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Nosocomial pneumonia is a frequent complication in hospitalized patients. Gram-positive pathogens, particularly Staphylococcus aureus, are responsible for the increasing frequency of nosocomial pneumonia. To evaluate the efficacy and safety of intravenous quinupristin/dalfopristin (Synercid) in the treatment of nosocomial pneumonia caused by gram-positive pathogens we conducted a prospective, randomized, open-label, international, multicenter, comparative clinical trial. Two hundred ninety-eight patients with nosocomial pneumonia were enrolled in 74 active centers in five countries: a subgroup of 171 (87 quinupristin/dalfopristin-treated and 84 vancomycin-treated patients) were evaluable for the major efficacy end points. One hundred fifty received 7.5 mg/kg of quinupristin/dalfopristin every 8 h; 148 patients received 1 g of vancomycin every 12 h. Aztreonam at a dose of 2 g every 8 h could be administered in both groups for coverage of gram-negative organisms, and tobramycin was added for coverage against Pseudomonas aeruginosa. The primary efficacy end point was the clinical response between the seventh and the thirteenth day after the end of treatment in clinically evaluable patients with documented causative pathogen(s) at baseline (bacteriologically evaluable population). Therapy was clinically successful (cure or improvement) in 49 (56.3%) of patients receiving quinupristin/dalfopristin and 49 (58.3%) patients receiving vancomycin (difference, -2.0% [95% CI, -16.8% to 12.8%]) in the bacteriologically evaluable population. Equivalent clinical success rates were also observed in the all-treated population (n = 298), and in the bacteriologically evaluable patients intubated in baseline (39/72 [54%] compared with 36/67 [54%]). The by-pathogen bacteriologic response was similar in both treatment groups, with equivalent clinical success rates for Streptococcus pneumoniae, Staphylococcus aureus, and methicillin-resistant Staphylococcus aureus. Adverse events (venous and nonvenous) were equally distributed between groups; 15.3% of quinupristin/dalfopristin patients and 9.5% of vancomycin patients discontinued therapy because of an adverse clinical event. In this study quinupristin/dalfopristin was shown to be equivalent to vancomycin in the treatment of nosocomial pneumonia caused by gram-positive pathogens. Quinupristin/dalfopristin merits further evaluation for the treatment of nosocomial pneumonia caused by methicillin-resistant S. aureus.

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.

Gastric outlet obstruction (GOO) secondary to peptic ulcer disease requiring therapeutic intervention remains a common problem. The incidence of Helicobacter pylori infection in this cohort has not been well defined. Pneumatic dilatation (PD) has been proposed as first-line therapy before surgical intervention. If H pylori infection in patients with GOO is infrequent, PD may not offer permanent control without the need for longterm antacid therapy.The purpose of this study was to examine the incidence of H pylori infection and surgical outcomes in patients undergoing resection for GOO. The records of all patients having resection (vagotomy and antrectomy) for benign disease from 1993 to 1998 for GOO at the University of Tennessee affiliated hospitals were reviewed retrospectively. Smoking history, NSAID use, weight loss, previous ulcer treatment, previous treatment for H pylori, and previous attempts at PD were among the factors examined. H pylori infection was documented by Steiner stain from either preoperative biopsy or, in most patients, final surgical specimens. Surgical complications and patient satisfaction were ascertained from inpatient records, postoperative clinical notes, and, where possible, followup telephone surveys.Twenty-four patients underwent surgical resection during the study period. There were 16 men and 8 women, with a mean age of 61 years (range 40 to 87 years). Weight loss was documented in 58% and averaged 27 lb. Five of 24 patients had previous attempts at PD, 3 of whom were H pylori negative. All five had further weight loss after these failed attempts. Of the 24 patients reviewed, only 8 (33%) were H pylori positive. There were no procedure-related deaths. Longterm clinical followup was possible in 16 of 24 patients, and all but one demonstrated dramatic clinical improvement by Visick score.We conclude the following: 1) In this cohort, H pylori infection was present in a minority; 2) previous attempts at PD were unsuccessful, which may be related to the H pylori-negative status of the patients; 3) mortality related to the operation was zero; and 4) patient satisfaction was positive by the Visick scale. Patients with H pylori-negative GOO resulting from peptic ulcer disease should be strongly considered for an early, definitive, acid-reducing surgical procedure.

Empiri c therapy of ventilator-associated pneumonia (VAP) in surgical patients should be based on intensive care unit (ICU)-specific surveillance data, because microbial flora patterns vary widely between geographic regions as well as within hospitals. Surgical ICUs have higher VAP rates than other units. Data from the National Nosocomial Infection Surveillance (NNIS) System report Pseudomonas aeruginosa and Staphylococcus aureus to be the most frequent isolates (each 17.4%). Data from the NNIS documents high resistance patterns in ICUs compared with hospitals at large, as well as unit-specific patterns. VAP risk factors for surgical patients include thoracoabdominal surgery, altered level of consciousness, advanced age, diabetes mellitus, malnutrition, chronic obstructive pulmonary disease, and prior antibiotic administration. Promising prevention strategies include restricting ventilator circuit changes, in-line heat moisture exchange filters, semi-recumbant positioning, and continuous subglottic aspiration. Pharmacodynamics should be considered when choosing antibiotic regimens. Postantibiotic effect and time-dependent versus concentration-dependent killing should be studied in clinical trials. Current guidelines for choosing regimens have been well developed by the American Thoracic Society.

