摘要:

To improve our understanding of this frequently lethal, but potentially salvageable problem, the case records of 105 patients with 138 major intraabdominal venous injuries seen over a 4 year period (1980—1984) were reviewed. The overall mortality rate was 54%. The most frequent abdominal venous injuries and their mortality rates were inferior vena cava, 54% (28/52); portal venous system, 51% (16/31); iliac veins, 71% (20/28); renal veins, 58% (11/19); and hepatic veins, 88% (7/8).Several important prognostic factors were identified. Of 48 patients who presented to the emergency department with no obtainable blood pressure, 41 (85%) died. Forty patients presented to the operating room with a systolic pressure less than 70 mm Hg and 36 (90%) died. Of 39 patients in hypovolemic shock for more than 15 minutes initially in the ED and operating room, 31 (79%) died. Of 71 patients who received 10 or more units of blood pre- and perioperatively, 48 (68%) died. Of 41 patients with five or more associated injuries, 30 (73%) died.Seventeen had a thoracotomy before laparotomy to cross-clamp the aorta for persistent severe shock; six responded with a substantial increase in blood pressure and three survived. Of 14 others with severe persistent shock who did not have a prior thoracotomy, only one survived. Atrial-caval shunts were attempted for severe retrohepatic bleeding in six patients with no survivors.Review of these cases suggests that improved survival might be obtained with: 1) more vigorous administration of fluids in the emergency department and operating room; 2) quicker movement to the operating room to control bleeding; and 3) earlier definitive management for controlling bleeding— especially with iliac and/or retrohepatic injuries. A thoracotomy to crossclamp the aorta prior to laparotomy with severe persisting shock should be considered.

ISSN:0022-5282    

出版商:OVID    

年代:1986

数据来源: OVID

摘要:

During an 18-month period, among 35,000 injured patients presenting to an urban trauma center, more than 3,500 were admitted, and 1,500 underwent surgery on the General Surgical Service. Three hundred fifty-two patients with prehospital systolic blood pressures of less than 90 mm Hg were randomized on an alternate day basis to receive treatment with 'MAST' (163 patients) or 'No-MAST' (189 patients). Age, mechanism of injury, prehospital management times, prehospital trauma scores, prehospital fluids administered, Injury Severity Scores, emergency center treatment, operative protocol, and calculated probability of survival were virtually identical for both groups. Eighty-eight per cent of the injuries were produced by penetrating wounds. The predominant injury area was the abdomen in 40%, the thorax in 37%, and the extremities in 13%. There was no statistically significant difference in evaluation and outcome data between the groups. Within a controlled catchment, only 2.5% of injured patients and 22% of those undergoing operation qualified for prehospital use of MASTWe conclude that for penetrating trauma with prehospital times of 30 minutes or less, MAST provide no advantage with regard to survival, length of hospital stay, or reduced hospital costs.

ISSN:0022-5282    

出版商:OVID    

年代:1986

数据来源: OVID

摘要:

Immediate and delayed traumatic intracerebral hematomas (ICH) can produce devastating secondary brain damage after severe head injury. The relationship between the initial injury and eventual occurrence, size, and time of appearance of such hematomas is not well understood, but has great importance since delayed appearance may necessitate delayed surgical decompression of developing lesions not present on early CT scans.1111We reviewed the records of 35 consecutive patients with operated posttraumatic ICH to document when these lesions appeared on CT, what were the indications for surgery, and what was eventual outcome. Time between injury and ICH appearance was categorized as immediate (0—3 hours), intermediate (3—6), delayed (6—24) or very delayed (later than 24 hours).ICH appearance was immediate in 20%, intermediate in 6%, delayed in 29%, and very delayed in 46%. Half of the patients were not comatose at the time of admission (GCS>8). Hematoma removal was prompted by clinical deterioration or failure to improve in half the patients and by uncontrolled intracranial hypertension in the other half. Half the patients died, generally those in traumatic coma immediately after injury although advanced age also was associated with poor outcome.Only about one quarter of patients who require surgical removal of ICH can be shown to have their lesions soon after injury. Most operable intraparenchymal clots develop after initial CT scanning and trauma surgeons must be prepared to recognize and treat this delayed complication of brain injury. Even with aggressive management, ICH contribute significantly to poor outcome and improved treatment must be sought.

ISSN:0022-5282    

出版商:OVID    

年代:1986

数据来源: OVID

摘要:

Little information concerning the prognostic and functional significance of post-traumatic myocardial contusion appears to exist. During a 10-month period, 19 patients with major blunt thoracic trauma were diagnosed as having myocardial contusion using clinical findings, serial ECG and CPK-MB isoenzyme determinations, and biventricular radionuclide angiocardiography (RA). All patients had associated thoracic and extrathoracic injuries. ECG and RA were useful and complementary tests, detecting abnormalities in 90% and 47% of patients, respectively. Only one patient had an abnormally elevated CPK-MB. All patients required operative treatment for associated injuries, 15 (79%) on the day of admission. Eleven patients required perioperative cardiac inotropic support and one needed IABP. No late complications were attributable to the cardiac contusions per se; no patients died. Emergency surgery for associated injuries in patients with myocardial contusion can be safely performed using hemodynamic monitoring to guide cardiac inotropic support measures. Myocardial contusion does not constitute an absolute contraindication to necessary operations in polytraumatized patients.

ISSN:0022-5282    

出版商:OVID    

年代:1986

数据来源: OVID

摘要:

A computer model incorporating known behavior of the cardiovascular system and intravascular:interstitial fluid exchange was designed which allowed bleeding rate, IV infusion rate, and prehospital care times to be independently specified. All possible circumstances were examined. The model shows that IV's are potentially of benefit only when all of the following occur: 1) the bleeding rate is initially 25—100 ml/min, 2) the prehospital time exceeds 30 minutes, and 3) the IV infusion rate is approximately equal to the bleeding rate. IV infusions therefore appear of little benefit in the usual urban environment and have a sharply limited role overall. The possibility of pulmonary edema from fluid overload in nonhypovolemic patients, and reluctance of field personnel to infuse fluid at the rates necessary to produce benefit raise further questions about realistic benefit of IV's in all but the most rural systems.

