The role of nephrectomy in the acutely injured

HYPOTHESIS

The high mortality in patients who undergo nephrectomy after trauma is not secondary to the nephrectomy itself but is the consequence of a more severe constellation of injuries associated with renal injuries that require operative intervention.

DESIGN

A retrospective review of all patients identified using International Classification of Diseases, Ninth Revision codes as having sustained renal injuries over a 62-month period.

PATIENTS

Seventy-eight patients with renal injuries who underwent exploratory laparotomy were identified.

METHODS

All medical records were reviewed for patient management, definitive care, and outcome. Based on outcome, patients were assigned to either the survivor or nonsurvivor group. For patients who underwent nephrectomy, intraoperative core temperature changes, estimated blood loss, and operative time were also reviewed.

RESULTS

Seventy-eight patients with renal injuries who underwent exploratory laparotomy were identified. Twenty-nine patients underwent laparotomy with conservative management of the renal injury, of whom 5 (17.2%) died. Twelve patients had renal injuries repaired and all survived. Thirty-seven patients underwent nephrectomy, of whom 16 (43.2%) died. Compared with nephrectomy survivors, nephrectomy nonsurvivors had a significantly lower initial systolic blood pressure, higher Injury Severity Score, higher incidence of extra-abdominal injuries, shorter operative duration, and higher estimated operative blood loss. The nephrectomy survivors' core temperature increased a mean of 0.5 degrees C in the operating room, while the nephrectomy nonsurvivors' core temperature cooled a mean of 0.8 degrees C.

CONCLUSIONS

Patients who undergo trauma nephrectomy tend to be severely injured and hemodynamically unstable and warrant nephrectomy as part of the damage control paradigm. That a high percentage of patients die after nephrectomy for trauma demonstrates the severity of the overall constellation of injury and is not a consequence of the nephrectomy itself.

The importance of the command-physician in trauma resuscitation

OBJECTIVE

Definitive trauma team leadership, although difficult to measure, has been shown to improve trauma resuscitation performance. The purpose of this study was to evaluate the effect of an identified command-physician on resuscitation performance. In addition, the leadership capability of four physician combinations functioning as command-physician was studied.

DESIGN

Retrospective review.

METHODS

Videotapes of trauma resuscitations performed at a Level I trauma center over a 25-month period were reviewed. The presence of an identified command-physician was determined by multidisciplinary consensus. Resuscitation performance was measured by compliance with three objective criteria: primary survey, secondary survey, and definitive plan; and two subjective criteria: orderliness, and adherence to Advanced Trauma Life Support protocol. Performance was then analyzed (1) as a function of the presence or absence of a command-physician, and (2) between four identified physician combinations: AF (attending surgeon + trauma fellow); F (trauma fellow); ASR (attending surgeon + senior surgical resident); SR (senior surgical resident). Chi square and the Mann-Whitney U tests were applied.

RESULTS

A total of 425 trauma resuscitations were reviewed. A command-physician was identified (CP[Pos]) in 365 resuscitations (85.7%); no command-physician was identified (CP[NEG]) in 60 (14.3%). Compliance with completion of secondary survey (81.4%) and formulation of a definitive plan (89.6%) was significantly higher in the CP(POS) group. Subjective scores for orderliness and adherence to Advanced Trauma Life Support protocol were significantly higher in the CP(POS) group. In the CP(POS) resuscitations, formulation of a definitive plan was lower in SR when compared with the other three physician combinations.

CONCLUSIONS

An identified command-physician enhances trauma resuscitation performance. Completion of the primary and secondary survey is not affected by the physician combination. Prompt formulation of a definitive plan is facilitated by the active involvement of an attending traumatologist or a properly mentored trauma fellow.

Barrier precautions in trauma resuscitation: real-time analysis utilizing videotape review

Blood-borne pathogens threaten all individuals involved in emergency health care. Despite recommendations by the Centers for Disease Control and the American College of Emergency Physicians, documented compliance with universal precautions in trauma resuscitation has been poor. The purpose of this study was to determine the factors that predispose to noncompliance with barrier precautions at a level I trauma center. Videotapes of trauma resuscitations performed during 1 month (n = 66) were reviewed. Full compliance with barrier precautions was documented in 89.1% of health care workers. Of the noncompliant health care workers, 50.7% were emergency department personnel and 47.8% were first responders to the trauma resuscitation area. Barrier precaution compliance improved from 62.5% to 91.8% with prenotification of patient arrival. Immediate access to barrier equipment is essential for all potential in-hospital first responders. Prehospital communication systems should be optimized to ensure prenotification.