Nosocomial pneumonia is a frequent complication in hospitalized patients. Gram-positive pathogens, particularly Staphylococcus aureus, are responsible for the increasing frequency of nosocomial pneumonia. To evaluate the efficacy and safety of intravenous quinupristin/dalfopristin (Synercid) in the treatment of nosocomial pneumonia caused by gram-positive pathogens we conducted a prospective, randomized, open-label, international, multicenter, comparative clinical trial. Two hundred ninety-eight patients with nosocomial pneumonia were enrolled in 74 active centers in five countries: a subgroup of 171 (87 quinupristin/dalfopristin-treated and 84 vancomycin-treated patients) were evaluable for the major efficacy end points. One hundred fifty received 7.5 mg/kg of quinupristin/dalfopristin every 8 h; 148 patients received 1 g of vancomycin every 12 h. Aztreonam at a dose of 2 g every 8 h could be administered in both groups for coverage of gram-negative organisms, and tobramycin was added for coverage against Pseudomonas aeruginosa. The primary efficacy end point was the clinical response between the seventh and the thirteenth day after the end of treatment in clinically evaluable patients with documented causative pathogen(s) at baseline (bacteriologically evaluable population). Therapy was clinically successful (cure or improvement) in 49 (56.3%) of patients receiving quinupristin/dalfopristin and 49 (58.3%) patients receiving vancomycin (difference, -2.0% [95% CI, -16.8% to 12.8%]) in the bacteriologically evaluable population. Equivalent clinical success rates were also observed in the all-treated population (n = 298), and in the bacteriologically evaluable patients intubated in baseline (39/72 [54%] compared with 36/67 [54%]). The by-pathogen bacteriologic response was similar in both treatment groups, with equivalent clinical success rates for Streptococcus pneumoniae, Staphylococcus aureus, and methicillin-resistant Staphylococcus aureus. Adverse events (venous and nonvenous) were equally distributed between groups; 15.3% of quinupristin/dalfopristin patients and 9.5% of vancomycin patients discontinued therapy because of an adverse clinical event. In this study quinupristin/dalfopristin was shown to be equivalent to vancomycin in the treatment of nosocomial pneumonia caused by gram-positive pathogens. Quinupristin/dalfopristin merits further evaluation for the treatment of nosocomial pneumonia caused by methicillin-resistant S. aureus.

We have reported that treatment with exogenous granulocyte colony-stimulating factor (G-CSF) improves abscess localization and reduces mortality without aggravating neutrophil (PMN)-mediated reperfusion injury in a model of septic abdominal trauma. The purpose of this study was to determine actions of G-CSF on PMN function in the peritoneum.Anesthetized swine were pretreated with broad-spectrum antibiotics and underwent cecal ligation and incision and 35% hemorrhage (trauma). After 1 hour they were resuscitated with shed blood, crystalloid, and either G-CSF (n = 10) or saline solution vehicle (n = 9). The animals were observed for 72 hours.After trauma, saline solution treatment increased PMN infiltration into the peritoneum within 2 hours (P = .035), increased peritoneal PMN elastase production (i.e., cytotoxicity) by 24 hours (P = .004), and decreased adherence of peritoneal PMNs to an artificial substrate from 4 to 72 hrs (P = .043). The mean autopsy score was 7.0 +/- 0.5. With G-CSF treatment peritoneal neutrophilia was enhanced (maximum 48 hours, P = .002) and PMN cytotoxicity was augmented and delayed (maximum 48 hours, P = .004). Despite these changes, adherence of peritoneal PMNs was not significantly changed and there was no evidence for PMN-mediated damage in the lung as judged by bronchoalveolar lavage protein, bronchoalveolar lavage PMNs, lung tissue myeloperoxidase, or histologic changes. The mean autopsy score was improved to 4.1 +/- 0.3 (P.001).G-CSF in resuscitation fluids improved localization of an intra-abdominal septic focus by increased production of circulating PMNs, increased PMN extravasation into the peritoneal cavity, and increased PMN cytotoxicity at the abdominal septic focus, without exaggerating PMN-dependent reperfusion injury in the lung. Therefore these data further support the idea that G-CSF in resuscitation fluids might reduce septic complications in the multiply injured trauma patient.

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.

