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Colonic resection in trauma: colostomy versus anastomosis. Murray J A, Demetriades D, Colson M et al. J Trauma 1999; 46: 250-253.

The management of colonic trauma has been clarified over recent years. Simple injuries can often be treated with primary repair. More significant right-sided injuries are often managed by resection with either an ileo-colic or colo-colic anastomosis. Left-sided injuries are often treated by resection with either an end colostomy or colo-colic anastomosis. In this study a retrospective review was undertaken to evaluate the outcome and complications associated with colonic resections performed for trauma. Factors associated with anastomotic leak were assessed. Between 1992 and 1997, 720 patients were treated at the Los Angeles County and USC Medical Centers. Of these patients, 164 underwent colonic resection. Patients were stratified as to whether they underwent an end colostomy, ileo-colic or colo-colic anastomosis. Patient demographics and colon-related complications were recorded. Overall 41% patients developed colon-related complications. 28% developed intraperitoneal abscesses. Anastomotic leak was seen in 13% who underwent a colo-colic anastomosis and 4% who underwent a ileo-colic anastomosis. Right-sided colon injuries treated by colo-colic anastomosis had an increased leak rate compared to those undergoing an ileo-colic anastomosis. The risk of leakage was increased in those who had a high Abdominal Trauma Index (>25) or were hypotensive on arrival in the emergency room. It was concluded that colonic injuries requiring resection are associated with a high complication rate irrespective as to whether a colostomy or anastomosis is performed. Colonic resection and anastomosis can be safely performed in most patients, including those with left-sided injuries. For those with left sided injuries there remains a role for colostomy particularly in those with major injuries or severe hypotension.

Perihepatic packing of major liver injuries. Carusco D M, Battistella D, Owings S L, Lee S L, Samaco R C. Arch Surg 1999; 134: 958-963. 

The management of major liver injury with uncontrollable haemorrhage remains controversial. During World War II perihepatic packing was the major surgical treatment but post-operative morbidity and mortality were significant. In the 1940s, reduced infection rates and mortality were reported with liver resection and drainage and the practice of packing was questioned. With the emerging concept of 'damage control' surgery, improved antibiotic prophylaxis and intensive care support recent interest has been shown in early perihepatic packing followed by a later planned reoperation. This approach has resulted in improved survival and fewer infectious complications compared with hepatic resection in the acute post-injury setting. The aim of this study was to determine the complication rate of perihepatic packing in relation to the timing of pack removal in patients with liver trauma. A retrospective analysis of consecutive patients with liver trauma from an American level 1 trauma centre was performed. The principal outcome measures were liver-related complications (biliary leak and abscess), rebleeding and mortality. Between 1988 and 1997, 804 patients underwent a laparotomy during which hepatic injury was identified. Perihepatic packing was used in 129 (16%) of patients. Most had sustained blunt trauma. Of the 69 (55%) that survived more than 24 hours 75% lived to hospital discharge. Mortality rates were similar in those who did and did not develop liver complications. Liver complications were similar whether pack were removed within 36 hours or between 36 and 72 hours. However, the rebleeding rate was higher (21% vs. 4%. p<0.001) in the early group. It was concluded that liver complications associated with perihepatic packing did not affect survival. Removing packs 36 to 72 hours after the initial operation reduced the risk of rebleeding without increasing the risk of liver associated with complications.

Survival after emergency department thoracotomy: review of published data from the past 25 years. Rhee P M,  Acosta J, Bridgeman A, Wang D, Jordan M,  Rich N.  J Am Coll Surg 2000;  190:  288-298. 

