摘要:

Despite wide acceptance of use of sutureless intraluminal prosthetic grafts in surgical management of acute and chronic aortic dissection, their use in traumatic aortic rupture appears not to have been specifically addressed. This report describes the use of intraluminal prostheses in two cases of aortic disruption due to blunt trauma. Aortic cross-clamp times were 21 and 28 minutes, respectively. Both patients have recovered without sequelae from their aortic injuries. Although not all traumatic aortic disruptions are suitable for repair with intraluminal prostheses, the ease and safety with which this device may be employed recommends consideration of their use in appropriate cases of traumatic rupture of the aorta.

ISSN:0022-5282    

出版商:OVID    

年代:1986

数据来源: OVID

摘要:

During the past 5½ years, 86 patients were treated for pulmonary contusion resulting from blunt trauma. Injury mechanism was motor vehicle in 65 patients (76%), farming in nine (10%), fall in eight (9%), and miscellaneous in four (5%). There were 68 males (79%) and 18 females. Ages ranged from 4 to 75 years (mean, 32 years). Twenty-two patients (26%) presented in hypovolemic shock. Injury Severity Score (ISS) averaged 26 (range, 9–57). Intubation was performed in the Emergency Department in 21 patients (24%.), 19 of whom were severely hypoxic with pO2/FIO2ratio less than 300. Thirtyfour patients were ultimately treated with mechanical ventilation for 1 to 103 days (mean, 9.1 days). The average hospital stay was 22 days.Eleven patients (13%) died. Mortality was significantly greater (p<0.05) in patients with ISS ≥ 25, initial Glasgow Coma Scale ≤ 7, transfusion of>three units of blood, and pO2/FIO2<300. Mortality was not correlated with either presence of shock or amount of intravenous fluid administration. Eighteen patients with concomitant flail chest demonstrated no increase in mortality but were likely to require mechanical ventilation (p<0.05). The extent of contusion assessed on admission chest roentgenogram was not predictive of mortality or need for intubation.We recommend aggressive treatment of associated injuries, craniocerebral trauma, and selective mechanical ventilation based upon degree of intrapulmonary shunt.

ISSN:0022-5282    

出版商:OVID    

年代:1986

数据来源: OVID

摘要:

Conventional policy mandates exploration of retroperitoneal hematomas presumed to contain penetrating injuries of the inferior vena cava (IVC). In clinical practice this maneuver frequently results in torrential blood loss, suggesting the injury may be best managed without exploration and IVC suturing. The present study was undertaken to define the natural history of untreated IVC perforations, and to assess venous access with such injuries. Twelve adolescent Hampshire pigs (20-25 kg) underwent halothane anesthesia and laparotomy. The infrarenal IVC was isolated temporarily and a posterior cruciate incision, equivalent to 50% of the IVC circumference, made via anterior venotomy. Animals were resuscitated with Ringer's lactate. Technetium sulfur colloid was injected 20 min postlaparotomy closure via either a jugular or femoral venous cannula, and count activity measured over the IVC injury site using a mobile gamma camera. The procedure was repeated via the counterpart limb. Background from the first injection was subtracted, and count ratios integrated from 16 to 19 min postinjection. Extravasation following lower extremity infusion was not significantly different from that following central venous administration. One pig succumbed to cryptogenic peritonitis one wk postinjury. The remaining animals were killed at periods ranging from 3 to 12 wk. No animal had clinical evidence of delayed bleeding, pulmonary embolus, or other venous sequelae during the observation period. At autopsy all vena cavae were normal caliber without evidence or pseudoaneurysm of thrombosis.This swine study confirms the efficacy of lower extremity venous access with contained IVC injury, and suggests that isolated retroperitoneal IVC injuries may be treated nonoperatively in very selected patients.

ISSN:0022-5282    

出版商:OVID    

年代:1986

数据来源: OVID

摘要:

A case of cardiac impalement is presented and the general principles of torso impalement discussed. Leaving the impaling object in situ is desirable but when this requires substantial time, the patient's clinical status and the difficulties of resuscitation due to the object may necessitate prompt removal. Emergency department assessment and resuscitation should be brief and preoperative studies minimal.

