摘要:

A Burn Depth Indicator, utilizing reflectance ratios of red, green, and infrared light, has been devised and clinically tested for 18 months at our Burn Center. Using the endpoint of wound healing in less than or more than 3 weeks, clinical assessment by two experienced surgeons of intermediate depth wounds was compared to readings from the BDI. In about one third of cases the surgeons were unwilling to commit themselves to a prediction. In the cases where the surgeons were willing to make a prediction, they were incorrect about 25% of the time. The BDI was significantly more accurate than the clinical assessment in those predicted not to heal by the surgeons and maintained an accuracy of 79% in the wounds where the surgeons would not make a prediction.The BDI is portable, noninvasive, and provides an immediate reading. It may have utility as a triage tool for emergency rooms or combat situations, and has utility at present in our Burn Center as a more accurate tool than our clinical judgment in predicting which wounds should be excised and grafted during the first few days after injury.

ISSN:0022-5282    

出版商:OVID    

年代:1984

数据来源: OVID

摘要:

Analysis of pelvic fracture management based on the experience of 533 patients treated in a recent 5-year period is presented. Overall mortality was 6.4%. Of 190 (36%) 'complicated' pelvic fractures based upon the nature of the pelvic fracture itself or more often the associated injuries, the mortality was 18%. Management was facilitated by categorizing the complicated pelvic fractures into those in patients who arrived hemodynamically stable versus unstable. Mortality rates were 3.4% and 42%, respectively. Additional statistically significant differences between the two categories included age, types of pelvic fractures, and Injury Severity Scores. Furthur distinction of hemodynamically unstable patients unresponsive to the usual modalities of resuscitation into those exsanguinating versus those in which a hypotensive yet stabilized state could be maintained also guided management.The significance of associated injuries, as they relate to the 34 pelvic fracture deaths, is stressed. In only four cases (0.75%) of all pelvic fractures seen, or 12% of all deaths, was the pelvic fracture unquestionably the major cause of mortality. In 53% of the deaths, the pelvic fracture played a contributing role; in 35% of the deaths, the fact that patients sustained a pelvic fracture was objectively considered inconsequential in the victim's unfortunate demise.

ISSN:0022-5282    

出版商:OVID    

年代:1984

数据来源: OVID

摘要:

Objectives of temporary descending thoracic aortic cross-clamping for exsanguinating abdominal hemorrhage are to redistribute intravascular volume to the myocardium and brain, and to limit further blood loss. This report describes our experience with left thoracotomy and descending aortic occlusion (T/AO) performed in the operating room (OR) for massive hemoperitoneum.During a 5-year period, 39 (5%) of 791 patients undergoing laparotomy for acute injury required T/AO in the OR. According to protocol, T/AO was undertaken before celiotomy if systolic blood pressure (SBP) remained <80 mm Hg despite full resuscitation (23 patients), and after celiotomy if SBP fell to <60 mm Hg with upper abdominal hemorrhage (16 patients). Mechanism of injury was gunshot wound in 21, stab injury in eight, and blunt trauma in ten.Twelve patients (31%) survived to leave the hospital. Seven of these individuals sustained hepatosplenic injuries, three had major vascular trauma, and the remaining two had combined injuries. Average SBP increased from 51 to 126 mm Hg following T/AO in the preceliotomy group, and from 48 to 131 mm Hg in post-celiotomy patients. The aorta was cross-clamped an average of 43 minutes in the preceliotomy patients, and 19 minutes in the post-celiotomy group. Six survivors (50%) developed major abdominal complications (rebleeding, fistulae, abscess, and pancreatitis). Only two patients, however, had pulmonary problems associated with T/AO; and both were minor (atelectasis and recurrent pneumothorax).In our experience, T/AO in the OR is successful in salvaging nearly one third of patients with life-threatening abdominal hemorrhage. The procedure can be performed rapidly, safely, and with minimal late sequelae.

ISSN:0022-5282    

出版商:OVID    

年代:1984

数据来源: OVID

摘要:

The ability of the imidazole derivative, ketoconazole, to inhibit thromboxane (Tx)A2synthesis in response to ischemia was tested in ten volunteers. Two hours after taking placebo or ketoconazole 400 mg by mouth, plasma levels of the stable degradation product of TxA2, TxB2, were 300 ± 129 pg/ml (mean ± SEM) and 297 ± 80 pg/ml, respectively. Arm ischemia for 10 min induced by inflation of a cuff to 220 mm Hg led to a rise in TxB2levels to 657 ± 157 pg/ml after placebo (p< 0.05) and 337 ± 81 pg/ml after ketoconazole. One hour after cuff deflation, TxB2returned to pre-ischemia levels in both groups. Platelet TxB2concentrations were 27 ± 6 ng in the placebo and 35 ± 6 ng/109platelets in the ketoconazole group, and were unchanged by cuff inflation. The fact that plasma and platelet TxB2values were not lower 2 hr after ketoconazole treatment was explored in another group of four nonstressed volunteers who received 400 mg of drug. After 2 hr, TxB2values had fallen from 170 ± 30 pg to 120 ± 10 pg; at 4 hr, 6 hr, and 8 hr they were 30 ± 20 pg, 5 ± 5 pg, and 5 ± 5 pg/ml, respectively. These results indicate that tourniquet ischemia provokes TxA2 synthesis, and that the source of this prostanoid is likely to be ischemic tissue and not platelets. Finally, ketoconazole can profoundly inhibit both background and stimulated TxA2synthesis.

ISSN:0022-5282    

出版商:OVID    

年代:1984

数据来源: OVID

摘要:

This study assessed the effect of continuous infusion of prostacyclin on tissue blood flow throughout the GI tract to see whether small and large bowel flow was also affected. Twelve miniature swine were anesthetized, ventilated, and hemodynamically monitored. After stabilization each animal received either prostacyclin in buffer at 0.1 mcg/kg/minute for 3 hours or buffer alone (controls). Tissue blood flow was documented at baseline and at 1, 2, and 3 hours of prostacyclin infusion by injection of radiolabeled spheres. Prostacyclin infusion did not significantly affect mean arterial pressure, heart rate, or cardiac index compared to controls. At 3 hours tissue blood flow was significantly increased in the gastric mucosa (↑ 225%), small bowel (↑ 110%), cecum (↑ 260%), and transverse colon (↑ 160%) compared to controls. Prostacyclin may be an effective agent for prevention of ischemia in all areas of the GI tract prone to stress ulceration.

ISSN:0022-5282    

出版商:OVID    

年代:1984

数据来源: OVID

摘要:

The past 5 years' experience with diaphragmatic injuries at the University of Texas Health Science Center in San Antonio was reviewed to refine the clinical signs and appropriate treatment. During this period 102 patients were treated. Ninety-three patients incurred penetrating trauma to the diaphragm and nine patients suffered blunt trauma. Chest X-rays were normal in 40 patients, a hemo- and/or pneumothorax was present in 57, herniated abdominal viscera in four, and free air in one. Peritoneal lavage was positive in six of seven patients with blunt diaphragmatic injury, but was falsely negative in two of five patients (20%) with penetrating diaphragmatic injury. Eighty-nine patients (87%) experienced 137 associated injuries (excluding hemo- and/or pneumothorax). Nine patients (8.8%) had an isolated diaphragmatic injury. Four patients (4%) had a diaphragmatic injury associated with only a hemo- and/or pneumothorax. All patients, except for three with injuries recognized late, were operated upon immediately. Two patients had a missed diaphragmatic injury at initial laparotomy. There was one death in the series from a consumption coagulopathy.It was concluded that injuries to the diaphragm should be suspected in all patients with severe blunt torso trauma or with penetrating injuries near the diaphragm. Because of the nonspecificity of X-rays and the 20% false negative rate for peritoneal lavage, we believe that missed injuries and morbidity can be minimized by immediate laparotomy for all patients with abdominal and low thoracic penetrating injuries. Care must be taken not to overlook associated injuries.

ISSN:0022-5282    

出版商:OVID    

年代:1984

数据来源: OVID

摘要:

A review of 62 consecutive patients who sustained flail chest after trauma from 1971 to 1982 was conducted to document the late effects of this injury. The mechanism of injury was motor vehicle accident in 44 (71%), fall in nine (14.5%), and farming accident in nine (14.5%). Patients ranged in age from 7 to 87 years. Twenty-four (39%) patients arrived in shock and 54 (87%) had major extra-thoracic associated injuries. Thirty-seven (60%) patients were managed by intubation and mechanical ventilation and 25 (40%) by chest physiotherapy. Pulmonary complications developed in 60% of the total group.Eight patients (12.9%) died during the initial hospitalization. Five patients died 1 month to 9 years after discharge, and 17 were eventually lost to followup. Six-month to 12-year followup (mean, 5 years) was re-established for 32 patients. Twenty-one of these returned for comprehensive testing including physical examination, chest roentgenograms, spirometry, flow volume curves, diffusion testing, and calculation of dyspnea index.Of 32 patients questioned, only 12 had returned to full-time employment. Eight (25%) still had subjective chest tightness, 15 (49%) complained of thoracic cage pain, and 12 (38%) had experienced moderate or severe change in their overall level of activity. Using the British Medical Research Gradation for Dyspnea, three (9%) patients had moderate and six (19%) severe shortness of breath.Objective dyspnea index calculated from VEBTPS/MVV revealed mild dyspnea in 50% and moderate dyspnea in 20%. Formal carbon monoxide diffusion testing was normal in 90% of patients and revealed mild decrease in 10%. Spirometry was abnormal in 57% of patients and 33% exhibited at least a mild restrictive defect. Objective long-term disability, therefore, often follows flail chest injury.

