauma and critical care scoring systems underestimate mortality among vascular trauma patients

BACKGROUND

The impact of vascular injuries on patient mortality has not been well evaluated in multi-trauma patients. This study seeks to determine (1) whether the presence of vascular trauma negatively affects outcome compared with nonvascular trauma (NVT) and (2) the utility of existing severity scoring systems in predicting mortality among vascular trauma (VT) patients.

METHODS

A retrospective review of our trauma database from January 2005 to December 2007 was conducted. Demographics, Injury Severity Scores (ISS), Revised Trauma Scores (RTS), Trauma Score-Injury Severity Scores (TRISS), Acute Physiology and Chronic Health Evaluation II (APACHE II) scores, and mortality rates were compared. Control patients were selected from a matching cohort based on ISS. Comparisons were made between groups based on the above scoring systems. Statistical analysis used χ(2) analysis and Student t-tests.

RESULTS

Fifty VT and 50 NVT patients were identified with no significant differences in age, gender, mechanism of injury, ISS, RTS, or TRISS. The mean APACHE II score was higher in VT compared with NVT (12.3 vs 8.8, P < .05). Overall mortality was higher in VT compared with NVT but did not reach statistical significance (24% vs 11.8%, P = .108). VT patients with RTS score >5 had a higher mortality rate (26% vs 2.2%, P = .007). VT patients with an ISS score >24 had a higher mortality compared with NVT patients (61% vs 28.6%, P = .04). VT patients with an APACHE II score <14 also had a higher mortality rate (18.2% vs 0%, P = .007). Finally, VT patients with a TRISS probability of survival of >80% had a higher mortality rate (13.9% vs 0%, P = .05).

CONCLUSIONS

In multi-trauma patients, the presence of vascular injury was associated with increased mortality in less severely injured patients based on the RTS, TRISS, and APACHE II scores. These scoring systems underestimated mortality in patients with vascular trauma. Level of care and future trauma algorithms should be adjusted in the presence of vascular trauma.

Damage control techniques for common and external iliac artery injuries: have temporary intravascular shunts replaced the need for ligation?

BACKGROUND

Trauma to the common or external iliac arteries has a mortality rate of 24% to 60%. "Damage control" options for these severely injured vessels are either ligation or temporary intravascular shunts (TIVSs). Complications of ligation include a 50% amputation rate and up to 90% mortality. The primary goal of this study was to identify the consequences of using ligation versus TIVS for common or external iliac artery injuries in damage control scenarios.

METHODS

All patients with injuries to an iliac artery (1995-2008) at a Level I trauma center were reviewed. Demographics and outcomes were analyzed using standard statistical methodology.

RESULTS

Iliac artery injuries were present in 88 patients (71 external and 17 common; 72% penetrating; median Injury Severity Score, 25; mean hospital stay, 28 days). Most nonsurvivors (73%) died of refractory shock within the first 24 hours after presenting with hemodynamic instability (66%). Ligation was required in one (6%) common and 14 (20%) external iliac arteries. TIVS was used in two (12%) common and five (7%) external iliac arteries. Patients requiring ligation (1995-2005) or TIVS (2005-2008) for their common or external iliac arteries had similar demographics and injuries (p > 0.05). Compared with patients who underwent ligation, patients receiving TIVS required fewer amputations (47% vs. 0%) and fasciotomies (93% vs. 43%; p < 0.05). Mortality in the ligation group was 73%, versus 43% in the TIVS cohort.

CONCLUSIONS

TIVSs have replaced ligation as the primary damage control procedure for injuries to common and external iliac arteries. As a result, the high incidence of subsequent amputation has been virtually eliminated. With increased TIVS experience, an improvement in survival is likely.

Effect of TachoSil in a coagulopathic pig model with blunt liver injuries

OBJECTIVE

In this study, we investigated the efficacy of a fibrinogen/thrombin-coated collagen patch (TachoSil) to terminate severe bleeding in a coagulopathic pig model with blunt liver injury.