Two hypotheses were investigated: (1) helical computed tomography (CT) of the chest on victims of decelerating trauma can yield a diagnosis of, or "rule out," a traumatic rupture of the aorta (TRA) without the need for an aortogram; and (2) selective delay of aortic repair can be safely accomplished through a medical management protocol. Screening helical CT examinations were done on 6169 victims of blunt thoracic trauma; 47 were found to have TRA; in 8, indirect but nondiagnostic findings not clarified by an aortogram led to surgical exploration. The sensitivity of helical CT was higher than that of aortograms, and a "normal" helical CT scan was never associated with a proved TRA. It is estimated that the use of helical CT has resulted in at least a 40% to 50% decrease in the need for aortograms, in addition to yielding rapid, noninvasive valuable information about other injuries. Drugs (beta-blockers +/- vasodilators) to decrease the stress in the aortic wall were used in 93 patients when the diagnosis was suspected and were continued as necessary through the evaluation, stabilization, and until the aorta was cross-clamped at operation. Elective, delayed operation was done between 2 days and 25 months in 15 patients who were deemed to be excessive risks for emergency aortic repair; there were 2 deaths (13. 3%). Eleven patients never had aortic repair. No patient maintained on this protocol, whether repaired emergently, electively, or not at all, developed free rupture of the periaortic hematoma and death from TRA.

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.

The goals were (1) to characterize physiologic changes after a combined insult of hemorrhage plus sepsis in a large animal model and (2) to determine whether transient inhibition of the neutrophil CD18 adherence receptor during fluid resuscitation impairs host defense during recovery from this injury.Two series of experiments were performed in anesthetized swine. In the first series (n = 22), the cecum was ligated and incised immediately before 35% hemorrhage. After 1 hour, shed blood plus supplemental fluid was administered to restore and stabilize hemodynamics. On the basis of these results, a second series examined effects of anti-CD18 (2 mg/kg R15.7; n = 9) or its saline placebo (n = 10) administered during fluid resuscitation.In the first series the mortality rate was 41% (9 of 22). Early deaths occurred 3.0 +/- 0.8 days after injury and were distinguished by significantly lower neutrophil counts on resuscitation. Those alive a 7 days had intraabdominal abscesses and bacteremia. Alveoli and peribronchial spaces were congested, with edema and fibrin deposition in capillaries and alveoli. Livers were congested with biliary stasis. Despite these pathologic findings, hemodynamic, electrolyte, and serum enzyme changes were minimal. In the second series the mortality rate at 4 days was 30% with placebo (3 of 10) versus 33% with anti-CD18 (3 of 9). Lung changes (i.e., pneumonia, pleuritis, thrombosis, and edema) were similar in both groups, but liver congestion and hemorrhage were attenuated by anti-CD18. Some aspects of host defense were altered by anti-CD18. At 24 and 48 hours the oxidative burst potential for circulating granulocytes was 208% +/- 57% and 383% +/- 73% with placebo versus 1273% +/- 351% and 762% +/- 226% in anti-CD18. At 72 hours the granularity of circulating neutrophils was unchanged from baseline with placebo but was reduced to 82% +/- 5% by anti-CD18. At 48 hours lipopolysaccharide-evoked tumor necrosis factor production in vitro was reduced to 62% +/- 22% with placebo but was increased to 148% +/- 16% with anti-CD18.Anti-CD18 during fluid resuscitation did not increase vulnerability to endogenous pathogens because the transient inhibition of neutrophil demargination was balanced by enhanced oxidative burst, degranulation, and production of tumor necrosis factor in circulating cells later during recovery. Thus a single administration of antiadhesion therapy does not worsen posttrauma outcome even if given during ongoing sepsis.

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.

To determine whether the use of prophylactic recombinant human granulocyte colony-stimulating factor (filgrastim) reduces the frequency of nosocomial infections in patients with either acute traumatic brain injury or cerebral hemorrhage.Randomized, placebo-controlled, double-blind, multicenter phase II study.Intensive care units of seven medical centers.Patients with either acute traumatic brain injury or cerebral hemorrhage who were intubated within 6 hrs of admission and who were expected to be ventilated for72 hrs.Patients were randomized to receive daily subcutaneous injections of placebo (n = 21) or one of two doses of filgrastim (75 microg [n = 20] or 300 microg [n = 20]) for 10 days or until the absolute neutrophil count was75,000 cells/mm3 or until extubation.End points included increase in absolute neutrophil count, safety of filgrastim, and frequency of nosocomial infections (pneumonia, bacteremia, and urinary tract infection). Filgrastim caused a dose-dependent increase in absolute neutrophil count. There were no differences in the frequency of pneumonia or urinary tract infection; however, there was a dose-dependent decrease in the frequency of bacteremias (p.05). Adverse events were similar among the three groups. There was one case of acute respiratory distress syndrome in the placebo group.In this patient population, use of filgrastim was safe and the agent appeared to reduce the risk of primary bacteremias but had no beneficial effects on mortality, length of stay, or other nosocomial infections.

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.

