Air-powered guns: too much firepower to be a toy

OBJECTIVE: This study reviews our experience and calls attention to the potential danger of air-powered guns. DESIGN: Retrospective analysis. MATERIALS AND METHODS: Review of patients with air-powered gun-injuries admitted to a Level I trauma center and air gun deaths reported to the United States Consumer Product Safety Commission over a 5-year period ending July 1994. RESULTS: Sixteen children (median age 10) were admitted after sustaining BB or pellet gun injuries. Three children had cranial penetration; one remains severely brain impaired. One of two thoracic injuries required left ventriculorrhaphy. All five children sustaining abdominal wounds underwent laparotomy for enteric perforations; one was complicated by an intra-arterial pellet embolus. Three of five children with neck wounds had penetrating tracheal injury. Overall nine children required operative intervention. No deaths occurred in our series, but there were 33 air gun deaths reported to the United States Consumer Product Safety Commission during this period. CONCLUSION: Our data demonstrate that injuries from air-powered guns should be treated in a manner similar to those from low velocity powder firearms. We can no longer continue to underestimate the potential for life-threatening injury from these weapons.     

The role of diagnostic laparoscopy in treatment of penetrating injuries of the lower thoracic wall and anterior abdominal wall

Penetrating injuries of the lower thoracic wall and anterior abdominal wall cause difficulties in the decision for laparotomy. For gunshot wounds laparotomy without further investigations is in most cases justified, but in other penetrating traumata one should use every diagnostic modality to prevent unacceptably high negative laparotomy rates. We performed diagnostic laparoscopy (DL) on 39 patients with penetrating injuries of the anterior abdominal wall and/or lower thoracic wall. Of these 39 patients, 25 had negative and 14 positive results. We had only one false-negative finding. No false-positive result occurred. We think that DL is a very reliable diagnostic tool which requires a relatively high technology.     

Penetrating chest injuries in children: a review of 94 cases

Ninety-four children with penetrating chest injuries were treated at Dicle University School of Medicine during a 6-year period. The mean age was 11.51 +/- 3.31 years, and the male:female ratio was 5.25:1. Forty-five had stab wounds, 27 had high-velocity gunshot wounds, 13 had low-velocity gunshot wounds, seven had a bomb (shrapnel) injury, one had a shotgun wound, and one had a horse bite. Sixty patients had isolated thoracic injuries, and 34 had associated injuries. The most common thoracic injury was hemothorax (28), followed by hemopneumothorax (25). Tube thoracostomy alone was sufficient in 79.8% of the patients (75 of 94). Thoracotomy was performed in 4.25% (4 of 94). In two of the five observed patients, delayed hemothorax developed. The mean duration of hospitalization was 5.13 +/- 1.93 days. The mean Injury Severity Score was 14.71 +/- 8.62. Prophylactic antibiotics were used in all patients. The morbidity rate was 8.51% (8 of 94). Only one death occurred after cervical tracheal repair. The study suggests that the majority of penetrating chest injuries in children can be treated successfully by tube thoracostomy alone or in conjunction with expectant observation.     

Computed tomography screens stable patients at risk for penetrating cardiac injury

OBJECTIVE: To determine the accuracy of CT of the chest in diagnosing the presence of cardiac injury in stable patients with penetrating chest injuries. METHODS: A retrospective chart review of a convenience sample of stable patients with penetrating thoracic wounds evaluated for hemopericardium using chest CT at an urban level I trauma center. RESULTS: 60 stable patients with penetrating wounds in proximity to the heart underwent CT. Three patients had radiographic evidence of pericardial fluid, and 1 had an equivocal study. These 4 patients underwent subxiphoid pericardial window exploration: 2 had only clear fluid present, the other 2 had hemopericardium. The latter patients had a total of 3 cardiac and 1 diaphragmatic injuries, which were repaired at subsequent sternotomy. None of the 56 patients who had negative CTs had further clinical evidence of cardiac injury. The sensitivity, specificity, and accuracy of CT in this setting for hemopericardium are 100% (95% CI 18-100%), 96.6% (95% CI 88-100%), and 96.7% (95% CI 89-100%), respectively. CONCLUSION: Chest CT may be a useful test for diagnosing the presence of hemopericardium in the setting of penetrating thoracic injury. With the caveat that the patient must be removed from a closely monitored environment, the authors the use of CT in stable patients with penetrating chest wounds whenever echocardiography is unavailable.     

