Surgery

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Newsletters - February 2010


Trauma Care in Milwaukee: Scoping Out the Future

by Travis P. Webb, MD, Associate Professor of Surgery

One of this year’s great debates concerns health care in the United States. Cost containment and preventive health measures are hot topics. Missing from much of the healthcare reform discussion is the number one cause of deaths for individuals between one and 44 years of age: traumatic injury. Traumatic injury is a world-wide healthcare problem that remains largely ignored in the world of healthcare reform. Morbidity and subsequent loss of production associated with trauma is a greater than $400 billion drain on U.S. society. Yet, we continue to ignore the need for support in the areas of injury prevention, acute care and rehabilitation.

Froedtert & The Medical College of Wisconsin staff the only adult level I trauma center in eastern Wisconsin. Our programs provide care for injured patients in our community and education for students, residents and the public on the affect traumatic injuries have on our community. Over the past 10 years, the Division of Trauma and Critical Care has created a rich environment focused on education, patient care and outcomes research. Since 2000, in-house board certified critical care surgeons have staffed trauma and acute care surgery services 24 hours per day, seven days per week. The Trauma Center provides initial care to more than 3,000 injured patients per year.

While falls and motor vehicle crashes account for most injuries, our community has a high percentage of injuries from penetrating trauma. Penetrating injuries account for 26 percent of admissions to our level I Trauma Center. Our Injury Research Center has taken a lead role in trying to establish the magnitude of handgun violence in our city and preventive strategies that can be applied in the city of Milwaukee and surrounding communities.

The care of the injured patient continues to be an area of research, discovery and change. New concepts in the resuscitation of severely injured patients are now being evaluated. These treatment strategies include hypotensive resuscitation, hypertonic saline infusion and alterations in transfusion ratios (fresh frozen plasma and packed red blood cells) during massive transfusions. Other innovations include the greater use of laparoscopy and increases in the use of advanced endovascular therapeutic interventions, such as in the case of thoracic aortic disruption from trauma. The use of non-operative management for trauma has become the standard of care for the majority of patients with liver and spleen injuries.

As previously mentioned, one area of interest for many trauma surgeons is whether laparoscopic techniques can or should be utilized when caring for the acutely injured. Our institution has used laparoscopy selectively to evaluate and treat injured patients. A modest amount of data in the literature supports the current limited role of laparoscopy in this population.

Diagnostic laparoscopy has gained some popularity for clearly defined indications. Laparoscopy has been used to accurately identify peritoneal penetration from suspected tangential gunshot or stab wounds.1 Some authors have also recommended using laparoscopy to evaluate for occult diaphragm injuries from penetrating trauma.1, 2 When used diagnostically, it is clear that the patient must be otherwise asymptomatic with no signs of peritonitis. If peritoneal penetration is identified, the same principles of identifying all injuries and the tract of the bullet must be followed. Though the data is limited, laparoscopy has been shown to decrease laparotomy rates, length of hospital stay and costs. 1, 4, 5

Data in support of therapeutic laparoscopy is even scarcer. Case reports and series of laparoscopic repair of limited gastrointestinal injuries are in the literature.6 However, skilled surgeons must perform these repairs, and systems issues frequently hinder the widespread use of therapeutic laparoscopy. Most centers are not prepared to perform complex laparoscopic procedures in the middle of the night due to personnel, space and equipment limitations. One indication of laparoscopy we have found useful has been to perform a delayed washout of intra-peritoneal blood and/or bile following significant spleen or liver injury.7

Due to current limitations and lack of supporting data, it would seem appropriate to continue to rely on standard open abdominal exploration for the majority of trauma patients. Certainly, any patient who is in shock demands this treatment. Questions still remain in regard to costs and long-term outcomes of laparoscopy in trauma, and since cost containment is a real issue, these questions cannot be ignored. However, as experience and data is gathered, surgeons will likely utilize laparoscopy more and more frequently for the care of the injured patient. It is important for surgeons to remember that we should not be looking for more uses of laparoscopy; we should look for innovative ways to improve patient care and outcomes.

In the end, the focus of trauma care is on the patient and our community. The trauma team at Froedtert & The Medical College of Wisconsin remains committed to providing the highest quality of care.

Dr. Webb may be reached at 414-805-8622 or trwebb@mcw.edu.

References

  1. Leppaniemi A, Haapiainen R. Diagnostic laparoscopy in abdominal stab wounds: a prospective, randomized study. J Trauma. 2003;55:636–645.
  2. Friese RS, Coln CE, Gentilello LM. Laparoscopy is sufficient to exclude occult diaphragm injury after penetrating abdominal trauma. J Trauma. 2005 Apr;58(4):789-92.
  3. Powell BS, Magnotti LJ, Schroeppel TJ, Finnell CW, Savage SA, Fischer PE, Fabian TC, Croce MA. Diagnostic laparoscopy for the evaluation of occult diaphragmatic injury following penetrating thoracoabdominal trauma. Injury. 2008 May;39(5):530-4.
  4. Sosa JL, Baker M, Puente I, Sims D, Sleeman D, Ginzburg E, Martin L. Negative laparotomy in abdominal gunshot wounds: potential impact of laparoscopy. J Trauma. 1995; 38: 194 –197.
  5. Marks JM, Youngelman DF, Berk T. Cost analysis of diagnostic laparoscopy vs laparotomy in the evaluation of penetrating abdominal trauma. Surg Endosc. 1997;11:272–276.
  6. Mathonnet M, Peyrou P, Gainant A, Bouvier S, Cubertafond P. Role of laparoscopy in blunt perforations of the small bowel. Surg Endosc. 2003; 17: 641–645.
  7. Carrillo EH, Reed DNJ, Gordon L, Spain DA, Richardson JD. Delayed laparoscopy facilitates the management of biliary peritonitis in patients with complex liver injuries. Surg Endosc. 2001;15:319–322.
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