ISSN:0022-5282    

出版商:OVID    

年代:1984

数据来源: OVID

摘要:

Shotgun wounds present specific challenges for the surgeon. Multiple penetrating wounds frequently involve large anatomic areas with potential multi-system injury. Experience with 121 patients sustaining shotgun wounds over the 5-year period ending 31 December 1981 was reviewed to assess results and evaluate treatment protocols.Sixty-six patients had chest wounds with pleural penetration. Twenty-four wounds were minor and were observed. Each had less than five pellets penetrating the pleura. Twenty-two patients had close-range injuries. Fourteen of these required chest tube drainage alone and eight patients required thoracotomy for control of bleeding. Eleven patients died, six as a direct result of the chest injury.In 55 patients with abdominal-retroperitoneal wounds exploratory operations were done if more than four pellets were thought to be lodged intraperitoneally or if signs of peritonitis were present, while lesser wounds without peritoneal findings were observed. In the 15 patients who did not have exploratory operations, there were no deaths or major complications. Thirty-five patients had exploratory operations. Two patients had five intraperitoneal missiles and no clinical evidence of peritonitis but were found to have significant intestinal perforations. Four patients died.Eighty-three patients with extremity wounds were classified according to location of injury. Forty-five had upper extremity wounds, with nine vascular injuries. Two patients died and one limb was amputated because of soft tissue infection. Thirty-eight patients had lower extremity wounds. Five had major vascular injuries. Preoperative arteriography was obtained in 13 patients with extremity injuries; the results of one of these were falsely negative. There were no deaths or amputations.We conclude that patients with thoracic shotgun wounds are successfully managed according to principles established for other forms of penetrating chest trauma. Suspected peritoneal penetration requires exploratory laparotomy if more than four pellets have penetrated or if clinical signs of peritonitis are present. Extremity wounds require careful documentation of vascular integrity by angiography or complete vascular exploration.

ISSN:0022-5282    

出版商:OVID    

年代:1984

数据来源: OVID

摘要:

This study examines the validity of the Revised Estimated Survival Probability (RESP) index in a set of trauma patients admitted to three hospitals. For each patient four different severity indices were computed: 1) RESP derived from in-hospital assigned International Classification of Disease (ICD) codes; 2) RESP based on written face sheet discharge diagnoses; 3) RESP based on a full review of the medical record; and 4) Injury Severity Score (ISS) based on full review of the medical record. These four severity indices were then correlated with six measures of outcome or construct validity, including mortality, duration of hospitalization, intubation or tracheostomy performed, ambulance transport to hospital, admission to the intensive care unit, and ventilatory assistance received. The results indicate that for every validity measure examined, the ISS index was superior to the RESP index, regardless of the abstraction procedure. However, the RESP index was independently associated with mortality, length of hospitalization, and ventilatory assistance even after adjusting for the ISS. In addition, the performance of the RESP index improved dramatically as the quality of information improved. Last, strong evidence is presented which questions the utility of calculating any type of severity index using data from computerized discharge abstracts without careful quality control measures.

ISSN:0022-5282    

出版商:OVID    

年代:1984

数据来源: OVID

摘要:

The achievement of a very rapid fluid infusion rate may be critical in the resuscitation of the patient in hypovolemic shock. We studied flow rates of crystalloid and whole blood through various intravenous catheters and tubing systems. The 10-gauge Angiocath® and the 8 Fr pulmonary artery introducer catheter provide flow rates equivalent to intravenous tubing (3.2 mm I.D.) inserted directly into the vein. Substantially higher flow rates can be achieved with the use of large-bore intravenous tubing (5.0 mm I.D.) connected to these catheters in place of standard intravenous tubing, allowing the infusion of 1,200–1,400 cc/minute of crystalloid and whole blood into the patient in hypovolemic shock through one intravenous catheter. Clinical trials with larger bore intravenous tubing are probably indicated.

ISSN:0022-5282    

出版商:OVID    

年代:1984

数据来源: OVID