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Prehospital hypotension has been utilized for decades as a surrogate marker of injury severity. Several studies have discussed the correlation between injury and hypotension both in the field as well as in the emergency department. Increases have been noted in injury severity score and mortality. Resource utilization is higher in this patient population. This study revisits our original work from 2000 and reviews the current literature regarding hypotension and injury severity. We also examine the role of prehospital hypotension as an indicator of trauma team activation and resource allocation. This review serves as a part of a Literary Festschrift in honor of Dr J David Richardson's role as the Editor-in-Chief of The American Surgeon. [ABSTRACT FROM AUTHOR]

Multiple strategies have been used in an effort to increase the pool of organs for transplantation. Standardizing donor management has produced promising results. Donor management goals (DMGs) are now being used as end points of intensive care unit care during the prerecovery phase but no prospective results have been reported. Data from the United Network for Organ Sharing Region 11 were collected for successful achievement of eight common donor management goals (mean airway pressure [MAP], central venous pressure [CVP], pH, PaO2, sodium, glucose, single pressor use, and urine output) before organ recovery. Two time periods were studied with different panels of DMGs. The analysis identified the success rate of transplantation. Goals were stratified by their statistical correlation with the number of organs transplanted per donor (OTPD) in an effort to identify the most important parameter(s). Eight hundred five organ donors were studied with 2685 organs transplanted. DMGs were assessed through two phases of the study. Achieving DMGs rose from 18 to 66 per cent associated with significant improvement in OTPD (range, 2.96 to 3.45). The success of transplantation was primarily associated with limitations in vasopressor use and PaO2. Tight glucose control did affect the rate of pancreatic transplants. Thoracic organs were the most sensitive to DMGs with a 10- to 15-fold increase in lung transplantation when PaO2 rose above 100 mmHg. MAP, CVP, pH, sodium, and urine output had little effect on transplantation. Standardization of end points of donor management was associated with increased rates of transplantation. Surprisingly, not all standard goals are necessary for optimal organ use. The most significant parameters were the low use of vasopressor agents and oxygenation. Donor management strategies should strive to optimize these goals. [ABSTRACT FROM AUTHOR]

Pediatric liver and spleen injuries are frequently treated in specialized hospitals. Not all injured children, however, are treated in referral centers. We evaluated the management of pediatric liver and spleen injuries in a rural state without a state trauma system to determine if differences existed between trauma centers and nontrauma centers. A state database was queried for patients ≤15-years-old who suffered liver and spleen injuries from 2003 to 2005. Iatrogenic injuries were excluded. There were 115 pediatric liver and 183 pediatric spleen injuries. Fifty per cent of liver and 63 per cent of spleen injuries in nontrauma centers were isolated solid organ injuries compared with 18 per cent and 36 per cent, respectively, in trauma centers. The mortality rate for both liver and spleen injuries was similar in trauma and nontrauma centers. Hospital charges were higher in trauma centers but this was due to patients with associated injuries. The nonoperative management rate was similar for liver injuries. Pediatric patients with splenic injuries had a lower rate of nonoperative management in nontrauma centers (75% to 90%, nontrauma vs trauma), in Kentucky, pediatric solid organ injuries are usually managed nonoperatively in both trauma and nontrauma centers, but trauma centers cared for fewer isolated solid organ injuries. [ABSTRACT FROM AUTHOR]

The need for transplantable organs exceeds the available supply. Organ procurement organizations (OPOs) have undergone both voluntary and mandated changes to optimize available organs. The data from a single statewide OPO was reviewed from 1993 to 2008 and tracked with implementation of new protocols. During the study, 5548 organs were recovered with 4875 transplanted from 1441 donors (3.38 organs transplanted/donor IOTPD)). The conversion rate (CR) for consent rose from 42 to 72 per cent whereas the average age of donors increased from 33 to 45 years. After implementation of a family support liaison program, a higher performing hospital in the OPO realized an increase in CR from 57 to 97 per cent over 8 years. Implementation of an intensivist program improved OTPD. The number of standard criteria donors and extended criteria donors (ECD) increased. The increase in standard criteria donors yielded a large number of thoracic organs. ECD increased as did the organ discard rate from 8 to 16 per cent. Increases in organ retrieval were noted after incremental changes in OPO protocol. Family support and intensivist programs enhanced CR and OTPD. Increases in the number of ECD were noted with increasing age after the introduction of the intensivist program and an increase in transplant center use of these organs. [ABSTRACT FROM AUTHOR]