To evaluate the pharmacoeconomic implications of using aztreonam-clindamycin (A-C) versus gentamicin-clindamycin (G-C) from the perspective of the hospital and pharmacy directors.Pharmacoeconomic analysis performed at one of the sites participating in the prospective, randomized, double-blind, comparative, multicenter efficacy study.Referral hospital with level 1 trauma center.Eight-five adults with a suspected penetrating intraabdominal injury requiring laparotomy.Patients were randomized to receive aztreonam 2 g intravenously every 8 hours or gentamicin 2 mg/kg intravenous load followed by 5 mg/kg/day intravenously initially adjusted to peak concentrations of 6-8 micrograms/ml. All patients received clindamycin 900 mg intravenously every 8 hours.Charge data were gathered from the hospital billing system and converted to cost data using an institutional cost:charge ratio of 0.6. Study drug and aminoglycoside monitoring costs were also calculated. Overall, 43 (97%) of 44 patients receiving A-C had a favorable clinical response compared with 35 (85.4%) of 41 receiving G-C (p = 0.052). The mean hospital cost of $66,336 for 7 infected patients was significantly higher than that of $8014 in 78 noninfected patients (p0.0001). Mean hospital costs of $12,058 and $13,742 for A-C and G-C groups, respectively, were not significantly different (p0.05) despite having only a single failure (total cost $162,666) in the A-C group. Similarly, mean pharmacy costs of $1411 and $1604, respectively, were not significantly different (p0.05).Hospital costs for infected patients with penetrating abdominal trauma exceed those of noninfected patients by 5-fold. Despite a lower infection rate in the A-C group, neither hospital nor pharmacy costs were significantly different compared with those in the G-C group.

To evaluate the pharmacokinetic profiles of aztreonam and imipenem in critically ill trauma patients with pneumonia.Trauma patients in intensive care units who were intubated within 3 days of hospital admission were eligible for the study. Patients with the clinical diagnosis of pneumonia were consecutively randomized to receive either aztreonam plus vancomycin or imipenem-cilastatin. Serial blood samples were taken and sputum was collected to determine aztreonam and imipenem concentrations after 2-3 days and 7-8 days of therapy. Pharmacokinetics of both agents were estimated and compared with estimates from healthy volunteers.Twenty patients were enrolled in the study, 10 patients received imipenem-cilastatin, and 10 received aztreonam plus vancomycin. Steady-state volume of distribution (Vss) for aztreonam at 2-3 days and 7-8 days was significantly greater in patients than in historical controls, whereas the Vss for imipenem was greater at 2-3 days. The beta-half-life for aztreonam at both sampling periods was significantly greater in patients than in controls. No significant changes in pharmacokinetics occurred over time for either antibiotic. Sputum concentrations of aztreonam and imipenem were highly variable when sampled 2 hours after the infusion.Larger volumes of distribution were observed for both aztreonam and imipenem in trauma patients than in volunteers, suggesting that standard initial dosages of the antibiotics may result in lower concentrations in these critically ill patients. Both antibiotics penetrated into the sputum of most patients; however, the degree of penetration was highly variable in relation to serum concentrations.

OBJECTIVE: The effect of timing of femur fracture fixation for patients with multiple trauma was studied to determine the effect of operative timing on eventual outcome. METHODS: The relationship between timing of intramedullary rod (IMR) placement, degree of injury, and pulmonary complications was studied in 424 consecutive patients. The authors focused on 105 patients undergoing IMR placement with an Injury Severity score (ISS) of greater than or equal to 18. The effects of timing of IMR placement on various pulmonary complications, organ failure, intensive care unit (ICU) admission, and ventilatory assistance were studied for various time intervals. RESULTS: Of the 424 patients, pulmonary complications increased slightly in the more seriously injured group (ISS > 18) but were not influenced by the timing of IMR placement. Of the 105 patients undergoing IMR placement with an ISS > or = 18, only 2 patients died. Both patients had an IMR placed in less than 24 hours and died later of head injury and delayed hemorrhage. The incidence of organ failure, number of ventilator days, and length of ICU stay did not differ between the groups based on timing of fracture fixation. The incidence of severe head injuries was higher in the group undergoing delayed IMR placement (> 48 hours). CONCLUSIONS: Modest delays in IMR placement did not adversely affect patient outcome. Pulmonary complications were related to the severity of injury rather than to timing of fracture fixation. In a well-integrated trauma system, clinical judgment regarding the timing of IMR placement was the most important determinant of outcome. Delays that were made to stabilize the patient, treat associated injuries, and plan orthopedic reconstruction did not adversely affect patient outcome.

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.