Indications for thoracotomy following penetrating thoracic injury

The treatment of penetrating thoracic injuries has been reviewed in both civilian and military series. Although most surgeons agree that closed that closed thoracostomy drainage is the initial treatment of choice, the timing of early thoracotomy and perhaps cardiorrhaphy upon patients with penetrating thoracic injuries remains controversial. The purpose of this study was to determine which patients will require immediate thoractomy or cardiorrhaphy following penetrating chest injury. Over a two-year period 190 patients with penetrating thoracic injuries were treated. Of 53 patients who required immediate thoracotomy, 31 suffered cardiac wounds. Seventy-nine patients required laparotomy for associated intra-abdominal injuries. The mortality rate was related to exsanguinating hemorrhage or postoperative intra-abdominal sepsis. Cardiopulmonary complications were rare in the absence of intra-abdominal sepsis and could not be attributed to the thoracic injury or thoracotomy. Indications for immediate cardiorrhaphy or thoracotomy are: 1) location of the entrance wound (70% in upper mediastinum); 2) blood pressure on admission less than 90; 3) initial thoracostomy blood loss greater than 800 cc; 4) radiographic evidence of retained hemothorax; and/or 5) clinical evidence of pericardial tamponade.     

Noniatrogenic esophageal trauma

Few guidelines are available with which to facilitate treatment in patients with noniatrogenic injuries of the esophagus. Early diagnosis and proper management are essential if a good outcome is to be expected. In an effort to define better the treatment of patients with penetrating and blunt injuries of the esophagus, we report our recent 5-year experience at an urban trauma center. From July 1988 to June 1993, nineteen patients with esophageal perforations from penetrating (18) and blunt (1) trauma were identified by our trauma registry. There was no mortality in this group of patients and morbidity was mostly due to associated injuries. Eleven cervical esophageal injuries were repaired. One cervical injury was treated by stopping oral intake and giving intravenous antibiotics. The neck was not drained in 10 of the surgical cases. In 1 patient a tracheoesophageal fistula developed, which later was repaired with a pectoralis muscle flap. Seven perforations were identified in the thoracic (2) and abdominal (5) portions of the esophagus. All were due to gunshot wounds. In 4 cases, a fundal wrap was used to reinforce the repairs. Postoperative contrast studies confirmed that all repairs were intact. We conclude that penetrating and blunt tears of the esophagus can be repaired safely with minimal mortality. Morbidity is usually from associated injuries such as to the spinal cord and trachea. When identified early, cervical esophageal injuries do not need to be drained routinely.     

Actinic keratoses

Shotgun slug injuries have received little attention while shotgun pellet wounds have been well described. Twenty-two shotgun pellet and 13 shotgun slug injuries treated over a 14-year period were retrospectively reviewed. Extremity and thoracic wounds were most frequent in both groups. The incidence of vascular and nerve injuries was similar for slug and pellet wounds. Angiography was more often used to evaluate pellet wounds for vascular disruption. The rate of wound infection was 38% for slug wounds versus 32% for pellet injuries. Tissue grafting was more frequently necessary for reconstruction after pellet injury. Long-term disability was documented in 15% of patients with pellet wounds and 23% with slug wounds. Despite similarities in wound location and outcomes, the ballistic differences between shotgun slugs and pellets resulted in significant differences in wounding characteristics and extent of injury which have important ramifications in management.     