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 complication [ABSTRACT FROM AUTHOR]

One of the major lessons learned in the World War II experience with liver injuries was that bile peritonitis was a major factor in morbidity and mortality; the nearly uniform drainage of liver injuries in the subsequent operative era prevented this problem. In the era of nonoperative management, patients who do not require operative treatment for hemodynamic instability may develop large bile and/or blood collections that are often ignored or inadequately drained by percutaneous methods. These inadequately treated bile collections may cause systemic inflammatory response syndrome and/or respiratory distress. We present an experience with laparoscopic evacuation of major bile/blood collections that may prevent the inflammatory sequelae of bile peritonitis. Patients usually underwent operation between 3 and 5 days postinjury (range, 2-18) if CT demonstrated large fluid collections throughout the abdomen/pelvis not amenable to percutaneous drainage. Most patients had signs of systemic inflammatory response syndrome, respiratory compromise, or elevated bilirubin. The bile and retained hematoma was evacuated from around the liver and closed-suction drainage was placed. Twenty-eight patients underwent laparoscopic evacuation/lavage of bile collections (about 4% of total blunt liver injuries). The majority (75%) had Grade IV or V injury. The amount of evacuated fluid ranged from 300 to 3800 mL. Other adjunctive procedures (endoscopic retrograde pancreaticocholangiography, angiography, and laparotomy) were occasionally required. There were no complications related to the procedure. Most patients had a dramatic decline in tachycardia, temperature, white blood cell count, serum bilirubin, and pain. Respiratory failure also resolved in most patients. Large bile and/or blood accumulations are present in a subset of patients with severe liver injuries treated nonoperatively. Delayed laparoscopic evacuation of these collections prevents bile peritonitis and decreases inflammatory response and avoiding early operation, which has been implicated in increased death from hemorrhage. [ABSTRACT FROM AUTHOR]

Chest wall fractures, including injuries to the ribs and sternum, usually heal spontaneously without specific treatment. However, a small subset of patients have fractures that produce overlying bone fragments that may produce severe pain, respiratory compromise, and, if untreated mechanically, result in nonunion. We performed open reduction and internal fixation on seven patients with multiple rib fractures-five in the initial hospitalization and two delayed--as well as 35 sternal fractures (19 immediate fixation and 16 delayed). Operative fixation was accomplished using titanium plates and screws in both groups of patients. All patients with rib fractures did well; there were no major complications or infections, and no plates required removal. Clinical results were excellent. There was one death in the sternal fracture group in a patient who was ventilator-dependent preoperatively and extubated himself in the early postoperative period. Otherwise, the results were excellent, with no complications occurring in this group. Three patients had their plates removed after boney union was achieved. No evidence of infection or nonunion occurred. The excellent results achieved in the subset of patients with severe chest wall deformities treated initially at our institution and those referred from outside suggest that operative fixation is a useful modality that is likely underused. [ABSTRACT FROM AUTHOR]

