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Background Aggressive screening for blunt cerebrovascular injury (BCVI) and prompt anticoagulation for documented injuries has resulted in a significant reduction in ischemic neurologic events. An association between vertebral artery injuries (VAIs) and specific cervical spine fracture patterns has been suggested; however, current screening guidelines would subject all patients with cervical spine fractures to imaging because no distinction has been made for carotid artery injuries (CAIs). We hypothesized that specific cervical spine fracture patterns that warrant screening evaluation exist, hence limiting unwarranted diagnostic imaging. Methods Patients undergoing screening for BCVI on the basis of injury patterns and mechanism have been prospectively followed at our regional trauma center since January 1996. Results During the study period from January 1996 to January 2005, there were 17,007 blunt trauma admissions. Twenty-three patients presented with symptoms of BCVI. Screening angiography was performed in 766 patients (4.5%), and diagnosed 258 (34%) patients with BCVI. One hundred twenty-five patients with BCVI had cervical spine fractures; 18 patients had isolated CAI; 84 had isolated VAI, and 23 had combined CAI and VAI. Eight patients with VAI had minor cervical fractures but underwent screening for other injury patterns. Fractures in the remaining patients with BCVI were 1 of 3 patterns. Subluxations in 56 (48%) patients, C1 to C3 cervical spine fractures in 42 (36%), or extension of the fracture through the foramen transversarium in 19 (16%). Cervical spine fractures were the sole indication for screening in 90% of the study population. Screening yield of all patients admitted with 1 of these 3 fracture patterns was 37%. Conclusions Blunt cerebrovascular injury is associated with complex cervical spine fractures that include subluxation, extension into the foramen transversarium, or upper C1 to C3 fractures. Patients sustaining such cervical fractures should undergo prompt screening.

Background Postinjury multiple organ failure (MOF) is a result of a dysfunctional inflammatory response to severe injury and shock. Acute lung injury is thought to promote further organ dysfunction by the systemic release of inflammatory mediators from injured lung tissue. Although clinical evidence supports this model, a clear understanding of the relationship between lung dysfunction and multiple organ failure has yet to be defined. We hypothesized that respiratory dysfunction is an early obligate event in the progression of postinjury MOF. Methods Data were collected prospectively on 1,344 trauma patients at risk for postinjury MOF. Inclusion criteria were age greater than 16 years, trauma intensive care unit admission, Injury Severity Score greater than 15, and survival longer than 48 hours. Isolated head injuries and head injuries with an extracranial abbreviated injury score of less than 2 were excluded. Daily physiologic and laboratory data were collected through surgical intensive care unit day 28 and clinical events were recorded thereafter until death or hospital discharge. Organ failure was characterized using the Denver MOF scale. Results Organ dysfunction was observed in 1,011 (75%) of 1,344 patients. Lung dysfunction was observed in 951 (94%) patients with 1 or more organ dysfunctions and 598 (99%) of 605 patients with 2 or more organ dysfunctions. Lung dysfunction preceded heart, liver, and kidney dysfunction by an average of 0.6 ± 0.2 days, 4.8 ± 0.2 days, and 5.5 ± 0.5 days, respectively. The severity of lung dysfunction correlated with the severity of heart, liver, and kidney dysfunction, and the number of other dysfunctional organ systems. Conclusions Postinjury respiratory dysfunction is an obligate event that precedes heart, liver, and kidney failure. The severity of other organ dysfunction is related directly to the severity of respiratory dysfunction. These data implicate lung dysfunction as central to the promotion of pathogenic inflammation and the development of postinjury MOF.

Background Resuscitative thoracotomy performed in the emergency department (EDT) continues to have clear indications in patients sustaining trauma to the torso, particularly penetrating injuries. However, adjunctive use of aortic cross-clamping during EDT for hemorrhagic shock also may be useful in the acute resuscitation of patient with nontorso injuries (NTI). We questioned the utility of EDT in patients with nontorso trauma. Methods Patients undergoing EDT have been prospectively followed since 1977 at our regional level I trauma center. Results During the 26-year study period, 959 patients underwent EDT; 27 (3%) of these patients underwent EDT for penetrating NTI. Three (11%) of these patients survived to leave the hospital, with only 1 patient sustaining mild neurologic deficit. The mechanism of injury in the survivors was stab wound to the neck (1), gunshot wound to the neck (1), and extremity vascular injury (1). All survivors of EDT for NTI underwent prehospital cardiopulmonary resuscitation and successful endotracheal intubation in the field. There were no survivors of EDT for penetrating injury to the head. Conclusions Resuscitative EDT with aortic cross-clamping is a potential adjunct in the acute resuscitation of NTI involving penetrating neck or extremity vascular injuries.