Cervical vascular injuries: a trauma center experience

BACKGROUND: We analyzed 76 patients with cervical vascular injuries from penetrating neck trauma (n = 528) between 1977 and 1990 at a level I trauma center to evaluate the role of angiography in diagnosis and management and to assess the course and outcome of these patients. METHODS: Patients who were hemodynamically unstable underwent immediate surgical exploration. Stable patients were subjected to diagnostic investigation. Angiography was routinely performed to diagnose vascular injury in zones I and III and zone II if the trajectory was in the vicinity of major vessels. Therapeutic embolization was performed when possible at angiography; all other vascular injuries were treated surgically. RESULTS: Thirteen patients (2.5%) died of penetrating neck trauma, in 12 of whom hemorrhage was the contributing factor (12/76; 15.8% of patients with vascular injury). In nine patients who were hemodynamically stable vascular injury was diagnosed by angiography: 5 (6.8%) of 73 in zone I and 3 (5.4%) of 56 in zone III, four of whom underwent therapeutic embolic occlusion of the injured vessel. Injuries to vertebral and subclavian arteries and subclavian and innominate veins were often multiple, causing exsanguination and death (6.8% in zone I). In three patients with no preoperative neurologic deficit, the internal carotid artery was ligated without complication; in all other patients injury to the common carotid or internal carotid artery was repaired, in six of them with polytetrafluoroethylene grafts. CONCLUSIONS: Selective management of penetrating neck trauma should include routine angiography in zones I and III. Injuries to the common and internal carotid arteries should be repaired. The internal carotid artery may be ligated in the absence of preoperative neurologic deficit. Arterial injuries in the neck can be repaired with polytetrafluoroethylene grafts.     

Mortality and neurologic morbidity after repair of traumatic aortic disruption

BACKGROUND: Traumatic disruption of the thoracic aorta frequently results in death before operative repair. The determinants of mortality after repair, however, are uncertain. In addition, intraoperative strategies for reducing the incidence of spinal cord injury remain controversial. METHODS: The records of 45 consecutive patients undergoing repair of traumatic disruption of the thoracic aorta at a single institution during a 9-year period were reviewed in a retrospective fashion. Patient age ranged from 15 to 81 years (mean age, 33.9 years). Twenty-two patients (49%) had multiple associated injuries, and 8 (18%) had isolated aortic injuries. Nine patients (20%) experienced preoperative hypotension (systolic blood pressure of less than 90 mm Hg). Repair was performed with partial bypass in 22 patients, a heparinized shunt in 2, and no distal perfusion (clamp and sew technique) in 21. RESULTS: Nine patient (20%) died after operation. Multivariate logistic regression analysis of preoperative and intraoperative variables identified advancing age and preoperative hypotension as independent predictors of operative death. The presence of associated injuries was not an independent predictor of operative death. All 4 patients with injuries proximal to the aortic isthmus died. Ten patients were excluded from analysis of spinal cord injury either because of preoperative neurologic deficit or because of death before postoperative evaluation. Six (17%) of the remaining 35 patients had development of paraplegia: 5 of the 15 patients having the clamp and sew technique, 1 of the 2 with a shunt, and 0 of the 18 patients with bypass (p < 0.05, clamp and sew versus bypass). In the clamp and sew group, patients in whom paraplegia developed had significantly longer aortic clamp times than those without neurologic injury (40.6 +/- 4.4 minutes versus 28.7 +/- 2.9 minutes, respectively; p < 0.05). CONCLUSIONS: Advancing age, preoperative hypotension, and perhaps injury location are important determinants of death after repair of traumatic disruption of the thoracic aorta. Adjunctive perfusion with partial bypass should be used during repair to reduce the incidence of spinal cord injury.     

Management of external penetrating injuries into the hypopharyngeal-cervical esophageal funnel

OBJECTIVE: To compare outcomes related to observation versus exploration for the hypopharynx and the cervical esophagus as the site of proven external penetrating injuries. METHODS: The records of 70 patients (47 with hypopharyngeal and 23 with cervical esophageal wounds) were retrospectively reviewed. RESULTS: No patient, observed or explored, who sustained a penetration into the hypopharynx above the level of the tips of the arytenoid cartilages of the larynx developed a complication. However, 22% of the patients with a hypopharyngeal injury below this level and 39% of patients with a cervical esophageal injury developed either a deep neck infection that required drainage or a postsurgical salivary fistula. CONCLUSIONS: Overall, the consequences of an external penetrating injury become more serious in the descending levels of the funnel formed by the hypopharynx and cervical esophagus. Injuries located in the upper portion of the hypopharynx can be routinely managed without surgical intervention. Neck exploration and adequate drainage of the deep neck spaces are, however, mandatory for all penetrating injuries into the cervical esophagus and most injuries into the lower portion of the hypopharynx.     

