摘要:

Trauma resuscitation for 431 major trauma patients averaged 24 ± 0.61 minutes. Further analysis of the care of 350 of these patients documented a transitional evaluation and monitoring phase (TEMP), with a physician and nurse in attendance, for an additional 158 ± 12 minutes until arrival at the operating room, surgical intensive care unit (SICU), hospital ward, or discharge. The duration of TEMP did not vary according to severity of injury (R2= 0.02). Arrival time (days: 167 ± 23 minutes; evenings: 142 ± 13 minutes; and nights: 147 ± 30 minutes) had minimal effect on TEMP duration. The TEMP for 67 patients undergoing an operation was significantly less than for patients admitted to the hospital ward or SICU (112 ± 19 minutes vs. 171 ± 20,p< 0.05). These 350 patients underwent 582 activities during TEMP including radiologic evaluation (265), CT scan (173), and other activities (144). Extrapolating TEMP time for the 1,800 major trauma patients seen annually, this represents 4,740 hours each of nursing and physician time. A better understanding of TEMP is needed to provide appropriate support and organization during this critical period of trauma care.

ISSN:0022-5282    

出版商:OVID    

年代:1991

数据来源: OVID

摘要:

In patients suffering isolated head trauma, we have previously shown that levels of circulating catecholamines obtained within 48 hours of trauma correlate with the severity of brain injury and predict outcome and that intoxication blunts this response. The effects of alcohol on the increase in catecholamines in systemically injured patients, however, have not been well defined. From 1983 to 1990, 78 patients (74% male; median age 30 years) with blunt head and multisystem injury, who also had alcohol levels measured within 5 hours of injury, were studied. Norepinephrine and epinephrine levels were assayed by a radioenzymatic technique. Injury severity was assessed by the admission Glasgow Coma Scale (GCS) score (4–15; median, 12), the Injury Severity Score (ISS) (13–50; median, 25) and the volume of blood products administered within the first 24 hours (0–14.4 L; median, 0.5 L). The impact of alcohol on the norepinephrine response to injury was analyzed using multiple linear regression models, including polynomial interaction terms. Norepinephrine levels significantly (p< 0.0001) correlated with the GCS score and ISS. However, alcohol significantly lowered the norepinephrine response to decreasing GCS score (R = 0.49,p< 0.002) and to increasing ISS (R = 0.51,p< 0.0006). The blunting of the catecholamine response was most marked in those severely injured. The rise in norepinephrine concentrations seen with increasing volume of blood replacement was not affected by intoxication. An association between injury severity and epinephrine levels was also present, but not as consistently. Epinephrine concentrations rose with falling GCS score and with increasing ISS values, but unlike norepinephrine, there were no apparent effects of alcohol on changes in epinephrine levels. Thus, in patients suffering head and multisystem injury, catecholamine changes reflect the severity of injury using three different scalers. Furthermore, intoxication blunts only the norepinephrine component of this important biologic response.

ISSN:0022-5282    

出版商:OVID    

年代:1991

数据来源: OVID

摘要:

The balance between intravascular volume, oxygen transport, arterial oxygenation is delicate in patients with adult respiratory distress syndrome (ARDS). Recently, we used continuous arteriovenous countercurrent hemodialysis (CAVH-D) in 14 nonoliguric patients who had severe ARDS. The cause of the ARDS was pancreatitis in 1 patient, trauma in 10 patients, and postoperative in 4 patients. All patients were edematous, in marked positive fluid balance but not intravascularly overloaded before institution of CAVH-D. Transfemoral CAVH-D was instituted and managed by the SICU staff. Patients underwent CAVH-D for a mean of 65.2 hours (range, 12–140 hours) and cleared a mean of 480 mL/h of filtrate. The only complication was one patient who bled from a loose tubing connection. Three patients were grossly unstable when CAVH-D was begun. Their mean cardiac index (CI) was 2.3 L/min/m2despite maximal inotropes. Their CAVH-D filters cleared a mean of 600 mL/h, but they required constant fluid resuscitation and died of cardiogenic shock and ARDS within 3 days. The other 11 patients had significant improvement in their respiratory function. Mean F102was weaned from 0.73 to 0.45 (p< 0.005) and PEEP from 14.3 cm to 8.9 cm (p< 0.005). Peak airway pressures fell from a mean of 60 mm Hg to 45 mm Hg (p< 0.01). There was no significant change in CI or wedge pressure, but oxygen consumption rose from a mean of 279 to 409 mL/m (p< 0.05). The technique of CAVH-D offers an alternative to patients with ARDS who do not have large on-going fluid requirements. It is safe, can be managed by the surgical staff, and is associated with a significant improvement in respiratory variables without requiring a drop in filling pressures that might potentially compromise oxygen transport.