Despite routine prophylaxis, thromboembolic events (TEs) in surgical patients remain a substantial problem. Furthermore, the timing and incidence of hypercoagulability, which predisposes to these events is unknown, with institutional screening programs serving primarily to establish a diagnosis after an event has occurred. Emerging evidence suggests that point of care (POC) rapid thrombelastography (r-TEG) provides a real-time analysis of comprehensive thrombostatic function, which represents an analysis of both enzymatic and platelet components of thrombus formation. We hypothesized that r-TEG can be used as a screening tool to identify hypercoagulable states in surgical patients and would predict subsequent thromboembolic events.Rapid thrombelastography r-TEG analyses were performed on 152 critically ill patients in the surgical intensive care unit (ICU) during 7 months. Hypercoagulability was defined as clot strength (G)12.4 dynes/cm(2). Variables of interest for identifying hypercoagulability and thromboembolic events included sex, age, operating hospital service, specific injury patterns, injury severity score (ISS), transfusion within first 24 h, ICU duration of stay, ventilator days, hospital admission days, and thromboprophylaxis. Comparisons between the hypercoagulable and normal groups or between the groups with and without thromboembolic events were performed using Chi-square tests or the Fisher exact test for categorical variables and independent sample t tests or Wilcoxon rank sum tests for continuous variables. Multivariate logistic regression analysis (LR) was performed to identify independent predictors of thromboembolic events. A receiver operating characteristic curve was used to measure the performance of G for predicting the occurrence of a TE event. All tests were 2-sided with significance of P.05.In all, 86 patients (67%) were hypercoagulable by r-TEG. More than 85% of patients in the hypercoagulable group and 79% in the normal group received thromboprophylaxis during the study period. The differences between hypercoagulable and normal groups by bivariate analysis included high-risk injuries (52% vs 35%; P = .03), spinal cord injury (27% vs 12%; P = .03), median ICU duration of stay (13 vs 7 days; P.001), median ventilator days (6 vs 2; P.001), and median hospital duration of stay (20 vs 13 days; P.001). A total of 16 patients (19%) of the hypercoagulable group suffered a thromboembolic event, and 10 hypercoagulable patients (12%) had thromboembolic events predicted by prior r-TEG hypercoagulability. No patients with normal coagulability by r-TEG had an event (P.001). LR analysis showed that the strongest predictor of TE after controlling for the presence of thromboprophylaxis was elevated G value (odds ratio: 1.25, 95% confidence interval [CI]: 1.12-1.39). For every 1 dyne/cm(2) increase in G, the odds of a TE increased by 25%.These results indicate that the presence of hypercoagulability identified by r-TEG is predictive of thromboembolic events in surgical patients. Subsequent study is necessary to define optimal prophylactic treatment strategies for patients with r-TEG proven hypercoagulability.