Gunshot and blast injuries to the abdomen. The problems of mechanogenesis and of diagnostic and treatment procedures based on the experience of delivering surgical care to the wounded during the war in Afghanistan (1980-1989)

The work is bases on an analysis of treatment of 2687 wounded in the abdomen. There are two main groups of factors in mechanogenesis of military injuries of the abdomen: ballistic parameters of gunshot shells and additional injuring factors of mine-explosive ammunition. Bullet wounds prevailed (60.2%), lethality from penetrating abdominal injuries was 31.4%. Laparotomies were performed in 10.7% of the patients on the basis of absolute symptoms of penetrating wounds of the abdomen, in 74.1%--on the basis of analytical signs and in 15.2%--due to results of abdominal paracentesis. The following questions are discussed: the adequacy of the access, reinfusion of the blood accumulated in the abdominal cavity, surgical treatment for gunshot peritonitis, errors in treatment of wounded with abdominal injuries, application of new methods of treatment. Surgical features of traumatic disease and its treatment in wounded with gunshot abdominal injuries are described.     

Pediatric penetrating thoracic trauma: a five-year experience

Penetrating thoracic trauma is managed nonoperatively in 85% of adult patients. We hypothesized that similar trauma in children would lead to proportionately more vital tissue damage and a higher rate of operative intervention. The pediatric penetrating thoracic trauma experience of a level one trauma center was analyzed over a five-year period. Data reviewed included circumstances of injury, Pediatric Trauma Score (PTS), interventions performed, and outcome. Of 61 children with thoracic trauma, 13 had penetrating injuries. Of these 13, seven were unintentional (five from firearms); the rest were caused by assaults. Seven patients (54%) underwent thoracotomy or laparotomy. All five patients with a PTS < 8 underwent surgical intervention, whereas only two of the eight patients with a PTS > or = 8 needed surgery (P < 0.05). There was one death. We reached the following conclusions: 1) Children with penetrating thoracic trauma are more likely to require surgical intervention than adults. 2) Penetrating thoracic trauma in children should elicit a thorough search for operative lesions. 3) About half these injuries are unintentional, and thus potentially preventable.     

Expression of inducible nitric oxide synthase in the brains of scrapie-infected mice

Thoracic trauma in the elderly population constitutes a major challenge for both thoracic and trauma surgeons as their presentation and outcomes differ from the adult population in addition to their high morbidity and mortality. One hundred and one patients, 60 years of age or older, with thoracic trauma were treated at Dicle University School of Medicine during a 6-year period. Eighty-five per cent were male and 15% were female with a mean age of 64.5 years. The cause of thoracic injury was blunt in 77.2% and penetrating in 22.8% of the patients. Sixty-two patients (61.4%) had isolated thoracic injuries. The median Injury Severity Score (ISS) was 23. The morbidity rate was 23.8%. The mortality rate was 16.8%. Seven of 10 patients (70%) who had an ISS greater than 25 died, whereas six of 24 (25%) patients with an ISS between 17 and 25, and four of 67 (5.9%) patients with an ISS less than 16 died. In the elderly the morbidity and mortality rates were higher for blunt trauma compared with penetrating trauma. For ISS greater than 25 the mortality rate was 71.4% for blunt and 66.6% for penetrating trauma. As the morbidity and mortality rate are significantly higher in the elderly patients the approach to these patients should include recognition of their high risk for morbidity and mortality, especially for those who had an ISS greater than 25.     

Peripheral arterial injuries: a reassessment

Ninety-four patients with peripheral arterial injuries were subjected to acute repair, negative exploration, or late repair of the complications of the arterial injury (false aneurysm, A-V fistula, and/or limb ischemia). The causes of failure after acute injury include extensive local soft tissue and bony damage, severe concomitant head, chest or abdominal wounding, stubborn reliance on negative arteriograms in patients with probable arterial injury, failure to repair simultaneous venous injuries, or harvesting of a vein graft from a severely damaged extremity. There is a positive correlation between non-operative expectant treatment and the incidence of late vascular complications requiring late arterial repair. Delayed complications of arterial injuries occurred most frequently in wounds below the elbow and knee.     