Advances in the pre-hospital management of trauma have resulted in the rapid transport of the severely injured patients to the emergency department.  This has allowed the adoption of the Emergency department thoracotomy (EDT) for patients who actually arrest after injury.  Selection of patients for this surgery who are most likely to survive will prevent the waste of valuable resources.  The aim of this study was to determine the main factors that influenced survival after EDT.  A retrospective analysis of the results of 24 studies (4,620 patients) that reported the outcome after EDT following both blunt and penetrating trauma was performed.  The primary outcome analysed was in-hospital survival.  EDT had an overall survival of 7.4% with normal neurological outcome seen in 93% of surviving patients.  Factors influencing outcome were mechanism of injury, location of major injury and signs of life on arrival in the emergency department.  Survival was improved following blunt trauma (8.8% vs.1.4%).  Survival was better following stab than gunshot wounds (16.8% vs. 4.3%).  Survival rates for thoracic, abdominal and multiple injuries were 10.7%, 4.5% and 0.7% respectively.  Survival was improved if there were signs of life on arrival at hospital.  There was no single clear independent preoperative factor that could uniformly predict death.  It was concluded that the best survival results were seen in patients undergoing EDT from thoracic stab wounds and who signs of life in the emergency department.  Uniform reporting guidelines are needed to further elucidate the role of EDT, taking into account mechanism and location of injury.   

Indications for early mandatory laparotomy in abdominal stab wounds. Leppaniemi A K, Voutilainen P E,  Haapiainen R K.  Br J Surg 1999;  86:  76-80. 

Up to 50% of patients with abdominal stab wounds sustain no organ damage or only minor injuries that do not require surgical intervention.  The high negative laparotomy rate is associated with considerable postoperative morbidity and has led to the introduction of policies of selective non-operative management for some injuries. There is little controversy that patients presenting with shock or peritonitis should undergo early laparotomy without preoperative investigation. Whether patients with other clinical signs such as evisceration, bleeding wounds, peritoneal penetration or retained knives justify mandatory laparotomy is more controversial.  The aim of this study was to validate the clinical and radiological criteria justifying early laparotomy in patients with anterior abdominal stab wounds using the presence of significant abdominal organ injury as the primary end-point. In a retrospective analysis of 209 consecutive patients with stab wounds of the anterior abdomen, flank and lower chest, 23 clinical and radiological criteria were evaluated for their accuracy in predicting the presence of significant abdominal injury.  Overall 89 (43%) had signs of significant injury.  The signs with the highest predictive value were continuing haemorrhage (86%), shock on admission (81%) and generalised peritonitis (81%).  Peritoneal penetration, omental evisceration, free fluid on ultrasound examination were not independent predictors of significant injury.  It was concluded that signs of haemorrhage or peritonitis were reliable criteria for early mandatory laparotomy,  Other signs warranted direct organ-specific evaluation (by CT or laparoscopy) to identify those patients that could be safely treated without operation.    

Management of isolated sternal fractures: determining the risk of cardiac injury. Sadaba J R,  Oswal D,  Munsch C M.  Ann R Coll Surg Eng 2000;  82:  162-166. 

Isolated sternal fractures are defined as a sternal fracture without evidence of a significant cardiothoracic injury.  They occur most commonly in road traffic accidents and with the introduction of seat-belt legislation these injuries have been increasingly seen in the United Kingdom. Conventional trauma management suggests that sternal fractures are frequently associated with serious intrathoracic injury, particularly blunt cardiac trauma, and that all patients should be admitted for observation.  More recently other reports have suggested that these injuries are relatively 'benign' and rarely associated with significant complications. The aim of this study was to retrospectively review the management of isolated sternal fractures in a regional cardiothoracic unit over a two year period.  In total, 37 patients with isolated sternal fractures were admitted and investigated with echocardiography and cardiac enzyme measurements.  Minor blunt cardiac injury was detected in only one patient and this was associated with an acutely abnormal ECG.  Chest x-ray and ECG were normal in 23 patients and were predictive of the absence of significant complications.  It was concluded that patients with isolated sternal fractures, who are otherwise well and have a normal ECG and chest x-ray can be safely discharged home on oral analgesics.  The routine use of echocardiography and creatinine kinase in the assessment of these patients is not indicated.

