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All cases of penetrating extremity trauma (PET) seen at an urban trauma center were prospectively studied to determine the accuracy and safety of physical examination as the sole mode of evaluation for vascular injury. All patients with PET producing obvious or "hard" signs of vascular injury underwent immediate surgery. All asymptomatic proximity wounds were observed in hospital for 24 hours before discharge to outpatient followup. Patients with non-proximity wounds were discharged immediately. Patients with shotgun wounds and thoracic outlet injuries also underwent arteriography. Of 2,674 trauma patients evaluated during the 1-year study period, 310 (11.6%) had 366 penetrating extremity wounds, most (71%) occurring in the lower extremities. Gunshots caused most (82%) of the wounds, followed by stabs or lacerations (14.5%), and shotguns (3%). Clinically occult wounds in proximity to major limb vessels were the most common (78%) category of clinical presentation, followed by asymptomatic non-proximity wounds (16%), and wounds producing hard signs (6%). There were two missed vascular injuries, both in the asymptomatic proximity group (0.7% false negatives). Every patient taken immediately to surgery for hard signs had major arterial injury requiring repair, for a 100% positive predictive value for physical examination. No mortality or morbidity were related to protocol management. These results to date support prior reports of a negligible incidence of significant vascular injury following clinically occult proximity PET, and further suggest that the overall predictive value of physical examination of PET for vascular injury approaches 100%.

The purpose of this study was to determine the impact of an antibiotic regimen on the incidence of empyema in patients admitted with isolated chest trauma (ISS 9/10) and hemopneumothorax requiring tube thoracostomy. All patients with isolated chest trauma and hemopneumothorax (estimated ISS 9 or 10) seen in our trauma center were considered eligible for this study. Patients were excluded for the following reasons: age less than 18 years, presence of shock at the time of initial resuscitation, ongoing antibiotic therapy for unrelated disease, documented pre-existing infection or documented abnormal immune status. Ninety patients were randomized to two treatment limbs: antibiotics and tube thoracostomy or tube thoracostomy alone. All patients had the procedure performed in the trauma center in a standard fashion. Wound care and tube care were identical. Antibiotic therapy consisted of a first-generation cephalosporin (cefazolin), one dose given just before the procedure and then q 6 h into the tube removal. Injury Severity Scores were established as described by Schwab after the manner of Baker. Statistical analysis was performed using Fisher's exact test of binary outcome. In this study, antibiotics were able to reduce the incidence of empyema in patients with isolated chest trauma and for such patients antibiotic treatment appears justified. Further work is required to determine the effect on patients with more severe injury and multisystem involvement.

Carotid aneurysms are an extremely rare entity; mycotic carotid aneurysms are even more uncommon. Most articles in the past have advocated ligation as treatment of mycotic carotid aneurysms due to the dangers of graft placement in an infected field. Unfortunately, stroke occurs in many patients so treated. As the cerebral complications were so high, bypass using autogenous vein and fine monofilament polypropylene sutures is attractive. This technique was used in a patient having a mycotic carotid aneurysm who was referred to the Vascular Service of the Shands Teaching Hospital. Pre- and postoperative antibiotics, resection of the aneurysm, anastomosis in a noninfected area, and long-term oral antibiotics were felt to be other important aspects of the patient's treatment. This individual is well one year after operation without neurological sequelae. This case suggests that if strict operative and therapeutic guidelines are observed, bypass with autogenous vein is a feasible operative alternative in patients having mycotic carotid aneurysms. The risk of this procedure must be carefully weighed against the devastating neurological sequellae that might result with ligation.