Arterial bleeding diagnosed by CT in hemodynamically stable victims of blunt trauma

Although the presence of intra-abdominal blood is a common finding on abdominal computed tomography (CT) scans performed for trauma, acute intra-abdominal bleeding is rarely diagnosed by CT. A focal area of high-density contrast, as compared to the surrounding fluid and tissues, is the characteristic CT finding associated with acute intra-abdominal bleeding and should prompt immediate intervention.

Gluteal gunshot wounds: who warrants exploration?

It is difficult to determine which stable patients with gluteal gunshot wounds warrant exploration since 22% to 36% will have injuries requiring operative intervention. The ability of preoperative studies to identify major injuries was evaluated to determine which studies could accurately triage patients into a high-risk group that would warrant laparotomy and a low-risk group that could be managed with observation. The findings of abdominal tenderness or gross blood in the urine or rectum were each highly predictive of major injury. The determination of an extrapelvic versus transpelvic bullet trajectory allowed accurate triage of 94% of patients. Nearly 85% of patients with a transpelvic trajectory had injuries that required operative intervention. No patients with an extrapelvic trajectory required laparotomy. Given the density of vital structures above and below the peritoneum in the pelvis, we conclude that any patient with a transpelvic bullet trajectory warrants exploration.

Alternatives in temporary abdominal closures. 'Fish' abdominoplasty

Only infrequently is closure of the abdomen problematic in elective surgery. Options may be limited when a prolonged operation results in bowel edema that prevents primary closure of the abdominal fascia. The problem may be further magnified at facilities that do not routinely stock prosthetic materials that can be used for this purpose. We describe herein an inexpensive and readily available alternative for use in such situations.

Transcutaneous balloon catheter tamponade for definitive control of subclavian venous injuries: case reports

Two cases are presented in which transcutaneous balloon catheter tamponade of exsanguinating infraclavicular injuries was performed in the trauma admitting area. Angiography and venography demonstrated isolated injuries of the subclavian vein tamponaded by the balloon catheter. Balloon catheter tamponade provided emergency control of bleeding in the admitting area and ultimately definitive treatment of the venous injury.

Management of upper extremity ischemia

Upper extremity ischemia is insidious in onset and debilitating. It accounts for 1 to 4 percent of all peripheral vascular procedures. Once the site of the symptomatic lesion is determined, an extrathoracic extra-anatomic bypass often can provide long-lasting relief.

Surgical treatment of Meckel's diverticulum

Meckel's diverticula are the result of incomplete degeneration of the vitelline duct. It is generally believed that less than 5% of them become symptomatic, the frequency decreasing with age. Meckel's diverticula are most commonly manifested in children by painless lower gastrointestinal bleeding and in adults, as an inflammatory process or obstruction. Definitive diagnosis is usually made at surgery, though the Meckel's scan may suggest a diagnosis preoperatively, especially in the pediatric population. All symptomatic and pathologic Meckel's diverticula should be removed with a segment of ileum. The use of stapling devices, with their ease of use and low complication rate, make it reasonable to remove any Meckel's diverticulum that easily fits in the device. If a diverticulum found incidentally is so broad-based or short that stapling cannot be done without difficulty, it is unlikely to become symptomatic and should be left undisturbed.

Cost containment in the operating room: use of reusable versus disposable clothing

The need for fiscal austerity has prompted the re-evaluation of many aspects of medical care. Recent events in the northeastern United States have caused an increased awareness of the need for environmental responsibility as well. With these considerations in mind, the costs incurred by the operating suites of two comparable teaching hospitals in New Jersey, one of which uses disposable operating room attire, were examined; the other employs reusable scrub suits and gowns. The reusable scrub suits and gowns resulted in a savings in excess of $100,000 compared to the center using disposables. The authors conclude that hospitals should re-evaluate their use of disposable operating room attire to reduce operating costs and the amount of medical waste generated.

Spontaneous migration of long-term indwelling venous catheters

Our institution recently encountered two patients with an unusual complication of indwelling catheters, spontaneous migration of the catheter tip. Both patients had indwelling subcutaneous ports placed via the left subclavian vein into the superior vena cava for the treatment of breast cancer. Both catheters functioned well but were noted on follow-up radiographs to have repositioned themselves, one into the azygous vein and the other into the internal jugular vein. One patient required surgical intervention to properly position the catheter for further chemotherapy. Chest roentgenograms are indicated to confirm the continued appropriate position of indwelling catheters when their position is in doubt to minimize the likelihood of complications associated with delivery of caustic chemotherapeutic agents in low flow vessels.

Resuscitative thoracotomy and combat casualty care

Over the past few years, the indications for resuscitative thoracotomy in civilian trauma have been refined. The use of this procedure for military casualities has received only brief mention. We have described our experience with 93 consecutive thoracotomies performed in a level I trauma center and have attempted to better define the indications for this procedure in military medicine.