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Despite antiulcer prophylaxis 19 severely injured patients at our institution developed stress ulceration (SU) between 1989 and 1999 requiring surgery for perforation (n = 4) or bleeding (n = 15). A herald bleed (HB) 10.7 +/- 1.2 days after admission, 7.2 +/- 1.2 days before definitive operative therapy, and requiring 7.1 +/- 0.9 units of blood occurred in 93 per cent of patients operated on for bleeding. Bleeding preceded perforation in one patient. Central nervous system damage was part of the injury pattern in 68 per cent of the patients including spinal cord (42%), severe head injury (16%), or both (10%). Forty-two per cent had acalculous cholecystitis found at surgery. Eight patients had vagotomy and antrectomy (VA), and 11 patients had vagotomy and pyloroplasty (VP). VA required more time than VP (255 +/- 41 vs 158 +/- 13 minutes; P = 0.02). One patient (12.5%) rebled after VA versus two (18%) after VP; one patient in each group required reoperation. There was no difference in mortality, length of stay, or intensive care unit stay. A herald bleed preceded recurrent hemorrhage of SU by one week. Spinal cord or head injury increase the risk of SU. More than 40 per cent of patients with SU had acalculous cholecystitis found at operation. VA provides no benefit on rebleeding or reoperation over VP, so anatomical considerations and not rebleed rates should determine the surgical procedure.

Renal artery injury is a rare complication of blunt abdominal trauma. Increasing use of CT scans to evaluate blunt abdominal trauma identifies more blunt renal artery injuries (BRAIs) that may have otherwise been missed. We identified patients with BRAI to examine the incidence and to evaluate the current diagnosis and management strategies. Patients admitted from 1986 to 2000 at a regional Level I trauma center sustaining BRAI were evaluated. Patients undergoing revascularization or nonoperative management were followed for renovascular hypertension. Twenty-eight patients with BRAI were identified out of 36,938 blunt trauma admissions between 1986 and 2000 (incidence 0.08%). Most renal artery injuries were diagnosed by CT scans (93%) with seven confirmatory angiograms. Nine patients had nephrectomy (one bilateral), and three patients with unilateral injuries were revascularized. Sixteen were managed nonoperatively including one patient who had endovascular stent placement. Three patients died from shock and sepsis. Follow-up for all patients ranged from one month to 8 years. Two patients developed hypertension: one who was revascularized (33%) and one was managed nonoperatively (6%). The frequency of diagnosis of BRAI is increasing because of the increased use of CT. Nonoperative management of unilateral injuries can be successful with a 6 per cent risk for developing renovascular hypertension. The role of endovascular stenting is promising, and further study is necessary.

We demonstrated that the standard clinical criteria of fever, leukocytosis, purulent sputum, and infiltrate on chest radiograph are nonspecific for the diagnosis of post-traumatic pneumonia, and only approximately 50 per cent of patients with these conditions have pneumonia. Quantitative cultures of bronchoalveolar lavage effluent will differentiate pneumonia (requiring antibiotic therapy) from systemic inflammatory response syndrome (not requiring antibiotics). Early identification of patients at risk for pneumonia can target populations for clinical research. Because risk factors for pneumonia when diagnosed by quantitative cultures have not been defined we reviewed our recent experience to identify variables predictive of pneumonia. Patients over a 22-month period who survived48 hours were identified from the trauma registry. Pneumonia was defined as growth ofor = 10(5) organisms per milliliter in the bronchoalveolar lavage effluent. Risk factors evaluated included injury severity and severity of shock. There were 7503 patients (75% with blunt and 25% with penetrating injuries). The incidence of pneumonia was 6 per cent (7% of patients with blunt and 2% of patients with penetrating injuries). Logistic regression analysis identified age; Glasgow Coma Scale score; Injury Severity Score; transfusion requirements during resuscitation; spinal cord injury; chest injury severity; and emergent femur fixation, craniotomy, and laparotomy as being independent predictors of pneumonia. We conclude that multiple risk factors, which are all able to be determined early after injury, are predictive of post-traumatic pneumonia. Prompt identification of this high-risk group of patients allows prognostic considerations relative to patient management schemes and targets populations for prophylactic measures or immunomodulation.