Blunt trauma to the spleen. Aseervatham R,  Muller M. Aust NZ J Surg 2000;  70:  333-337. 

The management of splenic injury in adults resulting from blunt trauma is controversial.  The trend is towards non-operative management and splenic conservation.  A retrospective review was performed of all adult patients with blunt splenic trauma in an attempt to identify factors important in selecting an appropriate management plan and predicting the success of that option.  Associated injuries (standardised suing the ISS), clinical signs at presentation, CT findings and transfusion requirement were documented.  In total 85 patients were studied.  Non-operative management was used in 39, splenic conservation in 14 and splenectomy in 32 patients.  The mean ISS was lower in the non-operative group.  CT grading of the splenic injury failed to correlate with the operative findings.  Transfusion requirements were lower in the non-operative group.  Non-operative management failed in 4 (10%) patients - two for continued splenic bleeding and two for the presence of other intra-abdominal injuries.  Overall mortality was 7%.  There was one death in the splenic conservation group unrelated to the splenic injury.  There were five deaths in the splenectomy group, only one of which was related to the splenic injury.  It was concluded that the management of blunt splenic trauma remains controversial.  The decision to pursue a non-operative management option rather than surgery depends on the individual merits of each case.  There is an increasing trend towards splenic conservation , particularly in young, stable patients with single organ injury.

Analysis of 152 gunshot wounds of the liver. Marr J D F,  Krige J E J,  Terblanche J.  Br J Surg 2000; 87:  1030-1034. 

The liver is the most commonly injured viscus in patients with abdominal gunshot wounds.  The principal objectives in the management of these injuries are the early and effective control of bleeding, the preservation of hepatic function and the prevention of septic and ischaemic complications. Gunshot wounds to the liver can result in significant morbidity and death.  Most uncomplicated injuries can be managed with simple surgical techniques but the optimal management of complex injuries remains controversial.  The aim of this paper was to analyse the outcome of gunshot liver injuries treated at a major hepatobiliary trauma centre during a 10-year period with the objective of evaluating the efficacy of current treatment methods.  At the Groote Schuur Hospital between 1986 and 1995, 153 patients were treated with gunshot liver injuries.  Demographic, clinical and operative data were recorded.  Factors influencing postoperative complications and death were analysed. Overall,142 (93%) patients had single missile injuries and 11 (7%) had shotgun wounds.  In total 150 patients underwent operation.  In 105 (70%) of patients the injuries were minor and required no treatment or simple suture of bleeding vessels. In 42 (30%) of patients major injuries occurred requiring packing or more extensive surgical interventions.  These included resectional debridement, major venous repair and hepatectomy. Associated intra-abdominal injuries occurred in 77% of patients.  The overall mortality was 17% (26 patients).  Death was directly attributable to the liver injury in 13 patients the commonest cause of death being uncontrollable haemorrhage.  Complications developed in 51% of survivors and correlated with the type and extend of liver injury.  It was concluded that most gunshot liver injuries can be managed by simple surgical techniques.  In complex liver injuries control of major haemorrhage is vital and perihepatic packing may be life saving before undertaking definitive surgical repair of the injury.    

Free fluid on abdominal computed tomography without solid organ injury after blunt abdominal injury does not mandate celiotomy.  Livingstone D H,  Lavery R F,  Passannante M R et al.  Am J Surg 2001;  182:  6-9. 