METHODS

Following surgical preparation, which included splenectomy and cystotomy, coagulopathy was induced by exchanging 80% of the animal's blood volume with hydroxyethylstarch 130/0.4 and lactated Ringer's solution. Subsequently, a grade III liver injury was induced by a force of 238 ± 19 Newton and free bleeding was allowed for 30 s. Animals were randomly assigned to receive either a placebo patch (cotton patch) (control group, n = 7) or a fibrinogen/thrombin patch (FT patch group, n = 7), which was positioned 30 s after injury on the inflicted area. Coagulation parameters, hemodynamic variables, as well as treatment were monitored for 2 h post-injury and patch placement. Histology was obtained to evaluate the equality of liver injury and to show the morphology of the FT patch.

RESULTS

Hemostasis after hemodilution was severely impaired. Blood loss after trauma was significantly diminished in the FT patch group (419 mL ± 90 mL) compared with the control group (1775 mL ± 358 mL) (P < 0.001). All animals treated with the FT patch survived, whereas 100% of the control group died before reaching the end of the observation period (P < 0.001). Gross sectioning and histology showed an equal degree of injury with a tight adherence of the FT patch.

CONCLUSION

TachoSil under severe coagulopathy effectively controlled bleeding and successfully prevented hemorrhagic death.

Use of a modified chitosan dressing in a hypothermic coagulopathic grade V liver injury model

BACKGROUND

Exsanguination from hepatic trauma is exacerbated by the lethal triad of acidosis, coagulopathy, and hypothermia. We evaluated the application of a modified chitosan dressing in a hypothermic coagulopathic model of grade V liver injury.

METHODS

Subject swine underwent induced hypothermic coagulopathy followed by standardized grade V liver injuries. A modified chitosan dressing was applied and compared with standard packing.

RESULTS

Pretreatment temperature, activated clotting time, and blood loss were similar between groups. Post treatment blood loss was significantly less and resuscitation mean arterial pressure were significantly greater in the modified chitosan group (P < .0001 and P < .018, respectively). Mean fluid resuscitative volume was significantly less in the modified chitosan group (P < .0056). Hemostasis was achieved on average 5.2 minutes following modified chitosan and never achieved with standard packing. At 1 hour post injury, all treatment animals survived compared with half of controls.

CONCLUSIONS

Modified chitosan dressings provide simple rapid treatment of life-threatening liver injuries.

Impact of Hollow Viscus Injuries on Outcome of Abdominal Gunshot Wounds

Abdominal gunshot wounds (GSW) are a source of morbidity and mortality. Limited data are available on the effect of hollow viscus injuries (HVI) secondary to gunshot wounds. GSW sustained in the Louisville area from 2004 to 2007 were reviewed. Attention was given to the impact of HVI from abdominal GSW. Statistical significance was determined. One-hundred ten patients sustained GSW with peritoneal violation. Eighty-six had HVI. Eighteen died after laparotomy with 15 having an HVI. Patients undergoing damage control (DC) have a significant increase in mortality compared with those not requiring DC. Exsanguination was the major cause of mortality (67%). Mortality directly related to HVI was found in 11 per cent. Twenty patients underwent DC with 11 deaths. Isolated HVI did not show a significantly increased mortality compared with other injury patterns involving solid organ or major vascular structures. Various methods of repair showed no significant survival advantage. Recognition and repair of HVI in abdominal GSW is crucial to patient salvage. Definitive repair of HVI at the initial operation should be considered. Primary repair of HVI is preferred although no survival disadvantage is seen in other forms of repair in marginally stable patients. Definitive repair at the initial operation decreases complications.

Superior mesenteric venous injuries: to ligate or to repair remains the question

BACKGROUND

Superior mesenteric vein injuries are rare and incur high mortality. Given their low incidence, little data exist delineating indications for when to institute primary repair versus ligation. The purposes of this study are to review our institutional experience, to determine the additive effect on mortality of associated vascular injuries, to correlate mortality with the American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS) for abdominal vascular injury and to examine and define the indications and outcomes for primary repair versus ligation.