Principles of rectal wound management, including routine diversion, injury repair, presacral drainage and distal washout, evolved from World War II and the Vietnam conflict and have been questioned in recent years. We believe significant confusion arises because of imprecise definition of injury location relative to retroperitoneal involvement. Our 5-year experience with penetrating rectal injuries at a Level I trauma center was analyzed. Injuries to the anterior and lateral surfaces of the upper two-thirds of the rectum were classified as intraperitoneal (IP, serosalized), and those of the posterior surface extraperitoneal (EP, no serosa); injuries to the lower one-third were EP. A total of 58 injuries were managed (92% gunshot wounds). Of these, 16 were IP, and 42 had some EP component. Ten patients underwent repair without diversion (6 IP, 4 EP); there were no leaks. Ten septic complications occurred in the remaining population: 2 necrotizing fasciitis, 5 abdominal abscess, and 3 presacral infections (PIs) (2 presacral abscesses and 1 wound tract infection). PI is the only complication that can be specifically associated with EP rectal injuries relative to management; as associated injury confounds interpretation of the other complications. The operative management in the 38 patients with diverted EP wounds with respect to presacral infection (PI) demonstrated the following: repair injury (n = 10), 0 PI versus no repair (n = 28), 3 PI (P = 0.55); washout (n = 33), 2 PI versus no washout (n = 5), 1 PI (P = 0.35); presacral drain (n = 30), 1 PI versus no drain (n = 8), 2 PI (P = 0.11). We conclude that most IP injuries can be managed with primary repair. EP wounds to the upper two-thirds of the rectum should usually be repaired. EP wounds to the lower one-third, which are explored and repaired, do not require drainage. EP wounds that are not explored should be managed with presacral drainage to minimize the incidence of presacral abscess.

Risk factors for lower extremity ischemic complications (ICs) following iliac arterial injuries have not been addressed. Patients with penetrating iliac artery injuries over a 15-year period were reviewed. IC was defined as compartment syndrome with or without tissue loss. Patients with iliac artery repair who developed ICs were compared with those without ICs (excluding early deaths from hemorrhagic shock). Comparison included demographics, severity of shock, physical examination, and operative findings. There were 94 arterial injuries in 80 patients (34 common iliac, 23 internal iliac, and 37 external iliac). There were 26 deaths (33%), and 3 patients were excluded for technical reasons. Of the 51 who underwent arterial reconstruction, 34 had no ischemia, whereas 17 (33%) had ICs (9 with tissue loss and 8 with compartment syndrome only). Immediate fasciotomies were performed in 6 of the IC patients due to the early recognition of compartment syndrome; 1 required amputation from the profound ischemia. Delayed recognition of compartment syndrome in the remaining 11 IC patients resulted in eight amputations (P0.05). We conclude that ICs following iliac arterial injuries significantly correlate with shock as indicated by systemic pH, lactate and transfusion requirements, and a preoperative pulseless extremity. In these patients, close monitoring of compartment pressures is necessary, and immediate fasciotomies should be strongly considered.

Blunt injury of the brachiocephalic artery can pose diagnostic and management problems for the trauma and thoracic surgeon. To arrive at recommendations for dealing with this injury, we reviewed a seven-year experience at our trauma center. Between 1988 and 1995, five patients presented with blunt injuries of the brachiocephalic artery. All patients were stabilized and underwent repair through a median sternotomy with extension of the incision anterior to the sternocleidomastoid muscle. All patients had restoration of flow to the subclavian and carotid arteries utilizing bypass grafts (4) or primary repair (1). All patients survived to leave the hospital with no complications related to the procedure. Postoperative neurologic findings were present before the operative repair. Patients with blunt injuries of the brachiocephalic artery should be stabilized, and circulation of the subclavian and carotid arteries should be restored with graft placement or primary repair. Cardiopulmonary bypass and heparin or temporary shunts were not needed in this series of patients. Complications were related to associated injuries.

Thirty-two consecutive patients with subclavian artery injuries were evaluated to assess the mechanism of injury, types of repair, and results. In this series, most wounds were from firearms. Although the mortality was high (19%), most patients had the vessel repaired successfully. Associated injuries, especially to neural structures, led to significant morbidity. Principles used in dealing with these injuries should be 1) proximal and distal control prior to exposing the injury site, 2) reestablishing distal circulation through primary repair or graft placement, and 3) identifying and treating associated injuries.