The optimal management of patients with free fluid and no solid organ injury on abdominal CT scanning following blunt abdominal trauma is unclear.  Recommendations as to the care of these patients have ranged from mandatory laparotomy, to diagnostic peritoneal lavage, to serial examinations and observations.  This issue is important as both late diagnosis of a visceral injury and the performance of a negative laparotomy have both been associated with increased morbidity and mortality.  Previous recommendations have been based on retrospective data from studies performed prior to the widespread introduction of helical CT scanning.  The aim of this study was analyse data from a prospective trial of the role of CT in abdominal trauma to determine the true incidence of hollow visceral injury in those patients with isolated free fluid.  The study was performed over a 22 month period between 1994 and 1996 in four US Level 1 trauma centres.  Data was collected concurrently at the time of patient enrollment and included demographics, injury severity score, CT findings and the presence or absence of blunt intestinal injury.  Overall, 2,299 patients were evaluated.  Free fluid was present on 265 CT scans.  Of these patients, 90 had isolated free fluid with only 7 having blunt intestinal injury.  All patients with free fluid were observed for a mean of 8 days.  There were no missed injuries.  It was concluded that free fluid on abdominal CT scan does not mandate a laparotomy.  Serial observation with the possible use of other adjunctive tests is recommended.

Abdominal stab wounds:  Diagnostic peritoneal lavage criteria for emergency room discharge.  Gonzalez R P, Turk B, Falimirski M E, Holevar M R.  J Trauma 2001;  51:  939-943. 

The management of abdominal stab wounds remains controversial. In particular, little consensus exists as to the most appropriate treatment of the patient who is haemodynamically stable with no abnormal abdominal signs. The optimal diagnostic approach would minimise hospital admissions, reduce the number of non-therapeutic laparotomies whilst maximising the sensitivity for surgically significant intra-abdominal injuries. The aim of this study was to prospectively evaluate an abdominal stab wound management method of diagnostic peritoneal lavage (DPL) as a screen for immediate hospital discharge with physical examination as an indication for operative intervention. Over a 4-year period, anterior abdominal stab wound patients were prospectively entered into the study. The anatomic boundaries for an anterior abdominal stab wound were the costal margins, inguinal ligaments and the anterior axillary lines. Haemodynamically stable patients with negative physical examinations were entered into the study and evaluated with DPL. If less than 10 ml of blood was aspirated after insertion of the lavage catheter, one litre of saline was infused and removed. Patients with DPL results of less than 1000 RBC/ml were sent home. Patients with DPL results of greater than 1000 RBC/ml were admitted for observation. Haemodynamically stable patients with evisceration and no tenderness had the viscera replaced in the emergency room. Eviscerated patients did not undergo DPL and were admitted for observation. Patients that presented with haemodynamic instability or peritonitis were not entered in the study and underwent immediate surgical intervention. Overall, 90 haemodynamically stable patients were entered in the study. Some 44 (49%) patients had DPL less than 1000 RBC/ml , 34 of whom were discharged home. Of the 10 admissions that qualified for discharge, 4 were admitted due to elevated blood alcohol levels, 3 for psychiatric assessment and 3 required other surgical procedures. No patient with a DPL result less than 1000 RBC/ml required a laparotomy or had a complication related to the abdominal stab wound. Some 38 (42%) patients were observed because of a DPL count greater than 1000 RBC/ml. Of these patients, 8 (21%) developed positive physical signs that prompted an exploratory laparotomy of which 5 (63%) were therapeutic. There were no complications associated with the delayed laparotomy. Four (4%) patients had DPL results greater than 500 WBC/ml, all of which underwent an immediate laparotomy. Four (4%) patients presented with evisceration, one of which underwent a therapeutic laparotomy. It was concluded that patients with abdominal stab wounds who are haemodynamically stable can be safely sent home from the emergency room when their DPL counts are less than 1000 RBC/ml. Observation of haemodynamically stable patients allows for low laparotomy rates with minimal morbidity.

The utility of clinical examination in screening for pelvic fractures in blunt trauma.  Gonzalez R P, Fried P Q, Bukhalo M.  J Am Coll Surg 2002;  194:  121-125. 