MATERIAL

Retrospective 156 months study (January 1992 through December 2004) in a large Level I urban trauma center of all patients admitted with superior mesenteric vein injuries. Patients were stratified, according to surgical technique employed to deal with their injuries, into those undergoing primary repair versus ligation to determine outcomes and define the surgical indications of these methods. The main outcome measure was overall survival. Cases of survival were stratified according to surgical method: primary repair versus ligation.

RESULTS

There were 51 patients with a mean Injury Severity Score of 25 +/- 12. Mechanism of injury was penetrating for 38 (76%), blunt for 13 (24%), and patients undergoing emergency department thoracotomy for 4 (8%). Surgical management was ligation for 30 (59%), primary repair for 16 (31%), and 5 (10%) patients were exsanguinated before repair. The overall survival rate was 24/50 (47%). The survival rate excluding patients undergoing emergency department thoracotomy was 51%. The survival rate excluding patients that sustained greater than 3 to 4 associated vessels injured was 65%. The survival rates of patients with superior mesenteric vein and superior mesenteric artery was 55% and superior mesenteric vein and portal vein (PV) was 40%. The survival rate of patients with isolated superior mesenteric vein injuries was 55%. Mortality stratified to AAST-OIS grade III, 44%; grade IV, 42%; and grade V, 42%. Survival rates stratified to method of management consisted of primary repair (60%) versus ligation (40%).

CONCLUSIONS

SMV injuries are highly lethal. Multiple associated vessel injuries increase mortality. Mortality correlates well with the American Association for the Surgery of Trauma-Organ Injury Scale for abdominal vascular injuries. Patients undergoing primary repair have higher survival rates (63%) and lesser numbers of associated vascular and nonvascular injuries; whereas those undergoing ligation have a smaller survival rate (40%) and higher number of associated vascular and nonvascular injuries. Ligation appears to be safe and should be selected for hemodynamically unstable patients with a large number of associated injuries.

Patient factors and operating room resuscitation predict mortality in traumatic abdominal aortic injury: A 20-year analysis

BACKGROUND

Injuries to the abdominal aorta are rare and remain one of the most lethal causes of early death in trauma. The purposes of this study were to identify primary predictors of mortality and to examine the impact of a well-established operating room resuscitation protocol on survival in patients with traumatic aortic injury.

METHODS

A 20-year retrospective review was performed of medical records and autopsy reports of trauma patients admitted with confirmed injury to the abdominal aorta. Data on patient demographics, admission characteristics, operative findings, and the initial location of resuscitation were collected. The main outcome measure was death.

RESULTS

Abdominal aortic injuries were diagnosed in 60 patients. Their average age was 26.5 years, and the mean transport time was 10 minutes. The overall mortality rate (MR) was 73%. With the exclusion of 18 patients considered dead on arrival, the MR decreased to 61%. The mechanism of injury was blunt in 20% (MR 92%) and penetrating in 80% (MR 68%). Acidosis, defined as a pH <7.2 (MR 81%) or a base deficit >10 (MR 77%), was a predictor of death (P < .0001). Patients resuscitated directly in the operating room had a significantly lower MR (40%) than those resuscitated in the trauma room (MR 78%; P < .02). The lack of retroperitoneal tamponade (P < .02), the presence of associated intra-abdominal injuries (P < .001), and the location of aortic injury at the subdiaphragmatic (18%; MR 90%) or suprarenal location (37%; MR 71%; P < .005) at exploration resulted in significantly higher patient mortality. Surgical management consisted of primary repair in 26, end-to-end repair in 1, interposition graft in 8, or patch in 1. Resuscitative thoracotomy was performed in 27 patients (45%), with an overall MR of 92%.

CONCLUSION

Despite advances in fluid resuscitation, operative strategy, and transport during the past 20 years, the mortality of traumatic injury to the abdominal aorta remains high. Shock, acidosis, suprarenal aortic injury, and a lack of retroperitoneal tamponade all independently contribute to mortality and should raise the suspicion for a potentially lethal aortic injury in a severely injured patient. Rapid identification and resuscitation in the operating room may therefore be the only factors to improve current survival rates in such devastating injuries.