To determine whether the hepatic conjugation-detoxification function was altered during sepsis, the metabolism of bilirubin was measured with gamma-scintigraphy.Time-activity curves were generated after a radiolabeled bilirubin analog (technetium 99m-mebrofenin, hepatoiminodiacetic acid [HIDA]) was administered to anesthetized (fentanyl) mongrel pigs in the following conditions: control (n = 16); 30 minutes after 5 micrograms/kg intravenous Escherichia coli endotoxin (LPS; n = 6); 30 minutes after trauma (40% arterial hemorrhage plus soft tissue injury, n = 9); 72 hours after sham trauma (n = 6); 72 hours after fluid resuscitated trauma either before (n = 9) or 30 minutes after (n = 10) LPS administration. All were ventilated with 65% O2 and instrumented with pulmonary artery oximetric catheters.After trauma plus LPS, the rate of HIDA uptake was depressed 20% to 30% (p0.05), whereas its elimination half-time was increased almost threefold (p0.05) relative to before LPS administration. At the corresponding time after trauma alone or LPS alone, uptake was not altered and elimination was prolonged less than twofold (p0.05) relative to control. Perfusion differences could not explain these data because cardiac index (CI, ml/min/kg) was reduced to the same extent after trauma alone (62 +/- 10), LPS alone (79 +/- 6), or trauma plus LPS (71 +/- 6) compared with control (102 +/- 5), sham (112 +/- 11), or pre-LPS (120 +/- 10) (p0.05, respectively). Levels of serum alanine aminotransferase and creatine kinase were both elevated (p0.05) 72 hours after resuscitation, but there were no added increments caused by LPS administration. Levels of other enzymes and plasma bilirubin were not increased by trauma or LPS alone or in combination. Changes in HIDA uptake-excretion within 30 minutes of LPS after resuscitated trauma coincided with neutropenia and pulmonary hypertension and preceded a hyperdynamic inflammatory state characterized by increased CI (194 +/- 19 ml/min/kg, p0.05) at 90 +/- 13 minutes, decreased systemic vascular resistance (0.48 +/- 0.04 mm Hg per ml/min/kg, p0.05 relative to 1.08 +/- 0.07 for control or 0.88 +/- 0.08 for pre-LPS) at 81 +/- 8 minutes, and increased systemic O2 consumption (6.96 +/- 0.93 vs 4.16 +/- 0.23 ml O2/min/kg, p0.05 relative to pre-LPS) at 96 +/- 12 minutes.(1) A prior episode of resuscitated traumatic shock exhausts hepatic reserve and this occult dysfunction in the conjugation-detoxification system or bilirubin metabolism is unmasked by LPS; (2) hepatic dysfunction could have a role in the pathogenesis of the hyperdynamic circulatory response evoked by LPS because HIDA clearance was reduced before CI increased or systemic vascular resistance decreased; (3) HIDA clearance is a rapid, reliable, and inexpensive estimate of bilirubin metabolism that may have a practical application in patients with septic trauma or others with occult liver dysfunction.

Previous work documented a 40% depression of hepatic indocyanine green (ICG) clearance (ClICG) in pigs fasted to 20% weight loss, with return to normal within 12 days of food refeeding. ClICG in pigs is insensitive to changes in hepatic blood flow but very sensitive to changes in hepatic function (HF). Serial ClICG determinations were performed to quantify the effect of route of nutrient delivery on recovery of HF.Fourteen pigs were fasted to 20% weight loss (12.8 days average) with both gastrostomy and intravenous catheters placed in each animal midway through the fast. ClICG was measured before fast, after fast, and after 12 days refeeding through the enteral or parenteral route at 125 kcal/kg/day with isonitrogenous, isocaloric diets containing 9% fat. Urine and stool were analyzed for total nitrogen.No significant differences appeared between groups in nitrogen output during fasting (4.5 +/- 1.2 gm/kg enteral, 4.6 +/- 1.2 gm/kg parenteral), in nitrogen intake (800 +/- 19 mg/kg/day enteral, 810 +/- 10 mg/kg/day parenteral), or in before or after fast ClICG, but enteral feeding produced more positive nitrogen balance. ClICG improved significantly with enteral but not with parenteral feeding.Enteral feeding produces faster nitrogen accrual and reverses the depression of major pathways of bilirubin and organic anion excretion associated with malnutrition. Parenteral feeding failed to improve organic anion clearance despite weight gain.

Hemorrhagic shock and sepsis are usually studied separately or in rodents. This study combined the two insults in a large animal model.Anesthetized pigs were bled, held in shock for 1 hour, and then resuscitated with fluid. After 3 days, Escherichia coli endotoxin LPS was infused into the portal vein (150 micrograms/kg x 30 min) to mimic the effect of enteric substances breaching the mucosal barrier. Systemic and splanchnic hemodynamics, circulating leukocytes, and plasma levels of tumor necrosis factor (TNF) were measured in five groups: 40% hemorrhage plus fluid only resuscitation, 40% hemorrhage plus fluid-blood resuscitation, 50% hemorrhage plus fluid-blood resuscitation, sham, or sham plus 5 micrograms/kg LPS priming dose instead of hemorrhage.On day 4 before infusion of LPS, there were no differences between groups in hemodynamics or O2 utilization, but systemic O2 delivery and O2 consumption were each reduced in the hemorrhaged groups because of the hemodilution associated with resuscitation. For 3 hours after infusion of LPS, all animals received aggressive fluid and respiratory support, but arterial blood pressure decreased, and systemic O2 utilization, splanchnic O2 utilization, and arterial lactate level increased; there were no differences between groups. In the 50% group compared with sham, LPS-evoked decreases in cardiac index and stroke index were eliminated, and LPS-evoked tachycardia, pulmonary and systemic vasoconstriction, and increases in hepatic and portal vein lactate levels were blunted. Despite similar leukocyte counts before infusion of LPS and similar leukopenia after LPS infusion, plasma LPS level was higher in the 50% group compared with sham. Furthermore, LPS evoked increases in portal and hepatic vein plasma TNF in the shams, but those changes were reduced in the 50% group.Most responses to LPS were similar after hemorrhagic shock or a sham operation, which is inconsistent with the concept of "priming." LPS-evoked increases in plasma TNF were blunted after shock, probably because of trauma-induced immune dysfunction. A combined shock plus septic challenge in a large animal model may be valuable for investigating the pathogenic mechanism in human beings.