Pancreatic injuries resulting from penetrating trauma: a multi-institution review

Pancreatic injury from penetrating trauma continues to be a source of significant morbidity and mortality, with questions remaining regarding optimal treatment of injuries. Our goal was to evaluate current trends in the operative management of these injuries. Our patient population comprised all patients admitted to one of three Level I trauma centers over an 8-year period that had sustained penetrating pancreatic trauma. The study was a retrospective chart review. Sixty-two patients were identified. All had associated abdominal injuries, with the liver and stomach being the most commonly injured organs. There were 14 deaths (mortality 22.6%), 10 within the first 48 hours due to associated vascular injury. In the 52 patients surviving beyond 48 hours, there were 19 patients with injuries to the main pancreatic duct and 33 with parenchymal injuries only. Pancreatic resection was carried out for all patients with ductal injury except for one, who later required distal pancreatectomy for pseudocyst and pancreatic fistula. Significant pancreatic fistulae developed in five patients, three in patients treated by drainage and two in patients treated by resection. The incidence of fistula formation was significantly higher for drainage versus resection in the patients with ductal injuries. The incidences of other complications were not affected by type of pancreatic injury, associated injuries, or method of management. We conclude that the majority of deaths in patients with penetrating pancreatic trauma are due to associated organ or vascular injuries. Appropriate management of the pancreatic injury can reduce the long-term complications. These results support treating patients with suspected ductal injuries by appropriate resection. Drainage should probably be sufficient for most nonductal pancreatic injuries.     

Future education: what do nurse executives need?

A small number of trauma patients with penetrating thoracic trauma will require formal pulmonary resections to repair severe injuries or control massive haemorrhage. Although previous reports on this subject have addressed the management of these injuries in battle conditions, civilian experience with this type of chest injury is limited. In a 3-year period, 259 patients underwent urgent thoracotomies for penetrating thoracic trauma. We retrospectively reviewed 43 patients who underwent lobectomies or pneumonectomies to control bleeding (93%) or bronchial injuries (7%). Handguns were the aetiologic agent in 41 patients (95%). The most common complication, pneumonia, was seen in 21 patients (87%). Fifteen patients (62%) developed respiratory failure. The complications of wound infection, post-operative haemorrhage and empyema were seen in equal frequency in four patients (16%). Two patients (8%) developed bronchopleural fistulas. Nine pneumonectomies and 34 lobectomies were performed with mortality rates of 66% and 38%, respectively (overall mortality, 44%). Ten (53%) deaths occurred in the operating room, late deaths (2-15 days) were secondary to sepsis and multiple organ dysfunction syndrome (MODS). Currently, the management of patients with devastating thoracic injuries to the thoracic cavity is divided into two stages. First, initial resuscitation with rapid surgery to control major bleeding, cardiac tamponade, tracheal disruptions and potentially lethal air embolism is indicated. Once the life-threatening conditions have been resolved, definitive surgical procedures are performed to repair injuries to any of the thoracic structures.     

Kinetics of absorption, equilibration (or distribution), and excretion of orally and intraperitoneally administered cholesterol in the rat

Forty patients with abdominal injury and massive hemoperitoneum had left thoracotomy and thoracic aortic occlusion. All 40 patients had tense abdominal distention and 37 patients were hypotensive at the time of skin incision despite aggressive resuscitation with blood and crystalloid solution. Laparotomy was performed initially in 11 patients; seven patients had sudden cardiovascular collapse as the abdominal wall tamponade was released and four patients remained hypotensive. With thoracotomy and thoracic aortic occlusion six of the 11 patients were resuscitated and had their injuries repaired. Thoracotomy and thoracic aortic occlusion were performed before laparotomy in 29 patients: seven patients remained hypotensive and expired; blood pressure was promptly restored in 22 patients and 11 of them survived the operative procedure. Left thoracotomy and thoracic aortic occlusion, before laparotomy, is offered as an alternative approach in patients with refractory hypotension and tense, abdominal distention. This technique aids in rapid restoration of vital signs, insures continued perfusion of the brain and myocardium, provides proximal arterial control, and prevents sudden cardiac arrest as the abdominal wall tamponade is released.     

