摘要:

A 30-year experience in the management of 283 consecutive patients with acute pancreatic trauma was reviewed. Of these injuries 224 were penetrating; 59 were from blunt trauma. Diagnosis was made by laparotomy in all patients, although elevated serum amylase suggested this injury in 23 (56%) of 41 patients with nonpenetrating injuries. Operative measures were initially involved with correction of associated injury when present (961 organ injuries in 278 patients: 3.5 injuries per patient). During the earlier years, Penrose drains were placed to the site of injury. Significant pancreatic complications (fistula in 13, suppurative pancreatitis or abscess in six, pseudocyst in three) were noted in 19 (46%) of the 41 patients so managed. Routine sump drainage dramatically reduced the incidence of pancreatic complications to 2% in the 198 patients having external drainage alone. Distal resection was performed in 29 patients, without later pancreatic insufficiency. Most disappointing were the results from Roux-en-Y internal drainage: fistula developed in five and lethal bacterial pancreatitis in three of the seven patients so treated. Five patients died from exsanguination during exploration for major vascular trauma, and all three patients undergoing pancreaticoduodenectomy succumbed within 20 hours after operation. The overall mortality was 13.8%, with only seven deaths out of the last 100 patients treated. Profound hemorrhagic shock and its complications (19), suppurative pancreatitis (eight), and post-traumatic respiratory insufficiency (three) accounted for 30 of the 39 fatalities.

ISSN:0022-5282    

出版商:OVID    

年代:1981

数据来源: OVID

摘要:

The response of the plasma substrate and hormone profile of survivor and nonsurvivor septic trauma patients to varying rates of amino acid infusion (IVAA) were contrasted. When IVAA = 0 levels of most plasma amino acids (except aspartate, tryptophan, cysteine, and proline) were lower in nonsurvivors. At IVAA = 1 to 100, however, 11 of 20 plasma amino acids were significantly (p≤ 0.05) higher in nonsurvivors: only glutamate was significantly lower (p≤ 0.001) and valine, isoleucine, and arginine on average lower. At IVAA ≤ 101 to 200, only alanine, methionine, tyrosine, and phenylalanine were significantly (p≤ 0.005) higher in nonsurvivors; isoleucine was significantly (p≤ 0.02) lower. The sharp increase in methionine and decrease in tryptophan in nonsurvivors with IVAA was particularly marked.Polynomial regression analysis showed that urea increased significantly with IVAA in both patient groups, while free fatty acids and cortisol decreased only in nonsurvivors. Insulin increased with IVAA only in survivors, glucagon only in nonsurvivors. Triglycerides, glycerol, acetoacetate, β OH butyrate, and glucose appeared to show no significant response to IVAA in either patient group.The data are consistent with increased peripheral protein catabolism and branched-chain amino acid oxidation in association with decreased tissue uptake of conventional energetic fuels. These results may be interpreted to be consistent with an impairment of mitochondrial translocase systems.

ISSN:0022-5282    

出版商:OVID    

年代:1981

数据来源: OVID

摘要:

Supplemental albumin added to a standard non-albumin resuscitation regimen has been shown to significantly impair heartwork in seriously injured patients. The role of calcium dynamics in this myocardial depression was analyzed in 94 injured patients who were in shock for an average of 32 minutes, received an average of 14.5 transfusions, 9.2 L crystalloid, 0.9 L plasma, and 20.9 mEq calcium prior to the end of operation. By random selection, 44 patients received an average of 31 gms of albumin during operation, 207 gms during the early postoperative period (mean = 30 hrs) of extravascular fluid sequestration, and 402 gm during the mobilization period. The albumin resuscitated patients had normal total protein and serum albumin levels and higher total calcium (TC) levels, however, they had a significantly lower Ca++and Ca++/TC. The accumulative slope for heartwork/filling pressure was significantly depressed in albumin patients as was the mean work unit/filling pressure index. The level of Ca++and the Ca++/TC ratio correlated directly with the calculated work unit index in both the albumin and non-albumin patients. This suggests that supplemental albumin binds serum Ca++causing an increase in TC but a reduction in Ca++and Ca++/TC. The fall in Ca++and Ca++/TC seems responsible, in part, for heart failure and pulmonary edema in albumin resuscitated pptients.