ISSN:0022-5282    

出版商:OVID    

年代:1991

数据来源: OVID

摘要:

Venous flaps were used for coverage of hand wounds over exposed bones, joints, and tendons in 28 patients. Four types of operations were performed. Among them type IV was the best. It included the advantages of perfusion in types I and III, but excluded their disadvantages. The viability of venous flaps was confirmed. Clinical observation showed that a venous flap is not merely a composite graft. The presence of a vascular network in the flap helps to ensure initial survival before the establishment of neovascularization between the venous flap and the recipient site. Partial loss of a flap was observed in two cases and complete failure was seen in one case. Viability versus flap size and modality of perfusion are analyzed. With total venous perfusion, small venous flaps usually survive better than large ones. For large venous flaps, arterialized venous perfusion is better than total venous perfusion. Venous flaps are useful for wound coverage of fingers and hand, but they do not replace cross-finger flaps or other conventional flaps when these simpler flaps are available.

ISSN:0022-5282    

出版商:OVID    

年代:1991

数据来源: OVID

摘要:

The argon beam coagulator (ABC) delivers radiofrequency electrical energy to tissue across a jet of argon gas, providing noncontact, monopolar, electrothermal hemostasis. This study compared the efficacy of the ABC with conventional techniques for control of traumatic hepatic and splenic hemorrhage. Standardized lacerations were made to the liver and spleen of 6 heparinized dogs. Control of bleeding was attempted with the ABC (150 W), the Nd:YAG laser (90 W, noncontact), horizontal mattress suture, microcrystalline collagen, and regenerated cellulose. If bleeding had not been controlled within 3 minutes, coagulation was attempted with the ABC in order to prevent exsanguination. Tissue from both the liver and spleen was assessed histologically for damage induced by the ABC. Delayed injury and early healing after ABC coagulation was studied in six additional dogs killed 1 and 3 weeks postoperatively. The ABC stopped bleeding from 25/25 hepatic lacerations in 48 ± 8 seconds (mean ± SEM) and from 18/18 splenic lacerations in 28 ± 3 seconds. The Nd:YAG laser, mattress sutures, and topical hemostatic agents failed to control bleeding in 14 of 15 applications after 3 minutes. The ABC successfully salvaged all failures in less than 1 minute. The depth of splenic and hepatic thermal injury with the ABC ranged from 2 to 7 mm and was proportional to the duration of application. Postoperatively wound healing progressed normally without bleeding or infection at the coagulation site. The ABC appears to be a excellent instrument for achieving hemostasis in solid organ injury, and may be especially valuable in managing patients with coagulation deficits.

ISSN:0022-5282    

出版商:OVID    

年代:1991

数据来源: OVID

摘要:

Twenty-five fully anesthetized swine were tested for biomechanical responses to lower abdominal steering-wheel loading. Supine subjects were impacted with the lower rim of a segmented steering wheel in a ventrodorsad direction at approximately the L-4 level of the lumbar spine. Peak force ranged from 0.13 to 8.56 kN, peak stroke from 16.1 to 123.8 mm, and peak velocity from 1.7 to 12.4 m/s. Mechanical response is presented in terms of force-deflection cross plots of force-time and displacement-time histories. Overall stiffness, normalized for equal stress-equal velocity scaling using a standard human cadaver mass, was found to be rate dependent and corridors are suggested. These findings indicate that the stiffness of the lower abdomen is less than upper abdominal stiffness and significantly lower than chest stiffness, although lower abdominal stiffness in living subjects is still slightly higher than it is in the lower abdomen of human cadavers. The maximum viscous response (VCmax) was a strong predictor of injury risk for the entire data set.

ISSN:0022-5282    

出版商:OVID    

年代:1991

数据来源: OVID

摘要:

Injury to the retrohepatic vena cava and hepatic veins carries with it a very high mortality rate. This type of injury is fraught with difficulty because of poor exposure and uncontrolled bleeding. Various techniques for the management of these injuries have been reported. We describe the use of profound hypothermic circulatory arrest to facilitate repair of penetrating injury to the retrohepatic vena cava and hepatic veins.

ISSN:0022-5282    

出版商:OVID    

年代:1991

数据来源: OVID

摘要:

Two cases of ipsilateral open fracture of the femur and tibia treated using the dynamic ASIF-BM tubular external fixator are described. Results were very good, with short periods of occupational disability. These cases support primary stable osteosynthesis of these simultaneous fractures and the value of dynamic axial external fixation as a definitive treatment of open fractures of the femur and tibia shaft, either isolated or simultaneous.

ISSN:0022-5282    

出版商:OVID    

年代:1991

数据来源: OVID

摘要:

A case of a severe wrist injury (fractures of the scaphoid, capitate, hamate, and ulnar styloid process) with volar dislocation of the lunate into the soft tissues of the forearm is presented. This degree of displacement of the lunate is exceedingly rare, and we believe has not been previously reported. Possible mechanisms, hyperextension injury forcing the lunate forward out of the carpus, or contact between the volar wrist skin surface and another object or surface propelling the dislocated lunate into the forearm, are discussed.

ISSN:0022-5282    

出版商:OVID    

年代:1991

数据来源: OVID

摘要:

Late reconstruction of a rupture of the patellar tendon by transfer of the semitendinosus tendon supplemented by a strip of fascia lata and encircling twisted wires to bridge the gap was successful in one patient.

ISSN:0022-5282    

出版商:OVID    

年代:1991

数据来源: OVID