To characterize the pharmacokinetic profile of trimethoprim-sulfamethoxazole (TMP-SMX) in trauma patients and to compare these parameter estimates with those obtained in nontrauma patients.Open-label, multidose, pharmacokinetic study.Trauma intensive care unit of a level 1 trauma center located within a regional medical center.Fifteen adult trauma patients with serious gram-negative infections. All patients were studied on day 1 of treatment, nine on day 3, three on day 5, and two on day 7. One patient was discontinued from the study because of a possible drug-induced rash.Study patients received TMP 4 mg/kg and SMX 20 mg/kg intravenously every 12 hours. Serial blood sampling was performed up to 4 times per patient between treatment days 1 and 7. Serum was assayed for TMP-SMX using high-performance liquid chromatography. A one-compartment model was fit to the data using maximum likelihood estimation.Mean (SD) baseline parameter estimates for TMP were volume 2.1 (0.65) L/kg, half-life 9.7 (3.0) hours, and clearance 2.6 (0.80) ml/min/kg. Estimates for SMX were volume 0.51 (0.10) L/kg, half-life 7.8 (2.0) hours, and clearance 0.80 (0.29) ml/min/kg. Both volume (p0.01) and clearance (p0.001) for SMX were significantly higher and half-life (p0.05) significantly shorter than previously reported estimates in nontrauma patients. No significant differences in TMP parameter estimates were found. Neither TMP nor SMX clearance was significantly correlated with estimated creatinine clearance (p0.05).The results indicate that the pharmacokinetics of SMX in trauma patients differ significantly from nontrauma patients, which may result in lower than expected concentrations using standard dosing guidelines.

Nosocomial pneumonia is a frequent complication in hospitalized patients. Gram-positive pathogens, particularly Staphylococcus aureus, are responsible for the increasing frequency of nosocomial pneumonia. To evaluate the efficacy and safety of intravenous quinupristin/dalfopristin (Synercid) in the treatment of nosocomial pneumonia caused by gram-positive pathogens we conducted a prospective, randomized, open-label, international, multicenter, comparative clinical trial. Two hundred ninety-eight patients with nosocomial pneumonia were enrolled in 74 active centers in five countries: a subgroup of 171 (87 quinupristin/dalfopristin-treated and 84 vancomycin-treated patients) were evaluable for the major efficacy end points. One hundred fifty received 7.5 mg/kg of quinupristin/dalfopristin every 8 h; 148 patients received 1 g of vancomycin every 12 h. Aztreonam at a dose of 2 g every 8 h could be administered in both groups for coverage of gram-negative organisms, and tobramycin was added for coverage against Pseudomonas aeruginosa. The primary efficacy end point was the clinical response between the seventh and the thirteenth day after the end of treatment in clinically evaluable patients with documented causative pathogen(s) at baseline (bacteriologically evaluable population). Therapy was clinically successful (cure or improvement) in 49 (56.3%) of patients receiving quinupristin/dalfopristin and 49 (58.3%) patients receiving vancomycin (difference, -2.0% [95% Cl, -16.8% to 12.8%]) in the bacteriologically evaluable population. Equivalent clinical success rates were also observed in the all-treated population (n = 298), and in the bacteriologically evaluable patients intubated in baseline (39/72 [54%] compared with 36/67 [54%]). The by-pathogen bacteriologic response was similar in both treatment groups, with equivalent clinical success rates for Streptococcus pneumoniae, Staphylococcus aureus, and methicillin-resistant Staphylococcus aureus. Adverse events (venous and nonvenous) were equally distributed between groups; 15.3% of quinupristin/dalfopristin patients and 9.5% of vancomycin patients discontinued therapy because of an adverse clinical event. In this study quinupristin/dalfopristin was shown to be equivalent to vancomycin in the treatment of nosocomial pneumonia caused by gram-positive pathogens. Quinupristin/dalfopristin merits further evaluation for the treatment of nosocomial pneumonia caused by methicillin-resistant S. aureus.

