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A 1990 national survey of 66 closed trauma centers across 14 states was conducted to ascertain the factors that prompted closure. Data from 44 facilities, or 67% of the centers identified, indicate that inadequate financing and physician participation were commonplace. The findings support the work of other investigators and demonstrate that uncompensated care, inadequate reimbursement, high operating costs, and lack of physician support all adversely affect trauma care in both urban and suburban settings.

Blunt traumatic rupture of the heart and pericardium, rarely diagnosed preoperatively, carries a high mortality rate. From 1979 to 1989, more than 20,000 patients were admitted to a Level I trauma center. A retrospective review identified 59 patients requiring emergency surgery for this condition. Injuries resulted from vehicular accidents (68%), motorcycle crashes (10%), pedestrians being struck by vehicles (7%), falls (5%), crushing (7%), and being struck by a horse (2%) or crane (2%). Seventeen patients (29%) had isolated rupture of the pericardium; 37 (63%) had ruptures of one or more cardiac chambers. All patients had signs of life at the scene or during transportation, but only 29 (49%) had vital signs on admission: 15 with chamber injury, 12 with pericardial rupture, and two with combined injuries. Diagnosis was established by emergency thoracotomy in the 30 patients who arrived in cardiac arrest. In the remaining 29 patients, diagnosis was made by urgent thoracotomy (41%), by subxiphoid pericardial window (34%), during laparotomy (21%), or by chest radiography (3%). The overall mortality rate was 76% (45 patients), but only 52% for those with vital signs on admission. Rapid transportation and expeditious surgical treatment can save many patients with these injuries.

Sepsis and upper gastrointestinal hemorrhage due to duodenal-caval fistula complicated delayed treatment of an abdominal gunshot wound. Gastric and duodenal decompression, external drainage of the duodenal repair, and caval ligation are preferred for delayed treatment of combined duodenal and infrarenal vena caval injuries.

Thirty-six ruptured thoracic aortas have been diagnosed in a total of 3,500 patients seen at the Maryland Institute for Emergency Medicine in the past 5 years. To our knowledge, no ruptured thoracic aortas have gone undetected. A new method of performing portable chest radiography has been developed which we feel clarifies the diagnosis of mediastinal hematomas and which allows us to determine which patients will undergo aortography. The reported survival rate of 75% is felt to be due to the rapidity with which these patients are brought to the hospital and use of a carefully planned protocol which permits early diagnosis and treatment. These results are due to the combined efforts of the Maryland State Police Helicopter System, the traumatologists, anesthesiologists, nurses, paramedics, radiologists, and thoracic surgeons working together as a completely integrated team.

In recent years the syndrome of overwhelming post-splenectomy sepsis has been increasingly reported in adults. Since more than 50% of these infections are caused by pneumococcus these post-splenectomy patients are considered a suitable group to receive the pneumococcal vaccine. Previous studies of the response obtained in post-splenectomy patients have been conflicting and we found no study that looked at the response to immediate vaccination in this group of patients. Sixteen consecutive multitraumatized patients received polyvalent pneumococcal vaccine 0.5 ml IM within 72 hours of splenectomy and 10 normal controls were given 0.5 cc polyvalent pneumococcal vaccine. Patients received an average of 19.2 units of blood and blood products; seven were on steroids for concomitant head injury. Antibody was measured by the radioimmune assay. Most of the subjects of both groups responded to at least seven of the 12 measured antigens and no patient in the control group and only one in the splenectomized group responded to all 12 antigens. When rate of response to individual serotypes was compared no difference was found between the two groups. Comparison of geometric mean fold rise and fold rise between the two groups for each of the 12 serotypes revealed essentially no difference. We conclude the response to polyvalent pneumococcal vaccine among polytrauma splenectomized patients is similar to that of normal controls, and that the vaccine can be administered immediately post-splenectomy.

In the context of developing a mass casualty evaluation methodology and in the pursuit of increased realism in the field, a system of casualty time cards has been developed. These cards capture most elements of the physician evaluation and free decision-making from the ambiguity that necessarily accompanies having a doctor 'evaluate' mock victims. They manifest the deterioration or death of the victim as time goes by and condition the risks and outcomes to depend upon treatment.