ISSN:0022-5282    

出版商:OVID    

年代:1981

数据来源: OVID

摘要:

Expeditious surgical management in serious chest trauma improves survival rates. However, guidelines for emergency thoracotomy that depend on the initial amount of blood loss or continuing blood loss are imprecise and frequently require a period of observation. In an attempt to improve prethoracotomy diagnosis emergency thoracoscopy was used in the operating room in 36 patients who presented with hemothoraces. A diagnostic thoracoscope was inserted through the previously placed incisions for chest tubes. The procedure was well tolerated under local anesthesia and in most patients took less than 15 minutes to complete. No complications resulted from thoracoscopy. When the information obtained did not indicate further operations, the thoracoscope was withdrawn and chest tubes were reinserted through the same incisions. The method provided anatomic definition of the injuries in 35 of 36 patients and allowed the determination of whether blood loss was continuing. Management was altered as a result of thoracoscopy in 16 patients (44.4%). An unnecessary thoracotomy was avoided in 16 patients who had greater than 1,500 ml of blood in the thoracic cavity on admission and allowed a more rapid thoracotomy in one patient. Four patients had wounds located close to the diaphragm and laparotomy was avoided when the diaphragm was found free of injury. Bleeding from lacerated intercostal vessels was stopped with diathermy during thoracoscopy in two of three patients. In addition, 15 patients had 200 ml or more of clotted blood removed. The usefulness of removal of clotted blood remains to be proven but it is hoped that the incidence of empyema will be reduced. Emergency thoracoscopy has proven a valuable diagnostic and therapeutic measure in patients sustaining penetrating chest trauma.

ISSN:0022-5282    

出版商:OVID    

年代:1981

数据来源: OVID

摘要:

Presently available techniques for control of hepatic hemorrhage in patients with extensive parenchymal injuries include direct suture, topical hemostatic agents, hepatotomy or resectional debridement with selective vascular ligation, lobectomy, and selective hepatic artery ligation. In many trauma centers the placement of intra-abdominal packing for hepatic tamponade has been an infrequently used technique in recent years. From 1 July 1978 to 1 September 1980, ten patients with continued hepatic parenchymal oozing following all attempts at surgical control of extensive injuries were treated by the insertion of intra-abdominal packing around the liver as a last desperate maneuver. Packing was removed at relaparotomy in four patients and through abdominal drain sites in five patients. Nine of ten patients survived, and there were no instances of rebleeding following removal of the packing. Four patients developed postoperative perihepatic collections and two of the four patients underwent reoperation for drainage. Based on the recent experience at the Ben Taub General Hospital, intra-abdominal packing for control of exsanguinating hepatic hemorrhage appears to be a lifesaving maneuver in highly selected patients in whom coagulopathies, hypothermia, and acidosis make further surgical efforts likely to increase hemorrhage.

ISSN:0022-5282    

出版商:OVID    

年代:1981

数据来源: OVID

摘要:

Major urethral injuries from external trauma are complex problems of diagnosis and treatment. Complications resulting from injury, failed diagnosis, and inappropriate therapy include stricture, impotence, and incontinence. Opinions differ as to whether immediate suprapubic cystostomy followed by later reconstruction is preferable to immediate direct urethral realignment.A review of 30 patients with urethral injuries is presented, 27 male and three female, 29 from blunt trauma and one gunshot. Initial suprapubic cystostomy alone was used in 26 male patients, 21 with prostatomembranous disruption and five with straddle injury. Prostatomembranous reconstruction in 14 complete urethral transections resulted in one residual stricture, two impotent patients, and no incontinence. Partial prostatomembranous disruption and straddle injuries had insignificant residual stricture, none requiring dilation or reconstruction. The results of this management approach appear superior to those of immediate urethral realignment.Advantages of immediate suprapubic cystostomy are: 1) simplified early approach in management, and 2) successful elective reconstruction of major prostatomembranous injuries with low incidence of stricture, impotence, and incontinence.