Routine anterior-posterior (AP) pelvic radiography is used by many trauma centres as a screening tool for pelvic fractures in patients with blunt trauma. The ATLS course of the American College of Surgeons recommends obtaining pelvic x-rays on all patients who suffer blunt abdominal trauma, believing that pelvic x-ray screening allows early identification of potential sources of haemorrhage. Significant morbidity and mortality associated with pelvic haemorrhage may be prevented with early detection of pelvic fractures. The aim of this study was to evaluate, in a prospective manner, the sensitivity of clinical examination as a screening modality for pelvic fractures in awake and alert blunt trauma patients. During a 32 month period, 2176 consecutive patients with blunt trauma and a Glasgow Coma Scale of 14 or 15 were assessed at a Level 1 trauma centre. Clinical examination of all patients was performed by trauma residents. The clinical examination of each patient was documented on a study proforma before performance of a standard AP pelvic x-ray. Overall 97 (4.5%) of patients had a pelvic fracture. Seven of the injuries were missed on clinical examination (sensitivity 93%). None of the missed injuries required surgical intervention. The sensitivity of the AP pelvic x-ray was 87%, with 13 missed injuries. There were 463 patients with an ethanol level greater than 100 mg/dl. Twenty pelvic fractures were diagnosed in this group with only one missed injury on clinical examination. It was concluded that clinical examination of the pelvis can reliably exclude a significant pelvic fracture in the awake and alert trauma patients. The addition of a routine AP pelvic x-ray does not improve on the sensitivity in the diagnosis of surgically significant pelvic fractures nor does it significantly impact on outcome. Elevated ethanol levels is not a contraindication to the use of clinical examination as a screening modality for pelvic fractures.

Randomised clinical trial to determine if delay from time of penetrating colonic injury precludes primary repair.  Kamwendo N Y, Modiba M C M, Matlala N S, Becker P J.  Br J Surg 2002;  89:  993-998.

Many controversies regarding the management of penetrating colonic injury in civilian practice have been resolved but there are still unanswered questions about whether primary closure of such injuries in the presence of delayed presentation, shock, associated injuries or peritoneal contamination leads to increased morbidity and mortality.  Penetrating colonic injuries have in the past been treated by initial colostomy and later elective closure.  Recently primary colonic repair has emerged as the treatment of choice.  The aim of this prospective study was to determine whether primary suture of a penetrating colonic injury in the presence of delayed presentation, shock or associated injuries was associated with an adverse outcome.  Patients with penetrating colonic injuries were randomised to either primary closure or colostomy.  Patients were compared with regards to interval from injury to operation, associated injuries, duration of operation and postoperative complications.  Overall, 240 patients were assessed over a 69-month period.  The interval from injury to presentation ranged from 3 to 56 hours and was similar in the two treatment groups.  Postoperative complications were similar in the two groups. but there was a significant difference in operating time ( 127 (46) min for primary repair vs. 142 (43) min for colostomy. p=0.009).  It was concluded that delay from time of penetrating colonic injury is not a contraindication to primary repair.

Factors affecting management and outcome in blunt renal injury.  Kuo R L, Eachempati S R, Makhuli M J, Reed L.  World J Surg 2002;  26:  416-419.

Over 90% of injuries to the kidney result from blunt trauma.  To evaluate the severity of renal injuries CT has become the primary method of staging in patients not requiring immediate operation for the management of other injuries.  The radiological stage of injury has been thought to correlate with need for operative intervention.  Generally, minor injuries to the kidney are well tolerated and resolve without intervention.  Depending on the degree of injury and the stability of the patient, nephrectomy or a renal salvage procedure are both options for patients who require operation.  Severely injured kidneys may not be salvageable. The aim of this study was to evaluate whether radiological grade of renal injury correlated with need for nephrectomy and outcome in patients sustaining blunt renal trauma.  Patients with blunt renal trauma admitted to a Level 1 trauma centre between 1989 and 1997 were retrospectively reviewed.  Multiple factors were examined and logistic regression analysis performed.  Factors predictive for the need for nephrectomy and mortality were determined.  Of the 11,847 trauma patients admitted, 95 (0.8%) suffered blunt renal trauma.  Mean age and injury severity score (ISS) where 31.4 and 23.7 respectively.  The number of deaths and nephrectomies were 11 and 10 respectively.  Higher renal injury grade as well as higher ISS values and the 24-hour transfusion need directly correlated with the need for nephrectomy.  Greater age, higher ISS and higher 24-hour transfusion requirements lowered the probability for survival.  It was concluded that patients with blunt renal trauma often sustain multiple injuries.  The grade of renal injury, the overall ISS and the requirement of blood transfusion are the primary factors in determining both the patients need for nephrectomy and overall outcome.