The impact of patient volume on surgical trauma training in a Scandinavian trauma centre

OBJECTIVE

Some of the problems faced in trauma surgery are increasing non-operative management of abdominal injuries, decreasing work hours and increasing sub-specialisation. We wanted to document the experience of trauma team leaders at the largest trauma centre in Norway, hypothesising that the patient volume would be inadequate to secure optimal trauma care.

METHODS

Patients registered in the hospital based Trauma Registry during the 2-year period from 1 August 2000 to 31 July 2002 were included.

RESULTS

Of a total of 1667 patients registered, 645 patients (39%) had an Injury Severity Score (ISS)>15. Abdominal injuries were diagnosed in 205 patients with a median ISS of 30. An average trauma team leader assessed a total of 119 trauma cases a year (46 patients with ISS>15) and participated in 10 trauma laparotomies.

CONCLUSION

Although the total number of trauma cases seems adequate, the experience of the trauma team leaders with challenging abdominal injuries is limited. With increasing sub-specialisation and general surgery vanishing, fewer surgical specialties provide operative competence in dealing with complicated torso trauma. A system of additional education and quality assurance measures is a prerequisite of high quality, and has consequently been introduced in our institution.

Lessons learned in the management of thirteen celiac axis injuries

OBJECTIVES

Celiac axis injuries are rare. The purposes of this study were to (1) review institutional experience, (2) determine additive effect on death of associated vessel injuries, and (3) correlate mortality rates with the American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS) for abdominal vascular injury.

METHODS

This was a retrospective, 132-month study (January 1992 to December 2002) of patients with celiac axis injuries.

RESULTS

Thirteen patients were included in the study. Mean revised trauma score was 5.35+/-2.63; mean injury severity score was 25+/-12. The mechanism was penetrating in 12 (92%) and blunt in 1 (8%); 3 of 13 had Emergency Department thoracotomy (100% mortality rate). Treatment included ligation in 11 and primary repair in 1; 1 exsanguinated. Overall survival was 5 of 13 (38%). Adjusted survival excluding patients who had Emergency Department thoracotomy was 5 of 10 patients (50%). Those surviving with isolated injuries included 57% of patients. Mortality rate versus AAST-OIS was grade III, 43% (3 of 7 patients); grade IV, 50% (1 of 2 patients); and grade V, 100% (4 of 4 patients).

CONCLUSIONS

Celiac axis injuries are rare. Patients with isolated injuries have better survival rates. Mortality rate correlates well with AAST-OIS for abdominal vascular injury.

Application of a Granular Mineral-Based Hemostatic Agent (QuikClot) to Reduce Blood Loss After Grade V Liver Injury in Swine

BACKGROUND

Uncontrolled hemorrhage is a leading cause of death in cases of trauma. Many products currently are under development to control traumatic bleeding. One such Food and Drug Administration (FDA)-approved product is QuikClot. This study determined the efficacy of QuikClot, a hemostatic agent, in reducing blood loss and mortality in a standardized model of severe liver injury as well as the consequences of its use.

METHODS

Swine received either QuikClot or gauze treatment after induction of grade V liver injuries. Hemostasis, blood loss, resuscitation volume, 60-minute survival, and peak tissue temperatures were measured.

RESULTS

Hemostasis was improved with QuikClot (p < 0.05), and resuscitation volume was consequently reduced (p < 0.05). Posttreatment blood loss was reduced (p < 0.01) with QuikClot (1,397 mL), as compared with gauze (5,338 mL). The survival rate was seven of eight in the QuikClot group and one of eight in the gauze group (p < 0.01). Peak temperature at the tissue interface was increased (p < 0.01) with QuikClot (93.3 +/- 10.5 degrees C), as compared with gauze (37.5 +/- 6.5 degrees C). QuikClot use was associated with both macro- and microscopic tissue damage caused by the exothermic reaction.

CONCLUSION

QuikClot provides hemostasis and decreased mortality in this model of severe liver injury. The beneficial aspects of QuikClot treatment must, however, be balanced against the tissue-damaging effects of the exothermic reaction.

