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Blunt subclavian artery trauma is an uncommon but challenging surgical problem. The purpose of this study was to retrospectively review the management of blunt subclavian artery injuries treated by the Trauma and Vascular Surgery Services at the East Tennessee State University-affiliated hospitals between 1992 and 1998. Six patients with seven blunt subclavian artery injuries were identified. Physical signs indicating blunt subclavian artery injury were pain or contusion around the shoulder joint; fractures of the clavicle, scapula, or ribs; periclavicular hematomas; and ipsilateral pulse or neurologic deficits. Seven subclavian artery injuries were treated-two arterial transections, two pseudoaneurysms, and three intimal dissections. Associated injuries included four clavicle fractures, one humerus fracture, one combined rib and scapular fractures, and two pneumothoraxes. Vascular surgical treatment included three primary arterial repairs, two saphenous vein interposition grafts, and one polytetrafluoroethylene (PTFE) graft. One patient was treated nonoperatively with anticoagulation. No deaths occurred. Morbidity occurred in two patients with chronic upper extremity neuropathy producing prolonged disability from pain and weakness; one patient had reflex sympathetic dystrophy, and the other had a brachial plexus injury. In conclusion, blunt subclavian artery trauma can be successfully managed with early use of arteriography and prompt surgical correction by a variety of vascular techniques. Vascular morbidity is usually low, but long-term disability because of chronic neuropathy may result from associated brachial plexus nerve injury despite a successful arterial repair.

Purpose: Sonography provides a fast, portable, and noninvasive method for patient assessment. However, the benefit of providing real-time ultrasound (US) imaging and fluid quantification shortly after patient arrival has not been explored. The objective of this study was to prospectively validate a US hemoperitoneum scoring system developed at our institution and determine whether sonography can predict a therapeutic operation. Methods: For 12 months, prospective data on all patients undergoing a trauma sonogram were recorded. All sonograms positive for free fluid were given a hemoperitoneum score. The US score was compared with initial systolic blood pressure and base deficit to assess the ability of sonography to predict a therapeutic laparotomy. Results: Forty of 46 patients (87%) with a US score ≥ 3 required a therapeutic laparotomy. Forty-six of 54 patients with a US score < 3 (85%) did not need operative intervention. The sensitivity of sonography was 83% compared with 28% and 49% for systolic blood pressure and base deficit, respectively, in determining the need for therapeutic operation. Conclusion: We conclude that the majority of patients with a score ≥ 3 will need surgery. The US hemoperitoneum scoring system was a better predictor of a therapeutic laparotomy than initial blood pressure and/or base deficit.

Background: Determination of intra-abdominal injury following blunt abdominal trauma (BAT) continues to be a diagnostic challenge. Ultrasound (US) has been described as a potentially useful diagnostic tool in this setting and is being used with increasing frequency in trauma centers. We determined the diagnostic capability of US in the evaluation of BAT. Methods: A retrospective analysis of our trauma US database was performed over a 30-month period. Computed tomographic scan, diagnostic peritoneal lavage, or exploratory laparotomy confirmed the presence of intra-abdominal injury. Results: During the study period, 8,197 patients were evaluated at the Ryder Trauma Center. Of this group, 2,576 (31%) had US in the evaluation of BAT. Three hundred eleven (12%) US exams were considered positive. Forty-three patients (1.7%) had a false-negative US; of this group, 10 (33%) required exploratory laparotomy. US had a sensitivity of 86%, a specificity of 98%, and an accuracy of 97% for detection of intra-abdominal injuries. Positive predictive value was 87% and negative predictive value was 98%. Conclusion: Emergency US is highly reliable and may replace computed tomographic scan and diagnostic peritoneal lavage as the initial diagnostic modality in the evaluation of most patients with BAT.

Objective: To determine whether surgeons and residents with minimal training can evaluate accurately emergency ultrasound (US) examinations compared with radiologists for blunt abdominal trauma. Methods: Over 7 months, we conducted a prospective study comparing the evaluation of emergency US for blunt abdominal trauma by surgeons and attending radiologists. US readings from the surgical team and the radiologists were correlated with outcome. Results: One hundred-twelve patients were included in the study. Ninety-two patients had an US read as negative by the surgical and radiology services with no subsequent injuries identified. Eighteen patients had an US deemed positive by the surgical service and radiologists. Injuries were confirmed in this group by operation or computed tomography. One patient had an US deemed positive by the surgical team and subsequently negative by the radiologist. A diagnostic peritoneal lavage was performed which was negative. Another patient had an US interpreted as negative by the surgical evaluator and positive by the radiologist. Exploratory laparotomy was negative for intraabdominal hemorrhage or organ injury. Overall results reveal an accuracy on US reading of 99% for the surgical team and 99% for the attending radiologists. Conclusion: Surgeons and surgical residents at different levels of training can accurately interpret emergency ultrasound examinations for blunt trauma from the real-time images, at a level comparable to attending radiologists.

Because the abdominal insufflation and desufflation associated with laparoscopic procedures may adversely effect a compromised myocardium, patients with significant cardiopulmonary disease should be closely monitored during these procedures. The utility of intraoperative pulmonary artery catheter (PAC) and transesophageal echocardiography (TEE) monitoring was studied in 10 patients with moderate to severe cardiopulmonary disease to identify patients at greatest risk for cardiovascular complications during laparoscopic cholecystectomy.Ten patients were enrolled in this prospective study; 7 had suffered a previous myocardial infarction, 6 had undergone coronary artery bypass grafting, and 9 had disease classified as Goldman's class II or greater. The heart was monitored by TEE throughout the laparoscopic cholecystectomy by using real-time, two-dimensional mode to study the wall thickness and motion. Several PAC measurements were taken directly: cardiac output, systemic vascular resistance, pulmonary artery wedge pressure, and central venous pressure. Heart rate and blood pressure were also obtained at corresponding intervals. Cardiac index, stroke volume, and left and right ventricular stroke work were then calculated.TEE demonstrated no significant changes in ventricular wall motion throughout laparoscopy. In patients who had postoperative cardiovascular complications, significant changes in cardiac index, left ventricular stroke work, and stroke volume were seen after pneumoperitoneum release. Compared to that of patients who did not develop complications, the cardiac index in those with complications dropped 42% (3.10 +/- 0.72 versus 1.80 +/- 0.10 L/min per m2, respectively; P0.01); left ventricular stroke work dropped 64% (139.00 +/- 11.36 versus 50.38 +/- 10.55 g x min/beat, respectively; P0.01); and stroke volume dropped 51% (86.90 +/- 12.68 versus 42.50 +/- 5.08 mL/beat, respectively; P0.01).PCA monitoring in patients with compromised cardiac function is useful in identifying patients who may not tolerate hemodynamic changes after pneumoperitoneum release. Normalization of hemodynamic changes secondary to abdominal insufflation and desufflation in patients with compromised hearts may not occur in patients with compromised hearts may not occur for hours postoperatively. Abnormal hemodynamic changes occur within the first hour after desufflation in patients who later develop cardiovascular complications, which are heralded by significant drops in left ventricular stroke work, cardiac index, and stroke volume. TEE did not prove to be useful for intraoperative monitoring.