Management of traumatic aortic rupture.  A 30-year experience.  Cardarelli M G,  McLaughlin J S,  Downing S W et al.  Ann Surg 2002;  236:  465-470.

Traumatic aortic rupture (TAR) is a serious sequelae of blunt chest trauma with its diagnosis and treatment providing a challenge to thoracic surgeons.  It is responsible for between 15 and 25% of all road traffic accident fatalities.  It is also seen in other accidents which result in sudden deceleration and stress at the transition between the mobile distal aortic arch and the posteriorly bound isthmus.  Overall, cardiac and trauma surgeons have little exposure to TAR.  This article attempts to summarise a 30-year experience in the management of this entity at a single institution, with the accompanying evolution in diagnostic methodology and surgical technique.  Between 1971 and 2001, 219 patients with a diagnosis of TAR were operated on at the University of Maryland, Baltimore.  Since 1994 the diagnosis of TAR has been based exclusively on the use of contrast-enhanced spiral CT, with angiography reserved for equivocal cases.  Patients were divided according to surgical technique.  Overall, 82 patients (Group A) were operated on with a clamp-and sew technique, 64 patients (Group B) underwent surgery with the use of a passive shunt and 73 patients (Group C) were treated using heparin-less partial cardiopulmonary bypass.  The mortality was 21%. 36% and 18% in Groups A, B and C respectively.  Paraplegia occurred in 23%, 17% and none of the patients in Groups A, B and C respectively (p=0.005).  Aortic occlusion without lower body perfusion for more than 30 minutes (p=0.004) and surgical technique without lower body bypass support (p=0.0005) were associated with paraplegia.  It was concluded that surgery for TAR based on spiral CT screening and diagnosis is reliable.  The use of heparin-less distal cardiopulmonary bypass in the authors hands is safe and is associated with a reduced incidence of paraplegia.  

Non-operative management of blunt hepatic injury in multiply injured adult patients.  Al-Mulhim A S. Mohammad H A H. Surg J R Coll Surg Edinb Irel 2003;  1:  81-85.  

Until recently, operative management was the standard of care in treating liver injuries.  Non-operative management of blunt liver trauma, however, has now evolved into a common practice, especially since abdominal CT has enabled more precise evaluation of these patients.  The strategy for this arose from the observation that many liver injuries had stopped bleeding at the time of laparotomy and needed little or no intervention.  Guidelines for the non-operative management of blunt liver injuries have been produced.  Improvements in resuscitation careful monitoring in the intensive care unit, coupled with advances in diagnostic radiology have helped to make this non-operative possible.  The aim of this study was to determine the place of non-operative management in haemodynamically stable patients with blunt liver injuries and appropriate radiology.  A retrospective review was undertaken of 63 patients.  Overall, 52 (83%) were successfully managed non-operatively.  The remaining 11 (17%) failed conservative management and underwent laparotomy.  Patients managed non-operatively were younger than those requiring surgery.  The mean injury severity score (ISS) was 16.2 6.1 vs.  26.1 8.5 (p<0.001) in the two groups respectively.  Intensive care stay was reduced in the non-operative group.  The requirement for blood transfusion was increased in the operative group. Six (9%) patients managed non-operatively developed complication.  These included perihepatic collections (2), urinoma (1) and chest infections (3).  The perihepatic collections and urinoma were all drained percutaneously.  Overall, three (5%) patients died with only one death being related to the hepatic injury,  No deaths occurred in the non-operative group.  It was concluded that non-operative management should be the initial approach to all patients with blunt liver injury if haemodynamic stability can be ensured.  When continued bleeding can be safely ruled out, a period of intensive monitoring is warranted.