Combinations of penicillins with beta-lactamase inhibitors have become acceptable treatments for mixed bacterial infections. The objective of this multicenter, randomized, open-label study was to compare the efficacy, safety, and tolerance of ticarcillin/clavulanate with clindamycin/gentamicin (with or without ampicillin) when administered to adult and pediatric patients with intra-abdominal infections. A total of 993 patients 2 years of age or older were entered in this trial if they had suspected or bacteriologically documented intra-abdominal infection. Of these, 341 were determined at the time of operation to have intra-abdominal infection. Cure rates at the time of final assessment were 79%, 80%, and 82% for ticarcillin/clavulanate, and clindamycin/gentamicin without or with ampicillin, respectively (P = 0.829, Cochran-Mantel-Haenszel). The most frequent reason for failure was development of an intra-abdominal abscess (6% of patients overall), followed by wound infections (4%), and persistent fever (3%). Two patients who had received ticarcillin/clavulanate and five who had received clindamycin/gentamicin required discontinuation of the study regimen because of adverse drug reactions. The bacteria isolated most frequently from study failures were E. coli, B. fragilis, Pseudomonas, and Streptococci. In this study, ticarcillin/clavulanate was as effective as the combination of clindamycin/gentamicin for the treatment of intra-abdominal infections.

From 1983 to 1990, 76 patients with pancreatic pseudocyst (PP) were managed. Computed tomographic scan (CT) was the primary diagnostic tool (88%). Ethanol accounted for 71 per cent and biliary disease 6 per cent of the occurrence of PP. Thirty-eight patients required surgery and 37 were managed nonoperatively. Forty-four PP complications occurred in 29 patients (4 bleeding, 1 ruptured, 13 gastric outlet obstruction, 10 infected, 6 hyperbilirubinemia, 5 pancreatic ascites, 5 pulmonary insufficiency) at a range of 1 day to 5 weeks from diagnosis; all but one occurred during initial hospitalization. Indications for surgery included complications,12 nonresolution or persistence of symptoms,18 and expansion.9 Internal drainage was accomplished in 40 per cent, (half within 4 weeks of diagnosis), 40 per cent underwent distal resection, and 15 per cent external drainage. There were two deaths in the series. Chronic pancreatitis, gallstone etiology, and gastric outlet obstruction significantly correlated with surgical management of the PP. Endoscopic retrograde cholangiopancreatography (ERCP) was helpful in planning the surgical procedure; 70 per cent of those undergoing ERCP had their operative plan altered. Percutaneous drainage failed in six of eight cases. The authors conclude that nonoperative management is safe and effective in 50 per cent of PP patients, if close radiographic follow-up is maintained until resolution.

Laryngotracheal trauma (LTT) is a rare but clinically important injury that may be missed without a high index of suspicion. Forty patients with LTT admitted to the University of Tennessee, Memphis from 1984 through 1989 were retrospectively reviewed. Twenty-six patients sustained penetrating (P)-LTT and 14 had blunt (B)-LTT. Three patients with P-LTT and one with B-LTT arrived in full arrest. Sixty-five per cent of blunt injuries, and 100 per cent of penetrating injuries had neck tenderness or overlying evidence of trauma. A combination of angiography, barium swallow, esophagoscopy, CT scan, bronchoscopy and/or laryngoscopy was used for evaluation, depending on the mechanism. Twenty-two of the 23 surviving P-LTT patients underwent surgery; 11 (50%) had concomitant esophageal injury. All patients with complications from P-LTT were in the group with esophageal injury. B-LTT was classified as either mild5, moderate3, or severe6; all 6 severely injured patients had preoperative airway compromise. All complications of B-LTT occurred in the severely injured group. The following conclusions were reached: LTT usually presents with symptoms and/or signs, but they may be minimal and nonspecific. Emergency tracheostomy should not be delayed if ventilation is compromised. Concomitant esophageal injuries are frequent in P-LTT and predispose the patient to postoperative complications. Airway compromise frequently correlates with severity of injury in B-LTT and these patients are also at high risk for complications.

