In this multicenter study, 38.5% of adults with blunt splenic injury went directly to laparotomy. Ultimately, 54.8% of patients were successfully managed nonoperatively; the failure rate of planned observation was 10.8%, with 60.9% of failures occurring in the first 24 hours. Successful nonoperative management was associated with higher blood pressure and hematocrit, and less severe injury based on ISS, Glasgow Coma Scale, grade of splenic injury, and quantity of hemoperitoneum.

T his is a recommended algorithm of the Western Trauma Association for the management of penetrating neck trauma that has penetrated the platysma muscle of the neck. Because of the paucity of recent prospective randomized trials on the evaluation and management of penetrating neck injury, the current algorithm and recommendations are based on available published prospective cohort, observational, and retrospective studies and the expert opinion of the Western Trauma Association members. The algorithm (Fig. 1.) and accompanying text represents a safe and reasonable approach to this difficult injury type and attempts to incorporate the advent of recent advances in radiographic screening and selective or expectant management practice. We recognize that there will be variability in decision making, local resources, institutional consensus, and patient-specific factors that may require deviation from the algorithm presented. This annotated algorithm is meant to serve as a basis from which protocols at individual institutions can be developed or serve as a quick bedside reference for clinicians. The algorithm contains letters A through J, which correspond to the lettered text. Their purpose is to succinctly navigate the reader thru the algorithm and discuss those points, which require further elucidation or where data are lacking. 1Y3

This is a recommended management algorithm from the Western Trauma Association addressing the management of adult patients with rib fractures. Because there is a paucity of published prospective randomized clinical trials that have generated Class I data, these recommendations are based primarily on published observational studies and expert opinion of Western Trauma Association members. The algorithm and accompanying comments represent a safe and sensible approach that can be followed at most trauma centers. We recognize that there will be patient, personnel, institutional, and situational factors that may warrant or require deviation from the recommended algorithm. We encourage institutions to use this as a guideline to develop their own local protocols.

Blunt traumatic lung injury has higher mortality primarily due to associated extrathoracic injuries. Major resections are required more commonly than previously reported. While "minor" resections, if feasible, are associated with improved outcome, trauma surgeons should be facile in a wide range of technical procedures for the management of lung injuries.

Factors associated with a poor outcome following renovascular injuries include blunt trauma, the presence of a grade V injury, and an attempted arterial repair. Patients with blunt major vascular injuries (grade V) are likely to have associated major parenchymal disruption, which contributes to the poor function of the revascularized kidney. These patients may be best served by immediate nephrectomy, provided that there is a functioning contralateral kidney.

It is possible to quantify an amount of thoracic hemorrhage, after blunt and penetrating injury, at which delay of thoracotomy is associated with increased mortality.Design: A retrospective case series.Setting: Five urban trauma centers.Study Selection: Patients undergoing urgent thoracotomy (within 48 hours of injury) for hemorrhage (excluding emergency department thoracotomy). Data Extraction:Respective registries identified patients who underwent urgent thoracotomy. Injury characteristics, initial and subsequent chest tube outputs, time before thoracotomy, and outcomes were evaluated.Main Outcome Measure: Death.Results: One hundred fifty-seven patients (36 with blunt and 121 with penetrating injuries) underwent urgent thoracotomy for hemorrhage between January 1, 1995, and December 31, 1998. Mortality correlated with mean (± SD) Injury Severity Score (38±19 vs 22±12.6 for survivors; PϽ.01) and mechanism (24 [67%] for blunt vs 21 [17%] for penetrating injuries; PϽ.01). Mortality increased as total chest blood loss increased, with the risk for death at blood loss of 1500 mL being 3 times greater than at 500 mL. Blunt-injured patients waited a significantly longer time to thoracotomy than penetratinginjured patients (4.4±9.0 h vs 1.6±3.0 h; P=.02) and also had a greater total chest tube output before thoracotomy (2220±1235 mL vs 1438±747 mL; P =.001). Conclusions:The risk for death increases linearly with total chest hemorrhage after thoracic injury. Thoracotomy is indicated when total chest tube output exceeds 1500 mL within 24 hours, regardless of injury mechanism.

ObjectiveTo determine the optimal method of wound closure for dirty abdominal wounds. Summary Background DataThe rate of wound infection for dirty abdominal wounds is approximately 40%, but the optimal method of wound closure remains controversial. Three randomized studies comparing delayed primary closure (DPC) with primary closure (PC) have not conclusively shown any advantage of one method over the other in terms of wound infection. MethodsFifty-one patients with dirty abdominal wounds related to perforated appendicitis, other perforated viscus, traumatic injuries more than 4 hours old, or intraabdominal abscesses were enrolled. Patients were stratified by cause (appendicitis vs. all other causes) and prospectively randomized to one of two wound management strategies: E/DPC (wound packed with saline-soaked gauze, evaluated 3 days after surgery for closure the next day if appropriate) or PC. In the E/DPC group, wounds that were not pristine when examined on postoperative day 3 were not closed and daily dressing changes were instituted. Wounds were considered infected if purulence discharged from the wound, or possibly infected if signs of inflammation or a serous discharge developed. ResultsTwo patients were withdrawn because they died less than 72 hours after surgery. The wound infection rate was greater in the PC group than in the E/DPC group. Lengths of hospital stay and hospital charges were similar between the two groups. ConclusionA strategy of DPC for appropriate dirty abdominal wounds 4 days after surgery produced a decreased wound infection rate compared with PC without increasing the length of stay or cost.Dirty surgical wounds are associated with a high rate of wound infection.1 Postoperative wound infections have a significant impact on health resources and costs, 2,3 and the sequelae of wound infections (wound dehiscence and resulting incisional hernias) can result in significant long-term problems. 4 -6 Of the many risk factors influencing postoperative wound infections, the method of skin closure has been implicated as an important factor. Delayed primary closure (DPC) and primary closure (PC) are two commonly used methods, but there is no consensus as to the optimal method. Cruse and Foord 1 found in a retrospective survey a wound infection rate of 40% among 2,093 dirty wounds, but they did not specify how skin closure was performed. Three prospective randomized studies 7-9 performed on appendectomy wounds only showed no advantage to DPC in terms of decreased wound infection compared with PC. We conducted a prospective randomized trial on patients with dirty abdominal wounds and hypothesized that a strategy of DPC of appropriate dirty abdominal wounds would result in a decreased rate of wound infection.

Although patient selection is the primary factor determining outcome, there may be an independent benefit for performing TCY after GSW in a specialized resuscitation room or the operating room.