Penetrating trauma in children

Penetrating injuries account for 10% to 20% of all pediatric trauma admissions at most centers. Gunshot wounds are responsible for the overwhelming majority of penetrating traumatic injuries and have a significantly higher mortality rate than do blunt injury mechanisms. The management of penetrating injuries can be quite challenging and often requires rapid assessment and intervention. Specific management principles are guided by the anatomic location of injury, the determination of trajectory, and the suspected organs injured. Management approaches have been adopted in large part from the more robust adult experience. However, application of these strategies to similar life-threatening injuries in the pediatric population appears appropriate.

Use of a Centrifugal Vortex Blood Pump and Heparin-Bonded Circuit for Extracorporeal Rewarming of Severe Hypothermia in Acutely Injured and Coagulopathic Patients

BACKGROUND

Standard rewarming methods for posttraumatic hypothermia are ineffective or require systemic heparinization. Centrifugal vortex blood pumps (CVBPs), heparin-bonded circuits, and, potentially, percutaneous access techniques, facilitate the institution of an extracorporeal circulation by noncardiac surgeons.

METHODS

Seven severely hypothermic patients requiring emergent operative intervention were rewarmed intraoperatively using the CVBP with heparin-bonded circuitry.

RESULTS

Patients were critically ill (average Injury Severity Score of 43.5 [SD, 13.6] for the traumatized patients). The mean temperature before rewarming was 31.5 degrees C (SD, 1.6 degrees C). The CVBP outflow site was the common femoral vein in all patients, with the inflow into the superficial femoral artery (n = 2), contralateral common femoral vein (n = 2), and internal jugular vein (n = 3). The mean time to rewarm to 37 degrees C was 73.3 (SD, 30.5) minutes. All patients survived the initial operation, although the ultimate survival was 43%.

CONCLUSION

Noncardiac surgeons can effectively use an extracorporeal rewarming strategy incorporating a heparin-bonded CVBP to rapidly rewarm hypothermic coagulopathic patients undergoing surgery.

Advanced Hemostatic Dressing Development Program: Animal Model Selection Criteria and Results of a Study of Nine Hemostatic Dressings in a Model of Severe Large Venous Hemorrhage and Hepatic Injury in Swine

BACKGROUND

An advanced hemostatic dressing is needed to augment current methods for the control of life-threatening hemorrhage. A systematic approach to the study of dressings is described. We studied the effects of nine hemostatic dressings on blood loss using a model of severe venous hemorrhage and hepatic injury in swine.

METHODS

Swine were treated using one of nine hemostatic dressings. Dressings used the following primary active ingredients: microfibrillar collagen, oxidized cellulose, thrombin, fibrinogen, propyl gallate, aluminum sulfate, and fully acetylated poly-N-acetyl glucosamine. Standardized liver injuries were induced, dressings were applied, and resuscitation was initiated. Blood loss, hemostasis, and 60-minute survival were quantified.

RESULTS

The American Red Cross hemostatic dressing (fibrinogen and thrombin) reduced (p < 0.01) posttreatment blood loss (366 mL; 95% confidence interval, 175-762 mL) and increased (p < 0.05) the percentage of animals in which hemostasis was attained (73%), compared with gauze controls (2,973 mL; 95% confidence interval, 1,414-6,102 mL and 0%, respectively). No other dressing was effective. The number of vessels lacerated was positively related to pretreatment blood loss and negatively related to hemostasis.

CONCLUSION

The hemorrhage model allowed differentiation among topical hemostatic agents for severe hemorrhage. The American Red Cross hemostatic dressing was effective and warrants further development.

Acute bilateral iliac artery occlusion secondary to blunt trauma: successful endovascular treatment

INTRODUCTION

Endovascular treatment of blunt vascular trauma has been infrequently reported.