This study of the accident scene focuses on the effects of vehicular deformity and restraint devices on occupant injury. In 500 patients evaluated in a Level I trauma center, seatbelts significantly reduced the likelihood of individuals' requiring the trauma center (P less than 0.0001). Seatbelts also significantly reduced the mortality rate of those who were transported to the trauma center (P less than 0.04). Dashboard intrusion correlated with pelvic (P less than 0.001) and femur (P less than 0.03) fractures, closed head injuries (P less than 0.001), and intraabdominal injuries (P less than 0.02). Steering wheel deformity correlated with pelvic fractures (P less than 0.001) and closed head injuries (P less than 0.005). Windshield violation correlated with closed head injuries (P less than 0.014) and spinal fractures (P less than 0.03). Irreparable vehicles correlated with pelvic (P less than 0.0001) and femur fractures (P less than 0.01), closed head injuries (P less than 0.0001) and intra-abdominal injuries (P less than 0.0001). The authors conclude that a careful examination of the accident scene for specific mechanisms of injury can lead to better prehospital care, more rapid and consistent diagnosis of injury, and improved patient outcome. Further prospective studies should accumulate data that will improve prehospital care, alert physicians to possible injury, increase community awareness of injury prevention, and improve vehicle construction.

Between 1983 and 1988, 33 (21 men, 12 women) patients were treated for blunt diaphragmatic injuries following motor-vehicle (90%) or auto-pedestrian (10%) accidents at the Presley Trauma Center. Thirteen patients (39%) were right sided and 19 (56%) were left sided. One patient sustained bilateral ruptures. The mean Injury Severity Score (ISS) in both those that lived and those that died was not significantly different when right- and left-sided injuries were compared. Admission chest films were abnormal in 28 patients and diagnostic in nine patients (27%). The chest x ray was abnormal in 10 (78%) of those with right-sided injury. Twenty-three patients had diagnostic peritoneal lavage (DPL); 19 were initially positive, two were initially negative but became positive on relavage. There were two false-negative lavages. CT scan (4 patients) and barium enema (1 patient) were nondiagnostic. Diagnosis was delayed in four patients, two were diagnosed by repeat chest x ray and two by repeat lavage. All patients had multiple associated injuries, with 82 per cent having concomitant intra-abdominal injuries. All patients were explored via the transabdominal route. Complications occurred in 55 per cent and there were eight deaths (24%), all unrelated to the diaphragmatic injury. There was no relationship to mortality and hemidiaphragm injured. Chest x ray remains the single most beneficial diagnostic test for diaphragmatic injury. DPL is an insensitive test for isolated diaphragm injuries; however, the combination of CXR and DPL will lead to the diagnosis in the majority of cases. Ancillary radiologic tests are not beneficial. An elevated or obscured right hemidiaphragm should raise suspicion for blunt rupture.(ABSTRACT TRUNCATED AT 250 WORDS)

The diagnosis and operative management of 43 consecutive low velocity wounds of the rectum were evaluated with regard to postoperative morbidity and mortality. Rectal and proctoscopic examinations, although frequently positive (80% and 91%, respectively), were not uniformly reliable in making the preoperative diagnosis. Diversion of the fecal stream by colostomy occupies a key role in operative management. Loop colostomy appears not only as efficacious as end colostomy and mucus fistula, but also requires less time to perform and subsequently close. Distal rectal washout is an important adjunct which reduces the incidence of rectal and intra-abdominal infectious complications. Civilian and military wounds of the rectum appear to differ in terms of the postoperative complications, mortality rate, and management techniques.

The efficacy of pharmacologic doses of steroids in the treatment of septic shock was evaluated using a laboratory model. The model produced a septic insult of gradual onset followed by a rapid progression, allowing for the evaluation of postcontamination therapeutic regimens. In Sprague-Dawley rats, the cecum was ligated distal to the ileocecal valve and doubly punctured. Control animals (n = 41) received no postoperative therapy. Mortality was 37 per cent at 24 hours and 90 per cent at 48 hours. Approximately 25 animals were assigned to each of five experimental groups. Pharmacologic doses of methylprednisolone at four and eight hours postoperatively did not alter survival. Short-term gentamicin (STG) at four and eight hours improved early survival, which then declined to control values. Addition of steroid to STG had no effect. Long-term gentamicin (LTG) administered through the third postoperative day produced significant increased survival over controls throughout the study. Pharmacologic doses of steroid at four and eight hours added to LTG resulted in a significant increase (P less than 0.05) in survival rate over the treatment with LTG alone.