ISSN:0022-5282    

出版商:OVID    

年代:1981

数据来源: OVID

摘要:

Selective management of 465 patients with stab wounds limited to the posterior abdomen is reviewed. Celiotomy was based primarily on clinical findings. Tenderness not localized to the area of injury and absent or rare bowel sounds best identified patients with serious injuries. Peritoneal lavage and local wound exploration were used infrequently. All fatally injured patients were operated upon or expired within 5 hours of admission. Diagnosis was delayed in three serious injuries: one retroperitoneal colon perforation, and two diaphragmatic lacerations. The colonie and one diaphragmatic injury were identified and treated successfully in the initial hospital admission. The other diaphragmatic hernia was repaired uneventfully 3 months after injury. Eighty per cent of the patients never required surgery. Fourteen per cent had significant organ injury. The flank was more vulnerable than the back. The colon was the most common organ injured. Six per cent had ‘nonessential’ celiotomies. The overall morbidity was 11%, and mortality rate, 1.1%. Selective management of posterior abdominal stab wounds is a prudent and reliable approach.

ISSN:0022-5282    

出版商:OVID    

年代:1981

数据来源: OVID

摘要:

Ten patients with greater than 70% body surface burn from a group of 113 pediatric thermal injury admissions were studied. Of these children 70% had exision of their burn eschars by carbon dioxide laser and the remaining 30% by scalpel. Burn wounds in all these patients were covered by the expansion autograft technique in an attempt to reduce the resurfacing period in these major burn patients. Survival rate in this small group of patients was 67%.

ISSN:0022-5282    

出版商:OVID    

年代:1981

数据来源: OVID

摘要:

Aerobic and anaerobic bacterial flora of burn sites in 180 children were monitored. Specimens were obtained twice a week; each patient had between one and 21 cultures taken (mean 2.4). A total of 392 specimens were collected over 2 years, of which 319 were positive. Aerobic bacteria alone were present in 225 specimens (71%) and anaerobic bacteria alone were present in 26 (8%). Mixed aerobic and anaerobic bacteria were present in 68 burn specimens (21%). A total of 580 isolates (448 aerobes and 132 anaerobes) were recovered, accounting for 1.8 isolates per specimen (1.4 aerobes and 0.4 anaerobes). The predominant aerobic isolates were S.epidermidis, S. aureus, alpha hemolyticstreptococcus, Pseudomonas sp., and Group D streptococcus. The predominant anaerobic isolates were:P. acnes, anaerobic Gram-positive cocci, and Bacteroides sp. Blood cultures were drawn from 45 children: four showed bacterial growth of one of each of the following isolates:S. aureus, E. coli, Peptococcus asaccharolyticus, andB. fragilis. The numbers of isolates per specimen were higher in the oral and anal area (3.2 and 2.8) than in the extremities and trunk (1.8 and 0.9). Gram-negative enteric rods and Group D streptococci were more frequently recovered from the anal area.S. aureus, S. epidermidis, andP. acneswere more frequently recovered from extremities. Bacteroides sp. andFusobacterium nucleatumwere more frequently recovered from the anal and oral areas. All children were treated with local application of silver sulfadiazine, and antimicrobial therapy was used in 128 children. Statistical analysis showed no correlation between the bacteria isolated and use of antimicrobial agents. These data suggest a role for anaerobic bacteria in the colonization of burns in children, especially in burns of the anal and oral areas.

ISSN:0022-5282    

出版商:OVID    

年代:1981

数据来源: OVID

摘要:

Blunt injuries to the abdominal aorta with initial survival are rare. Two cases of aortic occlusion are reported: one with acute abdominal symptoms and leg ischemia and one with delayed intermittent claudication. The first patient died 9 days postinjury with possible sepsis and bronchopneumonia. The second presented with delayed symptoms 9 years postinjury: fibrous thickening of the intima, a dense, fibrous band around the aorta and left renal vein. After a Dacron graft from the descending thoracic aorta to the external iliac arteries the patient recovered and is employed full time.

ISSN:0022-5282    

出版商:OVID    

年代:1981

数据来源: OVID