Effects of intravenous corticosteroids on death within 14 days in 10 008 adults with clinically significant head injury (MRC CRASH Trial):  randomised placebo-controlled trial.  CRASH trial collaborators.  Lancet 2004;  364:  1321-1328.

Every year, millions of people worldwide are treated for head injury.  A substantial proportion die or are permanently disabled.  Although much damage is done at the time of the injury, post-traumatic inflammatory changes are believed to contribute to neuronal degeneration.  Corticosteroids have been used to treat head injuries for more than 30 years.  In 1977, findings of systemic review suggested that these drugs reduce risk of death by 1-2%.  The CRASH trial, a multicentre international collaboration, aimed to confirm or refute such an effect by recruiting 20,000 patients.  In May 2004, the data monitoring committed disclosed the unmasked results to the steering committee, which stopped recruitment.  In this study, 10,008 adults with head injury and a Glasgow Coma Score (GCS) of 14 or less within 8 hours of injury were randomly allocated to a 48 hour infusion of corticosteroids (methylprednisolone) or placebo.  primary outcome measures were death within 2 weeks of injury and death or disability at 6 months.  Prespecified subgroup analyses were based on injury severity (GCS) at randomisation and on time from injury to randomisation.  Analysis was by intention to treat.  Effects on outcomes within 2 weeks of randomisation were presented in this report.  Compared with placebo, the risk of death from all causes within 2 weeks was higher in the group allocated corticosteroids (1052 [21%] vs 893 [18%] deaths; relative risk of death 1.18 [95% CI 1.09-1.27] p=0.0001).  The relative increase in deaths due to corticosteroids did not differ by injury severity or time since injury.  It was concluded that there is no reduction in mortality with methylprednisolone in the 2 weeks after head injury.  The cause of the rise in the risk of death within 2 weeks is unclear.

Outcome and prognostic factors in head injuries with an admission Glasgow Coma Score of 3.  Demetriades D,  Kuncir E,  Velmahos G C et al.  Arch Surg 2004;  139:  1066-1068.

Patients with head injury with low Glasgow Coma Scale (GCS) scores on hospital admission have a poor prognosis.  A GCS of 3 is the lowest possible score and is associated with an extremely high mortality rate, with some suggesting that there is no chance of survival.  The aims of this study were to evaluate mortality in a large group of patients with head injury with admission GCS scores of 3 and to identify factors that are associated with outcome.  A total of 760 patients with head injury managed in a Level 1 trauma centre were studied.  All had an admission GCS of 3.  The analysis was performed in only those patients that reached hospital alive and had no major extracranial injuries.  Stepwise logistic regression analysis was used to identify independent risk factors associated with mortality.  Blunt trauma accounted for 477 (63%) and penetrating trauma for 283 (37%) of the 760 head injuries.  Penetrating trauma was significantly more likely to be associated with a lack of vital signs on admission (15% vs. 9%; p=0.03).  Overall mortality was 76% (94% for penetrating injuries and 65% for blunt injuries; p<0.001).  Overall, 79% of patients had a head Abbreviated Injury Score of 4 or greater.  Mortality in the subgroup was 64% (320/497) and was significantly higher in penetrating versus blunt trauma (89% vs. 52%; p<0.001).  Penetrating trauma, high head AIS, hypotension on admission and age more than 55 years were independent risk factors associated with mortality.  Only 10% of the 177 survivors had good functional outcome and hospital discharge.  Overall, 86 patients (17% of those with vital signs on admission) became organ donors.  It was concluded that patients with head injury with and admission GCS of 3 have a poor prognosis.  Mechanism of injury, head AIS, hypotension on admission and age play a critical role in outcome.  These patients are an important source of organ donation and should be evaluated and resuscitated aggressively.