During the 40 years from 1945 to 1984, 159 occurrences of sigmoid volvulus in 140 patients were diagnosed and managed. Treatment modalities gradually evolved from primarily operative decompression in the first 20 years to selective, sigmoidoscopic, nonoperative reduction in the most recent 10-year period. Operative reduction was associated with a 10 per cent mortality, while no deaths were associated with nonoperative reduction. A 60 per cent mortality was noted when gangrenous bowel was present. In the most recent 10-year period, 71 per cent of cases were associated with neuropsychiatric diseases, and one third had a previous episode of sigmoid volvulus. The diagnosis was made on the initial plain abdominal radiograph in 60 per cent, and nonoperative sigmoidoscopic reduction attained in 95 per cent. Following nonoperative reduction, elective resection was performed during the same hospitalization with a 5 per cent mortality. Initial management of sigmoid volvulus should consist of nonoperative attempts at reduction with operative reduction reserved for refractory cases or those with ischemic bowel. Elective resection can be safely performed during the same hospitalization.

From 1950 to 1980, 49 popliteal aneurysms in 34 patients have been treated at the University of Tennessee Center for the Health Sciences. A retrospective analysis of these patients' records revealed that 88 per cent of these aneurysms and 40 per cent of patients had synchronous or metachronous development of aneurysms in other locations. At the time of diagnosis, 22 per cent of patients were truly asymptomatic, and 36 per cent presented with claudication. Approximately one third of patients presented with an acute limb-threatening complication, e.g., thrombosis, embolization, or rupture. Limb salvage rates were worse in patients with thrombosis (45%) and embolization (75%). The diagnosis was made on physical examination in all patients, with arteriography and ultrasonography proving to be useful adjuncts. This analysis supports proximal and distal aneurysmal ligation with reversed saphenous vein bypass as the procedure of choice. Asymptomatic aneurysms should be repaired based on a significant incidence of limb-threatening complications when untreated and a superior patency rate following surgical management.

The development of peritonitis in hospitalized patients, especially those with significant associated illness, can be a difficult and delayed diagnosis. To ascertain the clinical presentation of acute cholecystitis in this group, a retrospective analysis was performed. Over a 10-year period 18 patients were identified who developed either posttraumatic or postoperative acute cholecystitis. The condition occurred in 12 patients admitted for some form of trauma and in six patients after elective surgery. Fever and right upper quadrant pain and tenderness were present in most. These physical findings were generally accompanied by leukocytosis (average = 16,200), hyperbilirubinemia (average = 4.2), and elevated alkaline phosphatase (average = 214). At laparotomy gangrenous cholecystitis was found in the majority, reflecting delayed diagnosis. Eleven patients had acalculous disease, and seven patients calculous cholecystitis. Three patients died, yielding a 17 per cent mortality. The majority with acalculous disease had significant underlying illness. Shock, multiple transfusions, or infection preceded acute cholecystitis in this group. Those with calculous cholecystitis were usually not as ill prior to its development. The morbidity of acute cholecystitis in previously hospitalized patients can be reduced by an awareness of the predisposing factors in those with acalculous disease. Emphasis should be placed on signs and symptoms rather than laboratory values to ensure early diagnosis and treatment of acute cholecystitis in hospitalized patients regardless of the presence or absence of gallstones.

Immune system function is thought to be depressed after hemorrhagic shock. We evaluated the delayed effect of hemorrhagic shock on the immune system in rats with and without spleens and investigated the effect of the colloid hetastarch on reticuloendothelial system (RES) function. There were six groups: controls (N = 30, no shock), two groups of shocked animals resuscitated with either hetastarch (HES, N = 13) or lactated Ringer's (LR, N = 13); the remaining three groups were identical except that splenectomy had been performed (N = 16, N = 14, and N = 16, respectively). One week after shock and resuscitation, all groups were challenged with intravenous Streptococcus pneumoniae; quantitative blood and tissue (liver, lung, and spleen) cultures were then obtained. There were no differences between the HES and LR groups. In nonsplenectomized animals, colony counts in the blood, liver, lung, and spleen were significantly higher in shocked animals when compared with controls. Splenectomized rats had no significant differences between shocked groups and controls. These data demonstrate that delayed immune function is depressed in nonsplenectomized rats. Splenectomy causes more severe immune dysfunction than does shock. Also, in similar animals without splenectomy, hetastarch does not appear to alter delayed RES function.