Retrospective study of the diagnostic criteria in a lead-poisoning survey of waterfowl

A review of childhood injuries at the Wesley Guild Hospital, a component of Obafemi Awolowo University Teaching Hospital Complex, Ile-Ife, Nigeria, showed that 1,471 patients seen in the children's emergency room during a period of 4 years (1992-1995) were there as a result of trauma, representing 9% of all patients seen. The case notes and accident and emergency cards of 1,224 were available for review. Ages ranged from 2 months to 15 years, with a mean of 6.9 years, and 40% of the patients were between 5 and 10 years of age. More males were affected than females, with a ratio of 1.5:1. Road traffic crashes were the most common causal factor, responsible for 324 injuries (26.5%). About 90% of these were pedestrians knocked down by automobiles and motorcycles. Passengers accounted for about 10% of the cases. Falls occurred in 305 patients (25%); 229 patients fell while on level ground either playing or running, accounting for 75%. There were 122 patients (10%) with misplaced foreign bodies; about 60% of these were recovered from the ears, and 26.3% from the nostrils. Edible seeds were the most common foreign bodies, followed by beads. Injuries from bites occurred in 108 patients, with dog and snake bites taking the lead. Burns, mainly from scalding, occurred in 89 patients. Other rare injuries were knife wounds, gunshot wounds, and injuries resulting from assaults. The home was the most common site of injury (570 patients, 46.7%) followed by streets or roadways (363 patients, 29.7%); 19.5% of injuries occurred at school. The most common anatomic region affected was the head and neck, followed by the limbs. One hundred ninety-seven patients (16%) had bony fractures, femurs being the most affected bone. Head injury was seen in 104 patients, representing 8.5%, although only 17 of these injuries were severe. There were 10 cases of abdominal injury and 9 cases of chest injury, representing 0.8 and 0.7%, respectively. Wound infection occurred in 6.4% of the patients. Death occurred in 19 patients, accounting for 1.6%; 10 of these patients had severe head injuries. Road traffic injuries and burns accounted for the greatest number of complications. The findings of this study suggest that trauma is an important factor in childhood morbidity and mortality in our environment, with road traffic injuries taking the lead. Preschool pedestrian children were most commonly affected, the majority of them on errands for their parents. We believe that the majority of these injuries are preventable.     

Widespread microsatellite instability in sebaceous tumours of patients with the Muir-Torre syndrome

OBJECTIVE: Thoracic injury remains a major source of morbidity and mortality in urban trauma centers. With the advent and increasing expertise in video assisted thoracic surgery, this modality has become an attractive alternative in the management of patients with thoracic injury. This report will review our experience with video assisted thoracic surgery at a level I trauma center and attempt to further delineate the indications for and timing of thoracoscopy in thoracic trauma. METHODS: We identified 16 patients who had undergone video assisted thoracic surgery following chest trauma between July 1991 and June 1994. There were 15 penetrating and one blunt trauma. All 16 patients were initially treated with tube thoracostomy. From 0-20 days post-injury, video assisted thoracic surgery was attempted with either diagnostic or therapeutic intentions. RESULTS: Twelve of the 16 patients (75%) had successful thoracoscopy. Three patients had diaphragmatic injury excluded and nine patients had successful evacuation of clotted hemothoraces. Evacuation of clotted hemothorax up to 7 days post-injury was safe and easily accomplished. Four patients (25%) had unsuccessful thoracoscopy and were converted to standard thoracotomy; failure was attributed to either suboptimal single lung ventilation or severe pleural inflammatory reaction. The only death in the entire group occurred 10 days after a thoracotomy for retained hemothorax. The median post-operative hospital stay following successful video assisted thoracic surgery was 3.5 days. CONCLUSIONS: Video assisted thoracic surgery can be utilized as an effective and safe method for the initial diagnostic evaluation and surgical management of stable patients with penetrating thoracic trauma.     

Cervicothoracic vascular injuries

Arterial and venous trauma of the cervicothoracic region continues to present challenging problems for the surgeon, despite advances in vascular diagnostics and surgical technique. Whether due to penetrating or blunt mechanisms, overall incidence of these injuries is low, whereas morbidity and mortality remain high. Despite collective experience from busy trauma centers, there still remain controversies regarding diagnostic evaluation, operative approach, and surgical treatment of these potentially devastating injuries. Therefore, this article compares and contrasts recent literature and controversies surrounding the treatment of cervicothoracic trauma. Pros and cons of duplex ultrasonography and angiography in the diagnosis of carotid and vertebral artery injury are highlighted, and selective versus mandatory neck exploration for zone II penetrating injuries are discussed. Increasing awareness of blunt carotid artery injury is emphasized, including management dilemmas that frequently accompany this type of injury. In addition, we review interventional radiological techniques for the management of vertebral artery injury and surgical approaches for aortic arch branch vessel or major cervicothoracic vein injury.