Nonoperative management of splenic trauma is now the most common treatment modality for splenic injuries and splenectomy has almost disappeared in some trauma centers. Splenectomy for cancer staging is infrequently performed suggesting that the indications for splenectomy continue to evolve. We evaluated a state database to assess a communitywide experience with splenic surgery. International Classification of Diseases, 9th Revision, Clinical Modification diagnosis codes were used to determine the indication for splenic surgery. Indications for splenic surgery were listed as trauma (injury codes), medical (hematological diseases, neoplasms, or procedures in which the spleen might be removed contiguously like distal pancreatectomy), or incidental (noncontiguous procedures). Splenectomies for medical indications (n = 607, 43%) were more common than splenectomies for trauma (n = 518, 37%) or incidental splenectomies (n = 276, 20%). Splenectomy for medical reasons was associated with hematologic disease in 56 per cent, neoplastic disease in 34 per cent, and other diagnoses in 10 per cent of cases. Incidental splenectomies were most commonly associated with operations on the esophagus/stomach (32%) and colon (30%). Mortality rate and length of stay were greatest for incidental (14.4 ± 0.9 days, 10.9% mortality) compared with trauma (11.0 ± 0.5 days, 7.7% mortality) or medical (9.7 ± 0.4 days, 4.8% mortality) splenectomies (all P < 0.05 versus incidental). Our results suggest that in the era of nonoperative management of splenic injuries, medical indications now represent the most common reason for splenectomy. As laparoscopic techniques for elective splenectomy become more common, the changing indication for splenectomy has important ramifications for surgical education and training. [ABSTRACT FROM AUTHOR]

The article presents the case of a 68-year-old man with a 3-day history of intermittent abdominal pain and worsening distention. It highlights the two separate gallstones identified by computerized axial tomography scan radiographs in the jejunum and terminal ileum. It concludes that gallstone ileus is a rare cause of bowel obstructions. It suggests gallstone ileus as a part of one's differential diagnosis.

The author comments on the study "The Number of Gunshot Wounds Does Not Predict Injury Severity and Mortality," by Michael Cripps et al. which discusses injury severity and mortality as a function of number of gunshot wounds (GSW). According to the author, the results are at first somewhat unexpected as most would assume that the presence of more than one GSW would raise injury severity and mortality. He notes that the study adds to a small body of literature on the epidemiology of GSW.

Flail chest represents a severe injury with mortality historically reported at up to 30 per cent. Although management has changed dramatically over the past several decades, there is a paucity of large recent series. With Institutional Review Board approval, a retrospective review of all patients with flail chest admitted from January 2001 through May 2010 was undertaken. Patient demographics, outcomes, and cause of death were specifically analyzed with univariate and multivariate analysis. There were 164 patients at a median age of 51.4 years. Head injury and pulmonary contusion were present in 67 (40.8%) and 125 (77%), respectively. Pneumonia developed in 72 (43.9%). There were 41 deaths (25%), for which flail chest contributed to 15 (9.1%). Of the patients with flail chest-related death, the majority (n = 10 [66.7%]) died within 48 hours of presentation. There were only five deaths (3.0%) related to flail chest after 48 hours. Multivariate analysis of ventilator dependency revealed requirement for laparotomy (P = 0.019) or tracheostomy (P < 0.0001) and pneumonia (P = 0.0002) as significant. Pneumonia was the most significant independent predictor of overall (P < 0.0001) and intensive care unit length of stay (P < 0.0001). The mortality associated with flail chest has greatly improved; however, the rate of pneumonia remains high. Further efforts at pneumonia prevention are thus warranted. [ABSTRACT FROM AUTHOR]

Blood stream infections in the critically ill are a common cause of morbidity. Strict adherence to sterile technique can reduce central line-associated blood stream infections (CLBSIs) and has become a quality improvement measure. We did a retrospective review of 6,014 trauma admissions representing 10,370 catheter days. CLBSI was defined as a positive blood culture with central venous access without evidence of other infectious sources. Thirty-five CLBSIs were identified in the study period (3.26/1,000 line days). The average Injury Severity Score was 32, the average intensive care unit stay was 24 days, and the average overall length of stay was 34 days, which is higher than that of nonCLBSI patients. In 25/35 cases, there was a break in sterile technique during central venous catheter placement (71%). Of the 25 cases, 16 of them were performed in the intensive care unit (64%), five in the operating room (20%), and four in the emergency department (16%). Twenty of the 35 patients with CLBSI (57%) had a total of 24 infections, a 2-fold increase in infectious complications for a given Injury Severity Score. Seventeen (17) of the 25 "dirty" central lines (68%) were changed within 24 hours in an effort to reduce the risk of CLBSI without success. A large percentage of CLBSI can be traced to the initial placement of a central venous line under less than ideal sterile technique. Changing a line within 24 hours may not be sufficient to reduce the risk of CLBSI. Every effort should be made to adhere to proper sterile technique while placing central venous catheter. [ABSTRACT FROM AUTHOR]