PRESENTATION

A 27-year-old man was crushed between a fork-lift truck and a concrete platform. The physical examination was remarkable for hemodynamic stability, significant lower abdominal ecchymosis and tenderness, obvious pelvic fracture, and gross hematuria. Vascular examination revealed no femoral pulses, no pedal signals bilaterally, and minimal left leg and no right leg motor function. Arteriograms revealed right common iliac artery and external iliac artery occlusion and a 2-cm near occlusion of the left external iliac artery.

TREATMENT

In the operating room, bilateral common femoral artery access was obtained, and retrograde arteriogram on the right side demonstrated free extravasation of contrast material at the level of the proximal external iliac artery. An angled glide wire was successfully traversed over the vascular injury, and two covered stents (Wallgraft, 10 x 50 mm and 8 x 30 mm) were deployed. The left iliac injury was similarly treated with an 8 x 30-mm covered stent. After calf fasciotomy, exploratory laparotomy revealed a severe sigmoid colon degloving injury, requiring resection and colostomy. A suprapubic catheter was placed because of bladder rupture, and an open-book pelvic fracture was treated with external fixation. Postoperatively the patient regained palpable bilateral pedal pulses and normal left leg function, but right leg paralysis persisted secondary to severe lumbar plexus nerve injury.

CONCLUSION

Endovascular repair of blunt intra-abdominal arterial injuries is possible and should be particularly considered when fecal contamination, pelvic hematoma, or multiple associated injuries make conventional repair problematic.

Effect of a chitosan-based hemostatic dressing on blood loss and survival in a model of severe venous hemorrhage and hepatic injury in swine

BACKGROUND

Hemorrhage is a leading cause of death from trauma. An advanced hemostatic dressing could augment available hemostatic methods. We studied the effects of a new chitosan dressing on blood loss, survival, and fluid use after severe hepatic injury in swine.

METHODS

Swine received chitosan dressings or gauze sponges. Standardized, severe liver injuries were induced. After 30 seconds, dressings were applied and resuscitation initiated. Blood loss, hemostasis, resuscitation volume, and 60-minute survival were quantified.

RESULTS

Posttreatment blood loss was reduced ( p< 0.01) in the chitosan group (264 mL; 95% confidence interval [CI], 82-852 mL) compared with the gauze group (2,879 mL; 95% CI, 788-10,513 mL). Fluid use was reduced ( p= 0.03) in the chitosan group (1,793 mL; 95% CI, 749-4,291) compared with the gauze group (6,614 mL; 95% CI, 2,519-17,363 mL). Survival was seven of eight and two of even in the chitosan and gauze groups ( p= 0.04), respectively. Hemostasis was improved in the chitosan group ( p= 0.03).

CONCLUSION

A chitosan dressing reduced hemorrhage and improved survival after severe liver injury in swine. Further studies are warranted.

Reevaluation of diagnostic procedures for transmediastinal gunshot wounds

BACKGROUND

Little controversy surrounds the treatment of hemodynamically unstable patients with transmediastinal gunshot wounds (TMGSWs). These patients generally have cardiac or major vascular injuries and require immediate operation. In hemodynamically stable patients, debate surrounds the extent and order of the diagnostic evaluation. These patients can be uninjured, or can have occult vascular, esophageal, or tracheobronchial injuries. Evaluation has traditionally often included angiography, bronchoscopy, esophagoscopy, esophagography, and pericardial evaluation (i.e., pericardial window) for all hemodynamically stable patients with TMGSWs. Expansion of the use of computed tomographic (CT) scanning in penetrating injury led to a modification of our protocol. Currently, our TMGSW evaluation algorithm for stable patients consists of chest radiograph, focused abdominal sonography for trauma, and contrast-enhanced helical CT scan of the chest with directed further evaluation. The purpose of this study is to evaluate the efficiency of contrast-enhanced helical CT scan for evaluating potential mediastinal injuries and to determine whether patients can be simply observed or require further investigational studies.

METHODS

Medical records of hemodynamically stable patients admitted with TMGSWs over a 2-year period were reviewed for demographics, mechanism of injury, method of evaluation, operative interventions, injuries, length of stay, and complications. CT scans were considered positive if they contained a mediastinal hematoma or pneumomediastinum, or demonstrated proximity of the missile track to major mediastinal structures.