Hypertonic resuscitation of hypovolemic shock after blunt trauma.  Bulger E M,  Jurkovich G J,  Nathens A B et al.  Arch Surg 2008;  143:  139-148.

The leading cause of late mortality after trauma is multiple organ failure syndrome, due to dysfunctional inflammatory response early after injury.  Preclinical studies demonstrate that hypertonicity alter the activation of inflammatory cells, leading to a reduction in organ injury.  The aim of this study was to evaluate the effect of hypertonicity on organ injury after blunt trauma.  This study was a double-blind randomised controlled trial with prehospital enrolment in a US level 1 trauma centre.  Patients were selected older than 17 years with blunt trauma and prehospital hypotension (systolic blood pressure < 90 mmHg).  They were managed with with either 250 ml 7.5% hypertonic saline and 6% dextran 70 (HSD) or lactated Ringer solution (LRS).  The primary outcome measure was survival without ARDS at 28 days.  Cox proportional hazards regression was used to adjust for confounding factors.  A pre-planned subset analysis was performed for patients requiring 10U or more of packed red cells in the first 24 hours.  A total of 209 patients were enrolled (110 in the HSD group and 99 in the LRS group).  The study was stopped for futility after the second interim analysis.  Intention-to-treat analysis demonstrated no significant difference in the ARDS-free survival (HR 1.01; 95% CI 0.63-1.60).  There was improved ARDS free survival in the subset (19% of the population) requiring 10U or more of packed red cells (HR 2.18; 95% CI 1.09-4.36).  It was concluded that although there was no significant overall difference in ARDS-free survival, there was a benefit in the subgroup requiring massive blood transfusion.  Massive transfusion may be a better predictor of ARDS than prehospital hypotension.  The use of HSD may offer maximum benefit in patients at highest risk of ARDS.

Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial.  Shakur H, Roberts I,  Bautista R and the CRASH-2 trial collaborators.  Lancet 2010;  376:  23-42 .

Tranexamic acid can reduce bleeding in patients undergoing elective surgery. The aim of this trial was to assess the effects of early administration of a short course of tranexamic acid on death, vascular occlusive events, and the receipt of blood transfusion in trauma patients. This randomised controlled trial was undertaken in 274 hospitals in 40 countries. 20 211 adult trauma patients with, or at risk of, significant bleeding were randomly assigned within 8 hours of injury to either tranexamic acid (loading dose 1 g over 10 min then infusion of 1 g over 8 h) or matching placebo. Randomisation was balanced by centre, with an allocation sequence based on a block size of eight, generated with a computer random number generator. Both participants and study staff (site investigators and trial coordinating centre staff) were masked to treatment allocation. The primary outcome was death in hospital within 4 weeks of injury, and was described with the following categories: bleeding, vascular occlusion (myocardial infarction, stroke and pulmonary embolism), multiorgan failure, head injury, and other. All analyses were by intention to treat. Overall, 10 096 patients were allocated to tranexamic acid and 10 115 to placebo, of whom 10 060 and 10 067, respectively, were analysed. All-cause mortality was significantly reduced with tranexamic acid (1463 [14.5%] tranexamic acid group vs 1613 [16.0%] placebo group; relative risk 0.91, 95% CI 0.85-0.97; p=0.0035). The risk of death due to bleeding was significantly reduced (489 [4.9%] vs 574 [5.7%]; relative risk 0.85, 95% CI 0.76-0.96; p=0.0077).Tranexamic acid safely reduced the risk of death in bleeding trauma patients in this study. On the basis of these results, tranexamic acid should be considered for use in bleeding trauma patients.

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