The optimal duration of antibiotic use in penetrating abdominal trauma is incompletely defined. It is generally accepted that short-term antibiotics are appropriate for low-risk wounds. However, with colon injury and significant degree of injury, abdominal trauma index (ATI) more than 25, concern exists that short-term treatment is not adequate.The study was a prospective double-blind trial of 24-hour treatment (cefoxitin or cefotetan) compared with 5-day treatment in 515 patients. Major abdominal infections (MAI) included abscess, necrotizing fasciitis, and diffuse peritonitis.MAI occurred in 8% of those patients with 1-day therapy and 10% with 5-day therapy. Subgroup analysis of high-risk groups (colon wounds and ATI of more than 25) showed the following MAI rates: colon, 1-day therapy, 14%; 5-day therapy, 15%; ATI of more than 25, 1-day therapy, 17%; 5-day therapy, 30%.Regardless of contamination and degree of injury, 24-hour antibiotic therapy is satisfactory for all penetrating abdominal trauma.

In summary, there are several factors essential to successful treatment of major vascular abdominal injuries. Prompt resuscitation and abdominal exploration is paramount. Proximal control can quickly be obtained at the esophageal hiatus and adequate exposure of the retroperitoneum is mandatory. Most aortic injuries can be repaired primarily; however, if an arterial substitute is necessary, then PTFE is the substitute of choice. Reimplantation of the injured iliac artery to the contralateral iliac artery is an option for bifurcation injuries if that will not inordinately constrict the lumen. And finally, four-compartment fasciotomies will decompress the lower extremities and prevent ischemic muscle necrosis following reperfusion injury.

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.

Over a 7-year period, 151 patients with gunshot wounds to the colon surviving beyond 24 hours were managed. The bullet was retained in the body in 66% and exited in 34%. Thirty-four (23%) developed major septic complications (diffuse peritonitis, 21%; intraperitoneal abscesses 24%; and extraperitoneal abdominal abscesses, 56%). The septic complication rate was 26% in the bullet-present group compared with 16% in the remainder (p less than 0.15). The increased septic rate in those with bullets present was the result of abscesses developing around the retained missile. That group with missile abscesses had a lesser degree of injury as measured by the abdominal trauma index compared with the other patients with septic complications (p less than 0.001). Fifteen (79%) of the 19 patients with missile and missile track abscesses had them develop in the psoas muscle. These abscesses occur by fecal contamination of the muscle following inoculation by the bullet, which passes through the large bowel. Computed tomography-guided and operative drainage tend to fail if the foreign body is not removed. Computed tomography-guided or operative drainage should be successful in draining missile track abscesses when the bullet has exited the patient.

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.

The Organ Injury Scaling Committee of the AAST recently published a consensus classification of splenic, hepatic, and renal injuries (J Trauma, 29:1664, 1989). The hepatic injury scale (HIS), based on parenchymal laceration and intrahepatic hematoma, includes grades 1 to 6, representing the least to most severe injury. This study classifies liver injuries by findings at celiotomy, correlates operative findings with transfusion requirements and method of management of liver injury, and relates preoperative CT to anatomic findings at laparotomy. Thirty-seven patients with blunt liver injury were evaluated by abdominal CT with and without intravenous contrast and then underwent celiotomy. Increasing operative HIS correlated well with increasing severity of injury as measured by transfusions and operative management. Thirty-one CT grades did not correlate with operative findings (84%). Four patients had intrahepatic hematomas that were not discovered at operation. Twelve lacerations were graded too high by CT and 15 too low. Of these 15, ten CT scores were at least two grades lower than operative findings. Injuries around the falciform ligament occurred in three of the low misclassifications. One patient with intrahepatic hematoma developed hepatic artery pseudoaneurysm. We conclude that the HIS readily characterizes operative findings of hepatic lacerations and that increasing operative grade correlates well with transfusion requirements and operative management. CT can define intrahepatic hematomas, but does not correlate well with hepatic lacerations. Extreme caution is required when using CT alone to define "minimal" liver injury for prospective management of blunt trauma victims.

Over a nine-month period, patients with chest trauma were prospectively evaluated for myocardial contusion. Ninety-two patients with evidence of anterior chest trauma were entered into the study and had 1) an ECG on admission and daily for three days; 2) monitoring of the myocardial band fraction of creatine phosphokinase (CPK-MB) on admission and every eight hours for 24 hours; 3) continuous electrocardiographic Holter monitoring for three to five days; and 4) noninvasive pulsed-Doppler cardiac output measurements daily for three days. Twenty-three patients developed 25 significant arrhythmias (SARRs): 1 atrial fibrillation, 1 AV dissociation, 5 supraventricular tachycardias, and 18 paroxysmal ventricular tachycardias. Cardiac outputs were significantly higher in those patients without SARRs. The CPK-MB levels correlated with the SARRs but were neither sensitive nor specific. No patients required specific therapy and none developed adverse sequelae of the SARRs. We conclude that 1) CPK-MB monitoring should not be routinely used for screening and diagnosis; 2) continuous arrhythmia monitoring deserves further clinical investigation but not routine application; 3) stable patients at risk for myocardial contusion should be monitored for 24 hours; and 4) the Abbreviated Injury Score for "minor" myocardial contusion should be deleted for purposes of ISS tabulation.