It has been previously reported that trauma patients with cirrhosis undergoing emergency abdominal operations exhibit a fourfold increase in mortality independent of their Child's classification. We undertook this review to assess the impact of cirrhosis on trauma patients. We reviewed the records of patients from 1993 to 2003 with documented hepatic cirrhosis and compared them to a 2:1 control population without hepatic cirrhosis and matched for age, sex, Injury Severity Score (ISS), and Glasgow Coma Score (GCS). Demographic, severity of injury, and outcome data were recorded. Student's t test and χ² were used for statistical analysis and a P < 0.05 was significant. Sixty-one patients had documented cirrhosis and were compared to 156 matched controls. Comparing the two groups demonstrates there was no difference in age, ISS, or GCS. Intensive care stay, hospital length of slay, blood requirements in the first 24 hours postinjury, and mortality (33% vs 1%) was significantly greater in the trauma patients with cirrhosis. Fifty-five per cent of deaths in the cirrhosis group was due to sepsis, and, as the Child's class increases, so does the mortality (Child's A, 15%; B, 37%; and C, 63%). In 64 per cent of cirrhotics without an emergent abdominal operation, mortality was 21 per cent. In the 36 per cent of cirrhotics who had emergent abdominal operation, mortality was 55 per cent. Hepatic cirrhosis in trauma patients, regardless of severity of injury or the need for an abdominal intervention, is a poor prognostic indicator. The necessity of an abdominal operative intervention further amplifies this effect. Trauma and cirrhosis is, in fact, a deadly duo. [ABSTRACT FROM AUTHOR]

Blunt chest trauma produces a variety of injuries. We present a case report of a hemodynamically stable patient after blunt chest trauma with radiographic images suggestive of the left fifth rib penetration to the heart. The diagnosis, surgical approach, and course of the patient are discussed. [ABSTRACT FROM AUTHOR]

Our department has a database of thoracic gunshot wounds (GSWs), which has cataloged these injury patterns over the past five decades. Prevailing wisdom on the management of these injuries suggested operative treatment beyond tube thoracostomy is not commonly required. It was our clinical impression that the operative treatment required beyond chest tube placement has greatly increased over the past several decades, whereas the operative management of cardiac GSWs seemed to be increasingly infrequent events. To test these observations, we analyzed the treatment of GSWs to the chest and heart in four distinct time periods, categorized as "historical" (1973-1975 and 1988-1990) and "modern" (2005-2007 and 2015-2017). There was a significant increase in emergent thoracotomy, delayed thoracic operations, overall operative interventions, and pulmonary resections from the historical period to the modern era. There was a decline in cardiac injuries treated, whereas the number of injuries remained constant. Mortality was unchanged between the early and later periods. Operative treatment beyond tube thoracostomy was much more prevalent for noncardiac thoracic GSWs in the past two decades than in the prior decades, whereas the number of cardiac wounds treated decreased by half. [ABSTRACT FROM AUTHOR]

Despite low mortality rates, self-inflicted stab wounds (SISWs) can result in significant morbidity and often reflect underlying substance abuse and mental health disorders. This study aimed to characterize demographics, comorbidities, and outcomes seen in self-inflicted stabbings and compare these metrics to those seen in assault stabbings. A Level I trauma center registry was queried for patients with stab injuries between January 2010 and December 2015. Classification was based on whether injuries were SISWs or the result of assault stab wounds (ASWs). Demographic, injury, and outcome measures were recorded. Differences between genders, ethnicities, individuals with and without psychiatric comorbidities, and SISW and ASW patients were assessed. Within the SIWS cohort, no differences were found when comparing age, gender, or race, including need for operative intervention. However, patients with psychiatric histories were less likely to have a positive toxicology test on arrival than those without psychiatric histories (22% vs. 0%, P = 0.04). When compared with 460 ASW patients, SISW were older (41 vs. 35, P < 0.001), more likely to be white (92% vs. 64%, P < 0.001), more likely to have a psychiatric history (15% vs. 4%, P < 0.001), require operative intervention (65% vs. 50%, P = 0.008), and be discharged to a psychiatric facility (47% vs. 0.2%, P < 0.001). SISW patients have higher rates of psychiatric illness and an increased likelihood to require operative intervention as compared with ASW patients. This population demonstrates an acute need for both inpatient and outpatient psychiatric care with early involvement of multidisciplinary teams for treatment and discharge planning. [ABSTRACT FROM AUTHOR]