Thrombophlebitis leading to pulmonary embolism has been stated to cause as many as 9% of hospital deaths. Its diagnosis, sites of common occurrence, treatment and immediate sequelae have long been controversial subjects. A prospective study of thrombophlebitis was set up to evaluate these problems. One hundred and sixty-six patients diagnosed clinically as having thrombophlebitis or pulnmonary embolus were studied with the ultrasonic flow detector (doppler). To assess the stated accuracy of this instrument, venograms were done when possible. The doppler proved in this series to be 93% accurate as compared to venography which is comparable to other series. Pulmonary scans and angiograms were obtained from patients suspected of having pulmonary emboli. Results were as follows: 1) Of 113 patients suspected of having thrombophlebitis clinically, only 26 (23%) of the cases were confirmed by doppler; 2) Of 53 patients suspected of having pulmonary embolus clinically, only 18 (34%) had confirmation by scan, angiogram or doppler; 3) Of 39 patients in this series who had thrombophlebitis, 11 (23%) were not suspected of having lower extremity venous disease until pulmonary embolus occurred, 4) Calf vein thrombosis without additional proximal occlusion was present in only 10% of cases; and 5) Thirty per cent of doppler or venographically proven cases of thrombophlebitis occurred after orthopedic injuries or operations. It was concluded that physical examination alone was grossly inaccurate in determining the recurrence of lower extremity thrombosis. In fact physical examination alone appeared to select out for treatment large numbers of patients without venous disease while a significant number of patients with thrombophlebitis remained clinically asymptomatic until pulmonary embolism occurred. Most deep venous disease was found in the larger veins above the knee, explaining the paucity of diagnostic symptoms in these individuals. The ultrasonic flow detector was found to be an extremely accurate, simple and rapid bedside test that could be applied daily to the high risk groups. The appearance of thrombosis could then be treated with heparin with excellent prospects of preventing occurrence of pulmonary embolus.

Nineteen patients with 20 clinically occult arterial injuries were prospectively followed without surgery in order to define the natural history of these lesions. The patients were predominantly male (74%), with a mean age of 31 years. The mechanism of injury was penetrating in 13 cases and blunt in seven cases. The arterial injuries were located in the lower extremity (45%), upper extremity (35%), neck (15%), and abdominal aorta (5%). Neurologic trauma (55%) and musculoskeletal trauma (40%) were the most common associated injuries. There was no clinical manifestation of vascular injury in any case. All lesions were identified by arteriography, which was performed for high-risk blunt trauma and proximity of penetrating wounds to major vessels. Intimal flap was the most commonly demonstrated form of injury (65%), followed by focal narrowing (30%) and false aneurysm (5%). Followup of 19 injuries (95%) was obtained for periods ranging from 3 days to 19 months (mean, 3.8 months). Arteriographic followup was obtained in 15 cases (79%). One injury (5%), a false aneurysm, enlarged after 10 weeks and was surgically repaired without clinical sequelae. All other lesions either resolved (53%), improved (16%), or remained unchanged (26%). These results suggest that nonoperative observation may be a safe and feasible method of managing clinically occult arterial injuries.

Penetrating proximity extremity trauma (PPET) was prospectively studied to clarify the role of routine arteriographic evaluation (AG). Over a 24-month period, 135 patients were identified with 152 injuries from PPET. All patients underwent AG and were randomized to either immediate or delayed timing. There were 27 arteriographic abnormalities from these 152 wounds, of which 16 (10.5%) were in major arteries. One acute arteriovenous fistula underwent immediate surgery. The remaining 15 major vessel injuries were nonoperatively observed, including seven cases of segmental arterial narrowing, six intimal flaps, and two small pseudoaneurysms (one of which enlarged and underwent surgical repair after 10 weeks of followup). Nine of the remaining 14 lesions resolved; two improved and three remained clinically unchanged over a mean followup interval of 2.7 months. Shotgun trauma was the mechanism which carried the greatest risk of significant vascular injury. Although "soft" clinical signs were significantly more predictive of vascular injury following PPET than proximity alone (p less than 0.0005), 50% of all injuries to major arteries did not manifest soft signs. No extremity morbidity resulted from delayed AG or from vascular injury management. We conclude from our study population: 1) the natural history of clinically occult arterial injuries was predominantly benign; 2) AG could be safely delayed up to 24 hours; 3) "soft" signs were not clinically useful predictors of vascular injury; and 4) with the exception of shotgun wounds, AG did not appear to be a cost effective screening modality, since detection of a single vascular injury requiring surgery cost $66,420.00.

A mileage population death index (MPDI) was devised to compare the death rate from motor vehicle trauma in Florida counties. The MPDI was defined as the average death rate per one hundred million miles driven divided by the population of the particular county X 10(5). The resultant MPDI was correlated with the presence in a county of basic life support only and advanced life support. In addition, counties with large metropolitan hospitals which might possibly classify as Level I institutions were compared with other counties. A low MPDI was found to be highly correlated with the presence of an ALS system (p = 0.001). Counties with hospitals which might qualify as Level I also had a significantly lower MPDI (p = 0.04). We conclude that the presence of advanced life support and a sophisticated hospital is correlated with a significantly lower motor vehicle mortality.