ISSN:0022-5282    

出版商:OVID    

年代:1986

数据来源: OVID

摘要:

Vertical deceleration injuries represent a distinct form of urban blunt trauma. We reviewed 161 adult patients, admitted over 36 months, who jumped or fell from a height of one to seven stories and survived emergency department resuscitation. Charts and radiographs were analyzed to identify common injuries, complications, and causes of death.Those who fell five or more stories had a mean ISS of 41, for a predicted survival of 50% but actual survival of 83%. Virtually all these patients had multiple fractures. Sixty per cent of them presented in shock, yet more than two thirds had angiographically demonstrated retroperitoneal hemorrhage as their major source of bleeding. Thirteen patients had significant intra-abdominal injuries, with only one associated with major hemorrhage. Utilizing early diagnostic peritoneal lavage, ten of 13 patients explored had a therapeutic laparotomy. Hollow viscus perforations accounted for about one half of the abdominal injuries, including three duodenal injuries.Conclusions.1) Patients who present in shock after falls from height are much more likely to be bleeding from retroperitoneal than intraperitoneal sources. 2) Early tap and lavage followed by emergency angiography and transcatheter embolization is the treatment of choice in this group of patients. 3) Although these patients often have multiple complex injuries, the prognosis for long-term survival is good. Therefore, we advocate early aggressive operation stabilization of fractures to permit patient mobilization, facilitate pulmonary toilet and nursing care, and to decrease long-term disability.

ISSN:0022-5282    

出版商:OVID    

年代:1986

数据来源: OVID

摘要:

Any compromise of the reticuloendothelial system (RES) or host defense in general would militate against the potential benefit of fluorocarbon emulsions as oxygen-carrying resuscitation fluids. The relationship between lethal hemorrhagic shock resuscitation with Fluosol-DA 20% and subsequent host depression was examined in a rat model. Host tolerance to a standard intra-abdominal polymicrobial septic challenge was assessed 5 days after hemorrhagic shock. Resuscitation with fluorocarbon was more effective than no resuscitation and is equal to Ringer's lactate. The addition of O2did not enhance survival. In response to a septic challenge, survival of animals resuscitated with Ringer's lactate was similar to the control group, and fluorocarbon-treated animals had a significantly lower survival. It appears in this study that supplemental oxygen is not needed and that fluorocarbon emulsions act as a volume expander only. The enhanced mortality to a septic challenge may indicate a compromise in the host defense system induced by fluorocarbons, and clinical trials should proceed with caution accordingly.

ISSN:0022-5282    

出版商:OVID    

年代:1986

数据来源: OVID

摘要:

Diminished venous return is the primary determinant of reduced cardiac output in hemorrhagic hypoperfusion. In this study the hemodynamic response of two therapies commonly employed to increase venous return in hemorrhagic hypoperfusion—pneumatic antishock garment (PASG) application and Trendelenburg (TREND) positioning—were compared in normovolemic man. Five patients had PASG pressure of 20 mm Hg compared with 10° Trendelenburg, eight patients had 20 and 40 mm Hg PASG application compared with 10° Trendelenburg. PASG application at both 20 and 40 mm Hg resulted in a significant increase in CVP (11.1 ± 1.9 baseline to 16.0 ± 2.7 PASG 40;p< 0.01) left atrial pressure (LAP) (10.1 ± 1.3 baseline to 14.4 ± 1.8 PASG 20;p< 0.01) pulmonary capillary wedge pressure (PCWP) (11.6 ± 2.0 baseline to 16.8 ± 3.4 PASG 40;p< 0.01) and esophageal pressure (Pes) (5.0 ± 0.8 baseline to 8.6 ± 0.9 PASG 40;p< 0.01). However, transmural right and left atrial pressure (RATP, LATP) and cardiac index (CI) were unchanged. Ten degrees of Trendelenburg resulted in no increase in CVP, PCWP, RATP, or LATP, but CI (2.67 ± 0.07 baseline to 2.82 ±0.1 TREND;p<0.01) was significantly increased. Systemic vascular resistance index (570 ± 46 TREND vs. 668 ± 53 PASG 40;p< 0.01) was significantly less in Trendelenburg compared to PASG at 40 mm Hg. The data demonstrate that elevation in CVP, LAP, and PCWP following PASG application is secondary to an increase in intrathoracic pressure (as measured by Pes). The elevation in CVP inhibits venous return and does not allow for an increase in CI following compression of the lower extremities and abdomen. Trendelenburg positioning increased CI without elevating intrathoracic pressure. The increase in CI with Trendelenburg argues that Trendelenburg positioning increases venous return without other significant hemodynamic alteration. We conclude that Trendelenburg is superior to PASG application in promoting venous return in normovolemic man, an effect expected to be similar in hypovolemia.