Gunshot wounds (GSW) are becoming increasingly prevalent in urban settings. GSW to the trunk mandate full trauma activation and immediate surgeon response because of the high likelihood of operative intervention. Extremity GSW proximal to the knee/elbow also require full trauma activation based on American College of Surgeons Committee on trauma standards. However, whether isolated extremity GSWrequire frequent operative intervention is unclear. We evaluated GSW at our Level I trauma center from January 2012 to December 2016. Demographic data and injury patterns were abstracted from the trauma registry and charts. The number of GSW increased yearly but the age, gender, Injury Severity Score and injury pattern did not change (P = ns, not shown). There were 504 GSW that included an extremity and 194 (38%) involved multiple body regions. There were 310 GSW (62%) isolated to an extremity and 176 were proximal to the elbow/knee. If proximal GSW had an Emergency Department systolic blood pressure <90 mm Hg, 53 per cent underwent vascular repair, 12 per cent had soft tissue repair, and 29 per cent required no operation. If proximal GSW had an Emergency Department blood pressure >90 mm Hg, 57 per cent underwent orthopedic repair, 22 per cent required no surgery, and only 13 per cent required vascular repair (P < 0.01). In the absence of other criteria for full trauma activation such as shock, the need for the immediate presence of a general surgeon to perform emergency surgery for aGSW isolated to the extremity is low. [ABSTRACT FROM AUTHOR]

To date, no studies have examined the relationship between geographic and socioeconomic factors and the frequency of pedestrians sustaining traumatic injuries from a motor vehicle. The objective of this study was to analyze the impact of location on the frequency of pedestrian injury by motor vehicle. The University of Louisville Trauma Registry was queried for patients who had been struck by a motor vehicle from 2010 to 2015. Demographic and injury information as well as outcome measures were evaluated to identify those impacting risk of pedestrian versus motor vehicle accidents. Number of incidents was correlated with lower median household income. There was also a moderate correlation between number of incidents and population density. Multivariable analysis demonstrated a significant association between increased median household income and distance from downtown Louisville and decreased risk of death after pedestrian versus motor vehicle accident. Incidence of pedestrian injury by motor vehicles is influenced by regional socioeconomic status. Efforts to decrease the frequency of these events should include further investigation into the mechanisms underpinning this relationship. [ABSTRACT FROM AUTHOR]

To date, no studies have examined the relationship between geographic and socioeconomic factors and the frequency of pedestrians sustaining traumatic injuries from a motor vehicle. The objective of this study was to analyze the impact of location on the frequency of pedestrian injury by motor vehicle. The University of Louisville Trauma Registry was queried for patients who had been struck by a motor vehicle from 2010 to 2015. Demographic and injury information as well as outcome measures were evaluated to identify those impacting risk of pedestrian versus motor vehicle accidents. Number of incidents was correlated with lower median household income. There was also a moderate correlation between the number of incidents and population density. Multivariable analysis demonstrated a significant association between increased median household income and distance from downtown Louisville and decreased risk of death following pedestrian versus motor vehicle accident. Incidence of pedestrian injury by motor vehicles is influenced by regional socioeconomic status. Efforts to decrease the frequency of these events should include further investigation into the mechanisms underpinning this relationship. [ABSTRACT FROM AUTHOR]

