Wounds, Gunshot :: complications
Strong Memorial Hospital, University of Rochester, Rochester, NY 14610, USA. laura_naly@URMC.rochester.edu
Most cited papers:
Surgical intervention failed to stop life-threatening bleeding caused by injury complicated by severe coagulopathy. Administration of recombinant factor VIIa immediately corrected the coagulopathy and bleeding stopped.
Eighteen patients with left hemispheric strokes were compared to 11 patients with traumatic brain injury for frequency and severity of depression, using several mood scales. More than 60% of the stroke patients had clinically significant depressions as compared with about 20% of the trauma patients, even though the two groups had comparable impairments in their activities of daily living and global cognitive functions. Analyses of brain CT scans revealed that the two groups had similar-sized lesions, but the areas of ischemic injury were more anterior than the traumatic lesions. When the results were controlled for lesion location, there were no significant differences in mood between the two groups. The severity of depression was directly correlated with the closeness of the lesion to the frontal pole. These results suggest that depression following left hemispheric brain injury may not be a nonspecific neurological or psychological response, but rather may be a symptom of injury to specific pathways, such as the catecholamine-containing ones, as they pass through the frontal cortex.
PURPOSE: To demonstrate the feasibility and safety of endovascular stent-graft placement for treatment of traumatic aortic aneurysm. MATERIALS AND METHODS: Ten patients with traumatic aortic aneurysm were treated with endovascular stent-grafts. Three patients had an acute traumatic aneurysm; seven had a chronic aneurysm. Stent-grafts were constructed from modified Z-stents covered with woven polyester or expanded polytetrafluoroethylene graft material and were deployed through a 20-24-F delivery sheath in an exposed artery located remotely from the lesion. RESULTS: Stent-graft placement and thrombosis of the aneurysmal sac were successful in all patients. Major complications were encountered in three patients after endovascular treatment. One patient had a peri-graft leak; complete thrombosis of the aneurysmal sac was achieved after coil embolization of the leak. Transposition of the left subclavian artery was necessary to relieve left arm ischemia in another patient. In the third patient, stent placement in the left main stem bronchus was needed to relieve left lung atelectasis. All patients were alive and without complications during the follow-up period (mean, 15 months). CONCLUSION: Transluminal placement of endovascular stent-grafts is a technically feasible method for treatment of traumatic thoracic aortic aneurysm and may be an effective alternative to open-chest surgery.
A method of quantifying the risk of complication following penetrating abdominal trauma is described. A trauma index score was calculated by assigning a risk factor (1-5) to each organ injured and then multiplying this by a severity of injury estimate (1-5). The sum of the individual organ scores comprised the final penetrating trauma index (P.A.T.I.). A consecutive series from 1975 to 1979 of 108 isolated stab wounds and 114 gunshot wounds to the abdomen requiring laparotomy were analyzed by this scheme. Only patients surviving 24 hours postoperatively were evaluated. Gunshot wounds resulted in P.A.T.I. scores greater than 25 in 39 (34%) of the patients. This was associated with a 46% complication rate and contrasted to a 7% incidence when the P.A.T.I. was equal to or less than 25. Following abdominal stab wounds six (6%) of the patients had P.A.T.I. scores exceeding 25. Complications developed in 50% of this group compared to 5% when the P.A.T.I. was less than 25. Using the P.A.T.I., we conclude that gunshot victims are more likely to need trauma center treatment than those with stab wounds. The P.A.T.I. also might facilitate cost analysis of trauma care. The ability to assess effects of patient age, sex, amount of blood loss, duration of hemodynamic shock, and metabolic response to injury might further enhance the therapeutic implications in both penetrating and blunt abdominal trauma.
Presently available techniques for control of hepatic hemorrhage in patients with extensive parenchymal injuries include direct suture, topical hemostatic agents, hepatotomy or resectional debridement with selective vascular ligation, lobectomy, and selective hepatic artery ligation. In many trauma centers the placement of intra-abdominal packing for hepatic tamponade has been an infrequently used technique in recent years. From 1 July 1978 to 1 September 1980, ten patients with continued hepatic parenchymal oozing following all attempts at surgical control of extensive injuries were treated by the insertion of intra-abdominal packing around the liver as a last desperate maneuver. Packing was removed at relaparotomy in four patients and through abdominal drain sites in five patients. Nine of ten patients survived, and there were no instances of rebleeding following removal of the packing. Four patients developed postoperative perihepatic collections and two of the four patients underwent reoperation for drainage. Based on the recent experience at the Ben Taub General Hospital, intra-abdominal packing for control of exsanguinating hepatic hemorrhage appears to be a lifesaving maneuver in highly selected patients in whom coagulopathies, hypothermia, and acidosis make further surgical efforts likely to increase hemorrhage.
Neurosurgery Service, Walter Reed General Hospital, Washington, DC 20012, USA.
A series of 2187 cases of penetrating wounds of the brain, treated in a U.S. Army Hospital in Vietnam, is analyzed according to operability, wounding agents, sites of cranial penetration, associated organ system injuries, operative and postoperative complications, and mortalities. A detailed description of the operative technique of thorough intracranial debridement and dural repair is presented and stressed. The previously established principles of combat neurosurgery are confirmed and their continued use recommended.
Percutaneous transfemoral insertion of a stented graft to repair a traumatic femoral arteriovenous fistula.
This case report describes a new approach to repair a femoral arteriovenous fistula with a transluminally placed intraarterial graft-covered stent. A balloon-expandable stented polytetrafluoroethylene graft was inserted percutaneously to obliterate an arteriovenous fistula after a bullet injured the left superficial femoral artery and vein of an 18-year-old man. Follow-up duplex ultrasonography at 5 months demonstrated patency and luminal integrity of the involved artery and vein, with resolution of the associated pseudoaneurysm. Additional follow-up will be needed to further substantiate the utility of this minimally invasive procedure in the treatment of traumatic arterial injuries.