During an 11-month period 31 cases of nosocomial empyema were identified in 29 of 741 multiply traumatized patients who remained in our unit for more than 3 days. Nosocomial empyema was defined as purulent culture-positive material drained from the pleural space after five days' hospitalization. All patients had fever and leukocytosis. Possible risk factors included previous aspiration in five patients but none developing pneumonia, prior respiratory tract infection in nine but none with the same pathogen as their empyema, prior antibiotic use in over 50% of the patients, and severe head or chest injury in two thirds of the patients. Thirty-eight pathogens were recovered: S. aureus, 14; beta-streptococci, three; Pseudomonas, six; Klebsiella, two; Enterobacter, two; E. coli, two; other Gram-negative bacilli, six; and anaerobes, three. Fourteen infections were polymicrobic and bacteremia occurred in 42% of the patients. Of these 29 patients, 27 had chest tubes inserted for fluid in the pleural cavity before development of empyema; nine for hemo- or pneumothorax secondary to chest trauma, 11 for pneumothorax while on ventilators, and seven for unexplained sterile pleural effusion. If empyema complicated a prior hemothorax it was usually caused by Staphylococcus aureus and occurred about 10 days after draining blood from the pleural cavity. If empyema was a complication of pneumothorax or serothorax it was usually due to Gram-negative organisms colonizing the upper respiratory tract and occurred within 4 days of draining the fluid. Sixteen per cent of all patients who had chest tubes placed for fluid in their pleural cavity subsequently developed empyema.(ABSTRACT TRUNCATED AT 250 WORDS)

Significant differences were identified between a group of elderly patients (65 years and older) and a nonelderly group both with blunt thoracic trauma. There was a lower incidence of elderly patients presenting in shock; however, cardiopulmonary arrest at arrival was more frequent in this group. Although the types of complications were similar in both populations, the morbidity and mortality rates were higher in the elderly. A high index of suspicion must be generated for an elderly patient who has sustained blunt chest trauma. An aggressive diagnostic and therapeutic approach may lead to a decrease in the high morbidity and mortality rates in the elderly.

Breast augmentation is being done increasingly, not only for women who consider their breasts too small but also for those with breast asymmetry, and post-mastectomy patients with reconstruction. It appears inevitable that traumatologists will have to evaluate injury to an augmented breast in a patient who has sustained blunt chest trauma. This paper discusses the differential diagnosis and treatment of implant rupture, hematoma, and spherical capsular contracture as a result of trauma.

Over a seven-year period from 1973 through 1979, 31 patients with blunt gallbladder trauma were treated at the Maryland Institute for Emergency Medical Services Systems. Twenty patients had contusions, ten patients had avulsions and one patient had a perforation of the gallbladder. None of the gallbladder injuries were suspected preoperatively. Twenty-eight of the 31 patients had a diagnostic peritoneal lavage performed on admission, all were positive for blood; bile was not grossly evident. Among the 30 patients, there were 75 associated intraabdominal injuries; there were 25 liver injuries. Five patients died, none as a result of their gallbladder injury. Cholecystectomy is suggested as the definitive procedure of choice for severe contusions and for perforating and avulsive injuries to the gallbladder. Cholecystostomy is indicated in a few patients and should be regarded as a temporary procedure. A review of the English literature shows a total of 101 patients (including the 31 of this study) with gallbladder injuries secondary to blunt trauma. The most commonly reported injury was perforation. The 20 contusions described in the present study are the first such injuries reported.

Twelve patients developed acute cholecystitis complicating trauma. Acute acalculus cholecystitis was present in 11 patients. Nine patients died. A review of 20 reports comprising 98 patients shows 86.7% had acute acalculus cholelithiasis, and 61.1% had necrosis, gangrene, and/or perforation of the gallbladder. The overall mortality was 33.3% and only 16.1% of patients treated by cholecystectomy died. The etiology of acute cholecystitis complicating trauma is multifactorial. Gallstones are present infrequently whereas shock, increased bile pigment load, drugs, surgery, and (other) trauma are common precursors. Diagnosis is difficult and depends upon clinical suspicion and the physical examination. Immediate surgical intervention is required. Cholecystectomy is the procedure of choice. We recommend cholecystectomy at initial laparotomy whenever there is evidence of trauma to the gallbladder, or if the right or common hepatic artery is ligated for hepatic bleeding.