RESULTS

Twenty-two stable patients were studied. CT scans were positive in seven patients. Directed further diagnostic evaluation in those seven patients revealed two patients who required operative intervention. Sixty-eight percent of patients had negative CT scans and were observed in a monitored setting without further evaluation. There were no missed injuries. The hospital charges generated with the CT scan-based protocol are significantly less than with the standard evaluation.

CONCLUSION

Contrast-enhanced helical CT scanning is a safe, efficient, and cost-effective diagnostic tool for evaluating hemodynamically stable patients with mediastinal gunshot wounds. Positive CT scan results direct the further evaluation of potentially injured structures. Patients with negative results can safely be observed in a monitored setting without further evaluation.

Anatomic study of portal vein: transpancreatic vessels injuries approach

Introduction: The commitment of the great blood-vessels make up a situation of great complexity and a high rate of the complications and mortality patients with abdominal trauma. The injury of the portal vein matters because of the difficulty on the diagnosis and the approach surgery. Objective: To set the standard on the transverse section of the pancreas looking for a safer surgical access to repair the portal vein injuries. Methods: A quantitative analysis was performed to characterize the anatomical relationship between the portal vein and their tributaries relating them to the pancreas. On these corpses, the measurements of a anatomical triangle were studied. It base was the upper limit of the superior mesenteric vein and the initial portion of the portal vein; the apex, a point located on the upper limit of the confluence of the splenic vein and superior mesenteric vein, situated at the middle line of the superior mesenteric_ vein. Results: The portal vein is formed 3.24cm from the internal border of the duodenal arc at a distance of 1.61cm and 1.07 from the inferior and superior pancreas borders, respectively. Conclusion: The present study allow us to conclude that, to have access to the origin of the portal vein, in case of trauma of this vessel, one should proceed a transverse section of the neck of the pancreas next to the superior mesenteric vein, because its confluence with splenic vein occur, on average, 1.07cm and 1.61cm from the superior and inferior border of the gland, respectively.

Factors Affecting the Outcome of Patients with Splenic Trauma

This is a report of 546 consecutive patients with penetrating and blunt splenic trauma seen over a 17½-year period (1980–1997). The etiology of the splenic injuries and the associated mortality rates were: blunt injuries 45 of 298 (15%), gunshot wounds 48 of 199 (24%), and stab wounds four of 49 (8%). The overall mortality rate was 97 of 546 (18%). The most significant risk factors for death were all associated with major blood loss: transfusion requirements ≤6 units of blood, low initial operating room blood pressure, associated abdominal vascular injuries, and performance of a thoracotomy. The two most important organs injured in conjunction with the spleen that were significant predictors of postoperative infectious complications were colon and pancreas. The need for splenectomy was most significantly correlated with higher grades of splenic injury especially grades IV and V. The evolution in management of blunt splenic trauma has led to a significant improvement in splenic preservation and avoidance of laparotomy for many patients. Operative splenic salvage is reduced in patients subjected to laparotomy who are candidates for nonoperative treatment. Improved results with splenic injury should be obtained by rapid control of bleeding. This may require more liberal criterial in selecting patients with splenic trauma for early operative treatment.

Visceral vascular injuries

This article deals with injuries to the celiac trunk, superior and inferior mesenteric arterial injuires. Surgical approaches and physiological implications of interruption of the mesenteric arterial circulation are addressed in detail. Surgical techniques for the management of these injuries and the need for second look operations are also examined.

Vascular injury in Australia

Vascular injury poses a small but significant challenge in Australian trauma care. Opportunities such as better practice guidelines and minimum standards will allow surgeons to improve delivery of quality care to the next generation of vascular trauma victims. Training in the management of vascular trauma surgery with integration of vascular and general surgery in trauma care should optimize outcomes. The authors' vision is that all vascular and general surgery trainees would eventually undertake the Definitive Surgical Trauma Care Course and improve vascular trauma outcomes and reduce mortality.