ISSN:0022-5282    

出版商:OVID    

年代:1986

数据来源: OVID

摘要:

Thirty rats were subjected to a standardized lethal hepatic and retrohepatic caval vein injury. The animals were divided into six groups. In addition to controls (I), the animals were treated with a pneumatic antishock garment (PASG) (II), massive intravenous (III), or intra-aortic (IV), saline infusion, or PASG in combination with either massive intravenous (V) or intra-aortic (VI) saline infusion. Intravenous and intra-aortic infusion of saline led to a median survival time of 13 min and 37 min, respectively, not statistically different from the control group. Nine of ten animals who had the combined treatment with PASG and infusion of saline developed a fulminant pulmenary edema. The treatment with PASG alone, however, prolonged survival time significantly from a median survival time of 10 min in the control group, to >120 min in the treated group.

ISSN:0022-5282    

出版商:OVID    

年代:1986

数据来源: OVID

摘要:

The Committee on Trauma of the American College of Surgeons published a report in 1976 charging hospitals to provide care for seriously injured patients. Implementing an effective emergency care/trauma system in a not-for-profit community hospital was a task that demanded leadership, substantial time, and commitment. The building process could not have begun without a strong commitment from the hospital's board, administration, medical staff, and nursing service. Initially, the operating rooms, radiology, intensive care units, and emergency departments were renovated or replaced. General surgeons and surgical subspecialists committed to trauma care were recruited. Emergency department (ED) physicians were upgraded and resident rotations in the ED were begun. A ground and helicopter transport system was initiated; dispatch was centered in the ED. Educational programs in prehospital critical care and stabilization for flight nurses and EMT's were developed. The operating rooms began 24-hour service with in-house anesthesia coverage. Radiology provided 24-hour coverage of specialty services. Physicians began in-house coverage of the critical care units. The department of surgery developed a trauma section to encompass all the general surgeons and subspecialty physicians in emergency care. Monthly in-service programs were begun for the intensive care unit (ICU) and ED nurses. In each of the past 3 years, a 2-day trauma update program has been provided to the regional Emergency Medical Services (EMS) and medical community. The dedication and commitment of many people during the past 5 years has resulted in a sound system of emergency/trauma care in a community hospital.

ISSN:0022-5282    

出版商:OVID    

年代:1986

数据来源: OVID

摘要:

From July 1978 to July 1985, 1,348 patients with hepatic injuries were treated. During this period, 66 patients (5.3% or 9.4 patients/year) required perihepatic packing. Penetrating wounds accounted for 77.2% of injuries requiring packing. Seventeen patients died in the operating room from massive hepatic and other intra-abdominal injuries and were excluded from further analysis. Perihepatic packing was inserted in 41 patients at a first operation and at a second or third operation in eight others. The major indications for packing were post-repair coagulopathies (85.5%) and extensive subcapsular hematomas or capsular avulsion (12.2%). Packing was removed from 28 surviving patients (28/49 = 57.1%) at an average of 3.7 days following insertion. Pack removal was accomplished by laparotomy in 24 patients (85.7%) and extraction through a hole in the body wall in four others. Ten postoperative intra-abdominal fluid collections, hematomas, or abscesses occurred in nine patients (9/49 = 18.4%) surviving the first operation. Perihepatic packing continues to be a life-saving adjunct in a highly selected group of patients with the most severe hepatic injuries and nonmechanical bleeding at the completion of repairs or extensive subcapsular hematomas.

ISSN:0022-5282    

出版商:OVID    

年代:1986

数据来源: OVID