J Trauma
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As trauma systems have developed and board-certified in-house surgeons are now immediately available, enthusiasm has returned for thoracotomy as part of initial resuscitation. This study evaluated the impact of thoracotomy by board-certified surgeons during the resuscitative phase of treatment. ⋯ Survivors of penetrating injury had a probability of survival (Ps) of 0.48. Most patients suffering penetrating deaths had severe and advanced physiologic derangements at the time of admission despite similar anatomic injuries to survivors.
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Pulmonary contusion is the usual manifestation of lung parenchymal injury following blunt chest trauma. With rapid deceleration, however, parenchymal lacerations can result in cavities best termed post-traumatic pulmonary pseudocyst (PPP). This report discusses eight adult PPP cases encountered at the Denver General Hospital over the past 30 months. ⋯ Computed tomography of the chest was pursued in complicated patients and clearly influenced therapy. Three (38%) pseudocysts developed into lung abscesses; two required resection and the other responded to percutaneous drainage. Although previously described as a benign pediatric entity, in our adult experience, PPP may result in a recalcitrant lung abscess requiring aggressive intervention.
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During a 6-year period, 14 consecutive children with penetrating craniocerebral gunshot wounds (GSW) were studied. Eleven patients were comatose on admission. Five had an admission Glasgow Coma Scale (GCS) score of 4 or less and developed clinical signs of brain death within 12 hours despite maximum therapeutic efforts. ⋯ There were four survivors. Neurobehavioral and intellectual functions were evaluated over a period of 1 to 2 years. Although serious cognitive deficits were noted, all survivors had sufficient functional recovery to warrant aggressive cardiopulmonary resuscitation and measures to control ICP in the management of comatose victims of craniocerebral GSW.
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The effects of injury with hemorrhagic shock on the clotting and fibrinolytic systems were studied serially in 22 patients receiving 21 +/- 13 transfusions and 1.26 +/- 0.58 L of fresh frozen plasma (FFP) during operation (OR). The PT, aPTT, thrombin time (TT), fibrinogen (FI), factors V (FV) and VIII (FVIII), fibrin(ogen) split products (FSP) and fibrin monomers were measured in OR and after OR at 6 and 15 hours, days 2 and 4, and at convalescence (25 days). The TT, PT, and aPTT were were prolonged in OR and reflected the low FI, FV, and FVIII, respectively. ⋯ Later factor restoration likely reflects enhanced hepatic synthesis, factor half-life, capillary selectivity retaining large molecular weight factors, and intravascular relocation from abundant extravascular stores. Throughout this biphasic response, the clotting times reflect factor levels. Fibrinolysis contributes little to these changes.
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Tube thoracostomy (TT) is required in the treatment of many blunt and penetrating injuries of the chest. In addition to complications from the injuries, TT may contribute to morbidity by introducing microorganisms into the pleural space or by incomplete lung expansion and evacuation of pleural blood. We have attempted to assess the impact of TT following penetrating and blunt thoracic trauma by examining a consecutive series of 216 patients seen at two urban trauma centers with such injuries who required TT over a 30-month period. ⋯ Patients with blunt trauma experienced more complications (44%) than those with penetrating wounds (30%) (p = 0.04). However, only seven of 13 patients developing empyema or requiring decortication had blunt trauma. Despite longer requirements for mechanical ventilation, intensive care, and intubation, victims of blunt trauma seemed to have effective drainage of their pleural space by TT without increased risk of infectious complications.