Human immunodeficiency virus (HIV) infection rates among 1,497 consecutive adult trauma victims triaged from rural and urban sectors to a statewide trauma center in Baltimore were studied. Those studied were 71.7% men, 77.4% whites, 63.2% vehicular trauma victims, 11.2% assault victims, and 25.7% other trauma victims. Non-Baltimoreans predominated (86.0%) and 32.7% were 25 to 39 years of age. Overall, 1.67% of the victims were HIV antibody positive. Significantly higher infection rates were seen in men (1.96% vs. 0.95%; p less than 0.02), non-whites (4.13% vs. 0.95; p less than 0.005), assault victims compared with vehicular and other trauma victims (5.99% vs. 1.06% vs. 1.30%, respectively; p less than 0.001), and Baltimore City residents (3.81% vs. 1.32%; p less than 0.03). Among those 25 to 39 years of age, 68.0% of the HIV infections were noted. Results suggest that HIV infection rates among trauma center patients are a reflection of the patient population served.

A case of nonfatal air embolism from orogenital sex in the 30th week of pregnancy is described. Because of a delay in the diagnosis, the patient did not receive hyperbaric oxygen therapy until 39 hours after the incident. Severe neurologic dysfunction persisted despite hyperbaric therapy. The world literature on orogenital sex in pregnancy with resultant air embolism is reviewed. The pathophysiology of air embolism and the rationale for hyperbaric oxygen treatment are presented. It is strongly recommended that survivors of this form of air embolism be transferred to hyperbaric facilities as soon as possible to reduce the long-term neurologic sequelae.

Perumbilical portal vein catheters and arterial and central venous catheters were inserted in 16 patients recovering from trauma or other shock-producing events, and in 5 patients who later developed shock. This permitted serial measurement of blood gases, pH, and the levels of ammonia, lactate and certain other metabolites in all three circulatory systems simultaneously. Nine of the trauma patients were never in shock, had no liver disease or injury and consequently formed a baseline group for comparison with the shock patients. In the shock patients there was a significant degree of hypoxemia in the portal venous blood and an increase in the arterialportal oxygen saturation difference. Their portal venous blood showed a lower pH and a higher pCO(2) than did the portal blood of the patients who had never been in shock. In 3 of the 4 shock patients who died, the total blood lactate showed a greater increase in portal venous than in the arterial or central venous blood. In shock there was also an increase in portal venous blood ammonia which was later accompanied by increments in arterial and central venous blood ammonia. This suggests impairment of hepatic urea synthesis, allowing escape of ammonia through the liver. These phenomena, when added to the finding previously reported of an elevated portal venous pressure in some shock patients, lend support to the hypothesis that in certain cases of shock there is increased impedance to flow of portal blood through the liver with resultant stasis in the portal-splanchnic bed and ischemichypoxic hepatocellular injury.

The innominate artery of a patient requiring prolonged mechanical ventilation was palpated in the inferior portion of his tracheostomy wound. Life-threatening hemorrhage was prevented by rotation of a local muscle flap the protect the artery and rotation of pedicled skin flaps to create a permanent tracheostomy.

During an 8-year period, from 1974 to 1982, 13 patients were treated for superior mesenteric vascular injury secondary to blunt abdominal trauma. Ten male and three female patients ranged in age from 18 to 68 years (average age, 42.7 years). Six patients presented in profound shock, two presented in cardiopulmonary arrest, and five presented with mild shock. The 13 patients had an average of 3.2 associated intra-abdominal injuries. Six patients had devitalized bowel as a direct consequence of injury to the superior mesenteric vessels. One patient developed intestinal necrosis postoperatively from thrombosis of the superior mesenteric vein which led to extensive small bowel resection. The blood replacement ranged from 2 to 30 units, averaging 11.7 units per patient. Operative procedures included lateral arteriorrhaphy (five patients) and venorrhaphy (11 patients). Four patients required combined vessel repair and one patient required ligation of both vessels and bowel resection. The mortality rate of 57% was primarily due to massive acute hemorrhage, which was larger than could be accounted for by the associated intraabdominal injuries. Free intraperitoneal hemorrhage from the valveless portal system, which can carry up to 60% of cardiac output, causes massive bleeding until abdominal tamponade supervenes.