Background Although the safety of primary repair/anastomosis for civilian colon injuries after standard laparotomy (SL) has been established, recent civilian and military reports have questioned the advisability of this technique in the patient requiring damage control laparotomy (DL). We hypothesized that, even in the high-risk DL group, primary repair could be safely used after patient stabilization and that the open abdomen would facilitate the safety of this procedure. Methods All patients admitted to our level 1 trauma center with a colon injury over a 7-year period were reviewed from a prospectively collected database. Patients were categorized as having undergone either SL or DL at initial operation. Primary variables of interest were as follows: injury patterns; method of primary repair (suture repair, resection and primary anastomosis, resection and delayed anastomosis); diversion techniques (planned diversion or diversion for anastomotic dehiscence); and colon-related morbidity and mortality. High-risk status in the DL group was identified by the following physiologic variables: mean injury severity score (ISS), red blood cell (RBC) transfusions, ventilator days, and intensive care unit (ICU) duration of stay. Results During the study period, 309 patients had colonic wounds identified at laparotomy. Of these 309 patients, 280 (91%) underwent SL, of which 277 (98.9%) had primary colonic repair/anastomosis. In the SL group, 1 (0.3%) patient required diversion for subsequent leak and 2 (0.6%) patients had planned diversion The remaining 29 hemodynamically unstable patients required DL. Mean ± standard deviation indices of injury severity in this group included: ISS = 36.2 ± 15.8, RBC = 28.7 ± 25.4 units, ventilator days = 20.1 ± 16.3, ICU duration of stay = 29.5 ± 21.6 days. Of the 29 patients in the DL group, 21 (72%) had bowel continuity successfully reestablished in 2.6 ± 2 days after initial attempts at primary suture repair or resection/anastomosis. A total of 4 (16.6%) patients in this group developed colon-related complications, 3 of whom were treated with subsequent diversion before definitive abdominal closure. One patient developed a late leak. (day 43). Another 4 (13.8%) patients had planned diversion for injuries that were considered to be high risk for leak at subsequent reexploration. There were no colon-related deaths in either group. Conclusion Primary repair of colon injuries appears safe in the majority of patients after DL. Although it is associated with a higher leak rate than SL, the open abdomen affords careful inspection of abdominal contents at reexploration to identify patients who require subsequent diversion.

Postinjury organ dysfunction is a result of unbridled systemic hyperinflammation. According to the two-event construct, patients are resuscitated into an early vulnerable window of systemic hyperinflammation (primed) in which a second otherwise innocuous event precipitates uncontrolled hyperinflammation, leading to secondary organ damage and dysfunction (activated). Recent efforts to decrease postinjury morbidity have focused on limiting the potential of second events and systemic inflammation. We hypothesized that the collective effects of recently implemented therapeutic strategies have resulted in decreased activation of the systemic inflammatory response relative to priming in recent years.Data were collected prospectively on trauma patients at risk for postinjury multiple organ failure (MOF). Inclusion criteria were age15 years, trauma intensive care unit admission, Injury Severity Score15 and survival48 hours. Isolated head injuries and head injuries with an extracranial abbreviated injury score2 were excluded. Daily physiologic and laboratory data were collected through surgical intensive care unit day 28, and clinical events were recorded thereafter until death or hospital discharge. Organ failure was characterized with the use of the Denver MOF Scale. Acute respiratory distress syndrome (ARDS) was defined according to the consensus definition.Over a 6.5-year period 897 patients were studied; 271 (31%) developed ARDS, and 226 (25%) developed MOF. Early lung dysfunction, as a measure of systemic priming, did not change over the study period. In contrast, the incidence of ARDS and MOF decreased from 43% to 25% and 33% to 12%, respectively. The incidence of early MOF decreased from 22% to 7% over the study period.Priming of the postinjury inflammatory response is an early event and is primarily influenced by the injury itself. Recent advances in postinjury care such as judicious blood transfusion, lung protective ventilation, treatment of adrenal insufficiency, and tight glucose control are known to attenuate systemic inflammation. Step-wise adoption of these therapies is coincident with a decrease in the destructive processes resulting in ARDS and MOF. The global effect is a decrease in activation of the systemic inflammatory response over recent years.

CASE PRESENTATION A 63-YEAR-OLD CAUCASIAN FEMALE was evaluated at an outside emergency department for complaints of 48 hours of progressively worsening right upper quadrant abdominal pain associated with bilious emesis. She reported a 2-year history of intermittent postprandial midepigastric abdominal pain, for which an extensive outpatient workup had been nondiagnostic. Computerized tomography of the abdomen revealed retroperitoneal fluid around the head of the pancreas, suggestive of retroperitoneal hemorrhage. The patient was transferred to our facility for further evaluation. Mesenteric angiography demonstrated large caliber pancreaticoduodenal (PD) arteries that contained several small aneurysms (Fig 1). The common hepatic artery had filled retrograde from the PD arcade by way of the gastroduodenal artery (GDA). The celiac artery (CA) could not be selectively cannulated. We concluded that the PD aneurysms were caused by exuberant collateral blood flow to compensate for celiac occlusion. We planned a 2-stage approach: mesenteric vascular reconstruction followed by ablation of the PD aneurysms by selective embolization. Initial revascularization was undertaken because embolization of the PD arcade may have left the hepatic arterial circulation relatively ischemic, given that a significant amount of hepatic arterial flow occurred retrograde via branches from the