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BACKGROUND: Selective surgical exploration of penetrating neck wounds is now the standard of care, but the safety and cost effectiveness of selective diagnostic testing remains controversial. We herein review our 18-year prospective evaluation of a progressively selective approach. PATIENTS AND METHODS: Since 1979, 312 patients sustained penetrating trauma to the anterior neck; 75% were stabbed and 24% were shot. Zone I was penetrated in 13%, zone 11 in 67%, and zone III in 20%. RESULTS: In all, 105 (34%) of the patients had early exploration (16% were nontherapeutic). Of the 207 (66%) observed, 1 (0.5%) required delayed exploration. Length of stay was 8.0 days following exploration, 5.1 days following negative exploration, and 1.5 days following observation. In the last 6 years, 40% have had adjunctive testing: 69% of zone I, 15% of zone II, and 50% of zone III injuries. CONCLUSION: Selective management of penetrating neck injuries is safe and does not mandate routine diagnostic testing for asymptomatic patients with injuries in zones II and III. Am J Surg. 1997;174:678-682. [C] 1997 by Excerpta Medica, Inc.

BACKGROUND: The abdominal compartment syndrome (ACS) is now recognized as a frequent confounder of surgical critical care following major trauma; however, few prospective data exist concerning its characterization, evolution, and response to decompression. METHODS: Acutely injured patients with an injury severity scale (ISS) score [is greater than] 15 requiring emergent laparotomy and intensive care unit (ICU) admission were prospectively evaluated for the development of ACS. The syndrome was defined as an intra-abdominal pressure (IAP) [is greater than] 20 mm Hg complicated by one of the following: peak airway pressure (PAP) [is greater than] 40 cm [H.sub.2] O, oxygen delivery index ([DO.sub.2] I) [is less than] 600 mL [O.sub.2]/min/[m.sup.2], or urine output (UO) [is less than] 0.5 mL/kg/hr. Physiologic response to decompression was similarly documented prospectively. RESULTS: Over a 14-month period ending December 1995, 21 (14%) of 145 patients (ISS [is greater than] 15) requiring laparotomy and admitted to our surgical ICU developed ACS; mean age was 39 [+ or -] 9 years; injury mechanism was blunt in 60%; ISS 26 [+ or -] 6. At initial laparotomy, 67% underwent abdominal packing (57% for major liver injuries). Mean IAP was 27 [+ or -] 2.3 mm Hg, and time from laparotomy to decompression was 27 [+ or -] 4 hours; 24% were planned whereas the remaining were prompted by deteriorating organ function as defined above (cardiopulmonary in 43%; renal in 19%; both renal and cardiopulmonary in 14%). Following decompression, there was an increase in cardiac index, oxygen delivery, urine output, and static compliance while there was a decrease in pulmonary capillary wedge pressure, systemic vascular resistance, and peak airway pressure. CONCLUSIONS: The abdominal compartment syndrome occurs in a significant number of severely injured patients, and it develops quickly (27 [+ or -] 4 hours). Cardiopulmonary deterioration is the most frequent reason prompting decompression. Timely decompression of the ACS results in improvements in cardiopulmonary and renal function. These data support the use of the proposed ACS grading system for selective management of the syndrome. Am J Surg. 1997;174:667-673. [C] 1997 by Excerpta Medica, Inc.

BACKGROUND: Polymorphonuclear neutrophil (PMN) priming appears to be an important event in the pathogenesis of hyperinflammatory states, resulting in adult respiratory distress syndrome or multiple organ failure. Interleukin-6 (IL-6) is an integral mediator of the acute stress response to injury and infection, but excessive and prolonged systemic levels have been associated with morbidity and mortality following trauma, burns, and elective surgery. We hypothesized that IL-6 primed PMNs for exaggerated cytotoxicity. However, we have been unable to directly prime PMNs for superoxide release with IL-6. OBJECTIVE: To determine whether IL-6 acted in concert with another inflammatory mediator (platelet-activating factor [PAF]) to prime PMNs. METHODS: Polymorphonuclear neutrophils isolated from healthy human donors were incubated for varying times with IL-6 (0.01 to 100 ng/mL), PAF (0.01 to 100 ng/mL), or a combination of IL-6 and PAF. Superoxide production was then measured with and without the addition of the PMN-activating formylpeptide formylmethionyleucylphenylalanine. RESULTS: Over the range of times (5 to 90 minutes) and doses tested, IL-6 did not prime PMNs, while PAF primed PMNs in a dose- and time-dependent manner. Interleukin 6 (10 ng/mL) combined with a nonpriming concentration of PAF (0.1 ng/mL) primed PMNs for superoxide production over a range of incubation times. CONCLUSION: The inflammatory mediators IL-6 and PAF act synergistically to prime PMNs in vitro. This observation may begin to elucidate the mechanistic role of IL-6 in pathologic clinical states.(Arch Surg. 1994;129:1131-1136)