Damage control surgery (DCS) was developed to manage exsanguinating trauma patients, but is increasingly applied to the management of peritoneal sepsis and abdominal catastrophes. Few manuscripts compare the outcomes of these surgeries on disparate patient populations. A multi-institutional three group propensity score matched case cohort study comparing penetrating trauma (PT-DCS), blunt trauma (BT-DCS), and intraperitoneal sepsis (IPS-DCS) was performed comparing patients treated with DSC between 2008 and 2013. Propensity scoring was performed using demographic and presenting physiologic data. Four hundred and twelve patients were treated with DCS across two institutions. Propensity matching for age, gender, and initial Acute Physiology and Chronic Health Evaluation II score 80 identified 80 patients per group for comparison. Rate of primary fascial closure was lowest in the IPS-DCS group, and highest in the penetrating trauma DCS group. Intra-abdominal complication rates were highest in the IPS-DCS group. IPS-DCS had increased time to definitive closure compared with the other two groups (RR 1.8; 1.3-2.2; P < 0.03). Mortality at 90 days was highest in the IPS-DCS group and patients whose definitive closure was delayed >eight days were more than twice the risk of death at 90 days across all groups. (RR 2.15; 1.2-3.5; P < 0.002). Expected outcomes after the use of DCS for trauma and emergency general surgery are quite different. Despite this difference, prompt abdominal closure at the earliest possible opportunity afforded the best outcome in patients managed via DCS. [ABSTRACT FROM AUTHOR]

Interest in machine perfusion (MP) for donated kidneys has markedly increased in the past decade as a means to improve graft function, although the donor populations in which it should be applied have not yet been resolved. All adults undergoing de-novo isolated kidney transplantation from standard-criteria donors in the UNOS database 2005 to 2011 were reviewed with the primary endpoint of delayed graft function (DGF), defined as dialysis within seven days of transplantation, in those who received kidneys that underwent MP versus cold storage (CS) alone. Three methods were used to control for differences between groups. Multivariable logistic regression was performed, adjusting for donor and recipient characteristics significantly associated with DGF. Rates were also compared in a cohort of propensity-matched MP vs CS recipients. Finally, a paired-kidney study was performed, where one kidney underwent MP and the contralateral underwent CS. There were 36,323 patients, with unadjusted DGF rates of 18.6 per cent (n = 1830/9882) and 22.4 per cent (n = 5931/26,441; P < 0.001) in the MP vs CS groups, respectively. After multivariable analysis, the odds ratio for DGF in the MP group was 0.59 (P < 0.001) versus CS. In the propensity-matched cohort, there were 8929 patients each in the MP and CS groups. DGF occurred in 16.8 per cent of the MP group vs 25.3 per cent with CS (P < 0.001, OR 0.59). In the paired-kidney study, rates of DGF were 16.7 per cent vs 24.3 per cent (P < 0.001) in the 1665 recipients each in the MP versus CS groups (OR 0.6). In conclusion, machine perfusion is beneficial in reducing DGF even when standard donors are utilized, and thus should not be limited to marginal kidneys. [ABSTRACT FROM AUTHOR]

Damage control surgery involves an abbreviated operation followed by resuscitation with planned re-exploration. Damage control techniques can be used in thoracic trauma but has been infrequently reported. Our goal is to describe our experience with the use of damage control techniques in treating thoracic trauma. A retrospective analysis of all patients undergoing damage control thoracic surgery related to trauma from January 1, 2010, to January 1, 2013, at University of Louisville Hospital, a Level I trauma center. Variables studied included injury characteristics, Injury Severity Score, surgery performed, duration of packing, length of stay (LOS), ventilator days, transfusion requirements, complications, and mortality. Twenty-five patients underwent damage control surgery in the chest with packing, temporary closure, and planned re-exploration after stabilization. Seventeen patients underwent anterolateral thoracotomy, and eight patients underwent sternotomy. The mean LOS and duration of temporary packing was 20.6 and 1.4 days in the thoracotomy group, respectively, and 19.5 and 1 day in the sternotomy group, respectively. The overall mortality rate was 40 per cent, 35 per cent in the thoracotomy group and 50 per cent in the sternotomy group. Like in severe abdominal trauma, damage control techniques can be used in the management of severe thoracic injuries with acceptable results. [ABSTRACT FROM AUTHOR]