ISSN:0022-5282    

出版商:OVID    

年代:1986

数据来源: OVID

摘要:

To assess the need for a trauma system in San Diego County, a concurrent audit of trauma care was performed by an independent consultant in 1982. During the study period from 15 March through 15 June 1982, 591 consecutive major trauma victims (MTV) were collected by the 30 participating hospitals. All medical records, including autopsy reports, were audited for the timeliness and appropriateness of diagnosis and definitive care. Deaths were classified as being not preventable, potentially salvageable, or preventable. A trauma system subsequently became functional on 1 August 1984, with five adult centers and one pediatric center. A Medical Audit Committee composed of physicians and nurses from designated and nondesignated hospitals was organized to perform a monthly concurrent audit of trauma care. Between 1 August and 31 December 1984, 1,366 MTV were triaged to trauma centers. The care of MTV was considered suboptimal in 32% of patients before regionalization, compared to 4.2% after regionalization (p<0.01). Preventable deaths occurred in 13.6% of fatalities occurring before implementation of a trauma system, compared to 2.7% after implementation (p<0.01). Regionalization of trauma care significantly reduced delays, inadequate care, and preventable deaths due to trauma.

ISSN:0022-5282    

出版商:OVID    

年代:1986

数据来源: OVID

摘要:

Previous studies have emphasized injury mechanism, wound site, and presenting vital signs as critical determinants for survival following penetrating cardiac injury. Our experience suggests pericardial tamponade is another crucial factor and is the basis for this study. Prognostic features were reviewed in 100 consecutive, unselected patients with acute cardiac injuries. Mechanism was stab wound in 57, and gunshot injury in 43. Location included right ventricle in 55, left ventricle in 49, right atrium in 16, and left atrium in seven. Overall salvage was 31%,; 27 (47%) of 57 stab wounds, four (9%) of 43 gunshot wounds, 22 (49%) of 45 right, and nine (23%) of 39 left heart wounds. The presence or absence of pericardial tamponade was documented in 77 patients. Patients with tamponade had a survival of 73% (24/33) compared to 11% (5/44) in those without its protective effect. The presence of tamponade improved survival (p<0.05) following stab injuries (77% vs. 29%), gunshot wounds (57% vs. none), right heart wounds (79% vs. 28%), left heart injuries (71% vs. 12%), and overall in patients arriving with vital signs (96% vs. 50%). Multivariant discriminant analysis by logistic regression demonstrated cardiac tamponade was a critical independent factor in patient survival, and suggested that it may be more influential than presenting vital signs in determining outcome.

ISSN:0022-5282    

出版商:OVID    

年代:1986

数据来源: OVID

摘要:

The hospital records of 307 patients sustaining mandibular fractures between 1980 and 1984 were reviewed. The patient population consisted of 79% males, with precipitating events usually being fist fights (47%) and assaults with a blunt object (18%). The most common fracture involved the body (30%), followed by the angle (21%) and the condyles (19%).00000000Intermaxillary fixation (IMF) was the preferred method of treatment (42%); however, a large number of patients were treated by internal fixation (31%) or external stabilization (11%). Despite the large number with internal fixation procedures, the complication rate was relatively low (18%).000000 This review suggests changing trends in mandibular fractures. Motor vehicle accidents no longer comprise the most common etiology, so that condylar fractures are no longer the most common, and fractures of the body and angle are more common. Although most patients still are initially treated by intermaxillary fixation, the number of open reductions appears to be increasing. Despite this trend, the complication rate has remained relatively low.

ISSN:0022-5282    

出版商:OVID    

年代:1986

数据来源: OVID

摘要:

During a 7 year period, we have seen 111 patients with bladder rupture, 95 from blunt trauma and 16 due to penetrating injuries. All 16 patients with penetrating injuries, as well as an additional 34 patients with intraperitoneal injuries, nine patients with extraperitoneal injuries, and five with both intraand extraperitoneal injuries from blunt trauma, had formal closure of the wound and urethral or suprapubic catheter drainage. All did well. A total of 39 patients with extraperitoneal bladder injuries were treated with only catheter drainage and all did well. Eight patients died before institution of therapy.

ISSN:0022-5282    

出版商:OVID    

年代:1986

数据来源: OVID

摘要:

Spontaneous and pokeweed mitogen (PWM)-induced polyclonal immunoglobulin production in vitro were estimated in patients with severe burns (28-83% TBSA) immediately following their injury and at intervals of 8 to 14 days thereafter. In parallel, functional activity of patients' T lymphocytes was assessed in the mixed lymphocyte reaction (MLR). PWMinduced immunoglobulin secretion, of both IgG and IgM, was elevated in the first 2 to 3 weeks after burn, followed by a period of relatively suppressed antibody response at 3 to 4 weeks. Immunoglobulin production was then apparently restored to baseline or higher levels in surviving patients. However, in patients whose antibody response continued to be suppressed fatal septicemia developed. The background (spontaneous) immunoglobulin synthesis increased significantly over the normal range in 10/78 tests performed. These alterations in mitogen-induced immunoglobulin production were well correlated with changes in the T-cell alloreactivity in the MLR. Thus thermal injury-associated changes in the patients' humoral responses may be a consequence of changes within the T-cell compartment, especially the T-helper cell subset.

ISSN:0022-5282    

出版商:OVID    

年代:1986

数据来源: OVID