The Role of Surgeon-Performed Ultrasound in Patients with Possible Cardiac Wounds.

OBJECTIVE: The authors evaluate surgeon-performed ultrasound in determining the need for operation in patients with possible cardiac wounds. BACKGROUND DATA: Ultrasound quickly is becoming part of the surgeon\u27s diagnostic armamentarium; however, its role for the patient with penetrating injury is less well-defined. Although accurate for the detection of hemopericardium, the lack of immediate availability of the cardiologist to perform the test may delay the diagnosis, adversely affecting patient outcome. To be an effective diagnostic test in trauma centers, ultrasound must be immediately available in the resuscitation area and performed and interpreted by surgeons. METHODS: Surgeons performed pericardial ultrasound examinations on patients with penetrating truncal wounds but no immediate indication for operation. The subcostal view detected hemopericardium, and patients with positive examinations underwent immediate operation by the same surgeon. Vital signs, base deficit, time from examination to operation, operative findings, treatment, and outcome were recorded. RESULTS: During 13 months, 247 patients had surgeon-performed ultrasound. There were 236 true-negative and 10 true-positive results, and no false-negative or false-positive results; however, the pericardial region could not be visualized in one patient. Sensitivity, specificity, and accuracy were 100%; mean examination time was 0.8 minute (246 patients). Of the ten true-positive examinations, three were hypotensive. The mean time (8 patients) from ultrasound to operation was 12.1 minutes; all survived. Operative findings (site of cardiac wounds) were: left ventricle (4), right ventricle (3), right atrium (2), right atrium/superior vena cava (1), and right atrium/inferior vena cava (1). CONCLUSIONS: Surgeon-performed ultrasound is a rapid and accurate technique for diagnosing hemopericardium. Delay times from admission to operating room are minimized when the surgeon performs the ultrasound examination

Iliac Vessel Injury: Operative Physiology Related to Outcome.

BACKGROUND: Fifty-three patients treated at a level I trauma center with iliac vessel injury were studied to determine if body temperature and acid-base status in the operating room predicts outcome. METHODS: Records were reviewed for demographics, mechanism of injury, body temperature, acid-base status, operative management, and outcome. Statistical methods included Student\u27s t test, odds ratio determination, and chi-square analysis to determine statistical significance. RESULTS: Fifty-three patients (47 male, 6 female) sustained 92 iliac vascular injuries (36 arterial, 56 venous). Mortality was 34%, with 72% of deaths due to shock within 24 hours. Physiologic parameters differed significantly between survivors and nonsurvivors. Odds ratio identified six conditions; the number present predicted outcome. CONCLUSIONS: (1) There are significant differences between initial and final operating room temperature and acid-base status in survivors versus nonsurvivors with iliac vessel injury. Conditions for odds ratio can be calculated and correlated with outcome. (2) A patient with two or more conditions should be considered for an abbreviated laparotomy to allow for reversal of physiologic failure

Acute Posttraumatic Renal Failure: A Multicenter Perspective.

UNLABELLED: Acute renal failure (ARF) following trauma is rare. Historically, ARF has been associated with a high mortality rate. To investigate this entity we conducted a retrospective review of 72,757 admissions treated at nine regional trauma centers over a 5-year period. Seventy-eight patients (0.098%) developed acute renal failure requiring hemodialysis. Detailed demographic, clinical, and outcome data were collected. Patients with pre-existing medical conditions (group I) had a 70% increase in mortality over those without pre-existing conditions (p less than 0.004). Twenty-four patients (31%) developed ARF less than 6 days after injury (group II). The remainder (group III) developed late renal failure (mean time to first dialysis, 23 days). The predominant cause of death was multiple organ failure (82%). There were no differences in mortality because of multiple organ failure among the three groups of patients. Of the 33 survivors, six (18%) were discharged with renal insufficiency, three (9%) were discharged on dialysis, 23 (70%) were discharged home or to rehabilitation, and 27 (82%) had no significant evidence of renal insufficiency. CONCLUSION: Posttraumatic renal failure requiring hemodialysis is rare (incidence, 107 per 100,000 trauma center admissions), but the mortality rate remains high (57%). Two thirds of the cases of posttraumatic renal failure develop late and are secondary to multiple organ failure; one third of the cases of posttraumatic renal failure develop early and may result from inadequate resuscitation