Transarterial embolization (AE) can be a lifesaving procedure for severe hemorrhage associated with pelvic fractures. The purpose of this study was to identify demographic and radiographic findings that predict the need for embolization. We performed a retrospective review of all patients with at least one pelvic fracture and admission to the intensive care unit over a 35-month period. Computed tomography (CT) and pelvic radiographs were reviewed. Patient demographics, outcomes, time to angiography, and whether or not embolization was performed were determined. Statistical analysis was used to determine factors associated with the need for AE. Of the 327 total patients with pelvic fractures, 317 underwent CTscanning. Forty-four patients (13.5%) underwent angiography and 25 (7.6%) required therapeutic embolization. There were 39 total deaths (11.6%) with five deaths related to pelvic hemorrhage (1.5%). Multivariate analysis revealed that age older than 55 years (odds ratio [OR], 1.06; P<0.001), systolic blood pressure less than 90 mmHg in the emergency department (OR, 11.64; P = 0.0008), and CTextravasation (OR, 147.152; P<0.0001) were significantly associated with the need for embolization. Contrast extravasation was not present in 25 per cent of patients requiring therapeutic AE. The presence of contrast extravasation is highly associated with the need for pelvic embolization in patients with pelvic fractures, but its absence does not exclude the need for pelvic angiography. [ABSTRACT FROM AUTHOR]

Twenty-six per cent of adults in the Unites States are obese and trauma remains a major cause of death. We assessed the impact of morbid obesity on mortality in patients with blunt trauma. We reviewed the records of patients with a body mass index 40 kg/m² or greater injured by blunt trauma from 1993 to 2003 and compared them with a 4:1 control population with a normal body mass index and matched for sex and constellation of injuries. For comparison, patients were categorized by Injury Severity Score 9 or less or Injury Severity Score 10 or greater. Student t test and χ² were used for statistical analysis. P < 0.05 was considered significant. One hundred seven morbidly obese patients were identified and compared with 458 control subjects with a normal body mass index and matched for sex and constellation of injuries. Although the morbidly obese patients were found to be significantly younger, those who incurred multiorgan injury experienced a significantly longer hospital length of stay and displayed a greater than fourfold increase in mortality when compared with the control subjects. Furthermore, the number of morbidly obese patients admitted over the 10-year period significantly increased by fourfold (0.4% to 1.5%). Over the last decade, there has been a significant increase in morbidly obese patients cared for in our trauma center. Although these patients were significantly younger with a similar Glasgow Coma Score as that of the control population, morbid obesity significantly increased mortality when the injury from blunt trauma transitioned from a single to a multiorgan injury. [ABSTRACT FROM AUTHOR]

The indications for performing as urgent thoractomy after trauma are based on the criteria used for penetrating injuries. However, few data are available on the use of these indications for patients with blunt injuries. In a retrospective study (June 1996 to July 2001), we compared the indications of urgent thoracotomy after blunt injury and penetrating injury in patients who underwent thoracotomy within 24 hours of hospital admission at our institution. Patients with blunt aortic injuries or emergency department thoracotomies were excluded from evaluation. Fifty-nine patients were identified (37 penetrating injuries, 22 blunt injuries). Blunt trauma victims had a higher mortality rate than penetrating trauma victims (73% vs. 22%). Chest tube output was the indication for nontherapuetic thoracotomy in 5 patients with blunt injuries whereas this occurred in only 1 penetrating injury victim (P = 0.04). All 5 blunt injury patients underwent a prior procedure and were coagulopathic when thoracotomy was performed. In conclusion, thoracotomy following blunt trauma is associated with a high rate of mortality. The rate of non-therapeutic exploration is increased when chest tube output is the indication for thoracotomy after blunt trauma. Since the majority of such patients have multicavitary injuries that require prior operation and are commonly coagulopathic, caution should be exercised when deciding whether to proceed with thoracotomy based solely on chest tube output. [ABSTRACT FROM AUTHOR]