Medication prescribing patterns and costs of specific drug therapies in a trauma intensive-care unit (TICU) were studied. Demographic data and total drug use (scheduled, p.r.n., and single-dose medications) were recorded for all patients admitted to a TICU whose length of stay exceeded 24 hours. Scheduled and p.r.n. medications were categorized into major drug classes for purposes of analysis. Cost estimates were calculated for all scheduled medications. Correlations were made between demographic variables, injury severity indices, drug use, and length of stay by using simple linear regression. A one-way ANOVA was used to compare drug use between the trauma types. For the 278 patients who met the inclusion criteria, the mean +/- S.D. number of drugs prescribed was 9.1 +/- 6.5. Scheduled medications accounted for 58% of total drug use. Mean +/- S.D. duration of scheduled drug therapy was 5.0 +/- 4.8 days. Age (by decade), injury severity score, trauma score, and length of stay correlated with total and scheduled drug use per patient. Drug use (total, scheduled, and p.r.n.) did not differ significantly by trauma type. Antimicrobial therapy, stress ulcer prophylaxis, and bronchodilator therapy accounted for more than 66% of all scheduled drugs used; total cost estimates for these three drug categories exceeded $47,000 over the six-month study period. Analgesics, antipyretics, sedatives, and muscle relaxants constituted nearly 75% of all p.r.n. drug orders. Drug use in the TICU was extensive. The drug categories identified in this study may be useful in future cost containment efforts and initiation of drug use evaluations.

Changes in pulmonary function tests were compared in 14 thoracic trauma patients, of whom seven received thoracic epidural bupivacaine for analgesia and seven received lumbar epidural morphine. In both groups epidural analgesia decreased subjective pain levels when compared to parenteral narcotics which the patients received before epidural catheter placement. Patients in the bupivacaine group had statistically significant improvements in vital capacity and forced expiratory volume, and a decreased respiratory rate. Patients in the morphine group had no significant change in pulmonary function. The use of thoracic epidural bupivacaine for analgesia in post-traumatic chest injuries produced superior improvement in pulmonary function when compared to lumbar epidural morphine.

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)

Hypoxemia following long bone or pelvic fracture (LBPF) is often attributed to fat embolism syndrome (FES), but the true incidence and etiology of postfracture pulmonary shunt (Qsp) are not well defined. Over 12 months, 92 patients with LBPF admitted to a Level I trauma center were prospectively evaluated. Arterial blood gases, Hct, platelet count, serum fibrinogen, serum lipase, and urinary fat bodies (UFB) were determined serially from admission through the fifth hospital day. Patients were evaluated daily by chest x-ray, vital signs, mental status, and presence of petechiae. Four patient groups were established: No Qsp, Qsp with pulmonary injury (Qsp + PI), Qsp without pulmonary injury or petechaie (FES - P), and Qsp without pulmonary injury and with petechiae (FES + P). Qsp indicated by an alveolar/arterial PO2 gradient greater than 100 torr developed in 49 (53%) of the patients. Pulmonary injury was present in 39 (81%) of those 49 and was at least partially responsible for the shunt. The remaining ten patients were diagnosed as having FES; four had petechiae (FES + P) and six were without petechiae (FES - P). The minimum incidence of FES in LBPF is therefore 11%.

To establish a standardized protocol of obtaining coagulation studies from arterial lines without heparin contamination, two methods were evaluated in a prospective randomized fashion for accuracy by comparing PT and aPTT results with simultaneous samples drawn by venipuncture. Fifty paired samples were obtained, 25 by method A and 25 by method B, from critically ill patients in the surgical intensive care unit at City of Memphis Hospital. Analyses of PT and aPTT from these samples revealed a close statistical correlation with the venous controls and no clinically significant difference between the samples.

There were 225 patients with penetrating neck wounds admitted over a 4-year period. Mechanism of injury included stab wounds in 59%, gunshot wounds in 32%, and shotgun wounds in 9%. Location of injury was Zone 1, 16%, Zone 2, 42%, Zone 3, 18%, posterior triangle, 12%, and multiple, 12%. The patients were divided into five groups based upon clinical presentation, location of injury and method of management: Group 1 (n = 31) had serious blood loss or respiratory distress and were immediately explored; Group 2 (n = 76) had anterior wounds and equivocal physical findings either without (n = 60) or with negative (n = 16) contrast studies and these had "mandatory explorations"; Group 3 (n = 17) and Group 4 (n = 80) presented the same as Group 2 but Group 3 patients had positive contrast studies and were explored, while contrast studies were negative in Group 4 patients who were observed; Group 5 (n = 21) had posterior injuries and/or presented late with minimal physical findings and they were observed. Positive exploration occurred in 90% of Group 1, 28% of Group 2, and 82% of Group 3. There were no missed injuries in Groups 4 or 5. Two missed esophageal injuries occurred in Group 2, and a missed carotid injury occurred in Group 3. The following guidelines for management have resulted. 1) Unstable patients require immediate exploration. 2) Stable patients with equivocal physical findings can be managed according to results of esophageal examination and angiography. 3) Patients with low probability of injury due to location and clinical presentation can be observed.(ABSTRACT TRUNCATED AT 250 WORDS)