摘要:

In resuscitation from hemorrhagic shock, very small volumes of hypertonic saline (HS) improve blood pressure while reducing intracranial pressure and edema formation. The effects of hypertonic resuscitation fluids and hypernatremia on electrophysiologic brain function have not been studied. The present study was done in two parts. First we examined the effects of hemorrhagic shock and resuscitation with either 7.5% HS or lactated Ringer's (LR) solution on the flash evoked potential (FEP). Rats were bled to a mean arterial pressure (MAP) of 35 mm Hg for 1 hour, then resuscitated with HS (n = 10) or LR (n = 10) to a MAP of 80 mm Hg for another hour. Resuscitation required 3.8 ± 0.5 mL/kg HS and 42.9 ± 7.5 mL/kg LR (p < 0.05). During hemorrhage, FEP latencies increased and amplitudes decreased. During resuscitation, these variables returned toward baseline values. There were no significant differences between groups, although HS tended to restore the FEP better than LR. We next examined the effects on the FEP of hypernatremia and hyperosmolarity produced by two different hyperosmotic fluids. Over a 1-hour period, 16 mL/kg HS (n = 8), 16 mL/kg IsoSal (4.5% saline, 5.9% glucose, 6.4% mixed amino acids; n = 8), or 40 mL/kg LR (n = 8) was infused into normovolemic rats. Plasma sodium levels increased in both hyperosmotic groups (baseline = 145.2 ± 0.7 mEq/L; after infusion, HS = 202.4 ± 9.8 mEq/L, IsoSal = 163.3 ± 4.2 mEq/L; p < 0.05). Plasma osmolarity also increased in these two groups (baseline = 303.1 ± 1.6 mOsm/L; after infusion, HS = 404.6 ± 17.6 mOsm/L, IsoSal = 357.9 ± 6.7 mOsm/L; p < 0.05). Brain tissue water content was slightly decreased in both hyperosmotic groups compared with the LR group (HS = 77.4% ± 0.7%; IsoSal = 77.5% ± 0.6%; LR = 78.2% ± 0.4%) although the differences were not significant. Some deterioration was seen in the FEP at very high levels of serum sodium and osmolarity. Neural tissue dehydration as a result of hypertonic saline infusion in hemorrhaged and normovolemic rats has no apparent deleterious effects on acute brain function as measured by the FEP until very high levels of sodium and osmolarity are reached.

ISSN:0022-5282    

出版商:OVID    

年代:1993

数据来源: OVID

摘要:

A surgical technique of laryngotracheoplasty with long-term stenting was employed exclusively in the treatment of 105 patients with laryngotracheal stenosis in the Department of Otolaryngology, National Taiwan University Hospital from May 1977 to April 1989. The results were satisfactory, 92% of the treated patients being decannulated. The technique of laryngotracheoplasty can be summarized as follows: (1) Exposure of the stenotic region by laryngofissure, anterior and/or posterior cricoid splitting, vertical tracheal incision; (2) debridement of infected soft tissue; (3) relaxation or displacement of heavy scar tissue; (4) placement of sutures to tent the laryngotracheal mucosal remnants to the extraluminal region; (5) insertion of a endolaryngotracheal stent using a silicone T tube; (6) closure of the skin layer of the surgical wound only, without approximating the soft tissue layer between the T tube and skin; and (7) leaving the stunt in place for at least 6 months.

ISSN:0022-5282    

出版商:OVID    

年代:1993

数据来源: OVID

摘要:

One hundred nineteen patients suffered penetrating cardiac trauma over a 15-year period: 59 had gunshot wounds, 49 had stab wounds, and 11 had shotgun wounds. The overall survival rate was 58%. The most commonly injured structures were the ventricles. Twenty-seven patients had injuries to more than one cardiac chamber. Thirty patients had associated pulmonary injuries. Emergency thoracotomy was performed in 47 patients with 15% survival. Median sternotomy was used in 30 patients with 90% survival. Seventeen of the 83 patients with thoracotomies required extension across the sternum for improved cardiac exposure or access to the contralateral hemithorax. Only one patient with sternotomy also required a thoracotomy. All pulmonary injuries were easily managed when sternotomy was used. We conclude that sternotomy provides superior exposure for cardiac repair in patients with penetrating anterior chest trauma. We feel it is the incision of choice in hemodynamically stable patients. Thoracotomy should be reserved for unstable patients requiring aortic cross-clamping, or when posterior mediastinal injury is highly suspected.

ISSN:0022-5282    

出版商:OVID    

年代:1993

数据来源: OVID

摘要:

The ability of magnetic resonance imaging (MRI) to diagnose locked facets was examined in a series of six patients with traumatic cervical spine fractures. Plain films, computed tomography, and magnetic resonance scanning were done immediately following injury. Cord edema, contusions, and acute disc herniation were well visualized on magnetic resonance images. Magnetic resonance proved to be equally effective in diagnosing unilateral and bilateral locked facets, and demonstrated the disruption of the posterior longitudinal ligament (PLL) with clarity. The magnetic resonance diagnostic criteria of locked facets, herniation of intervertebral discs, and rupture of the posterior longitudinal ligament are described. Besides permitting direct visualization of the spinal cord, MRI may have a role in the diagnosis and management of acute bony injury to the cervical spine.

ISSN:0022-5282    

出版商:OVID    

年代:1993

数据来源: OVID

摘要:

The purpose of this study was to evaluate the ability of abdominal ultrasound (US) to detect intra-abdominal injuries that required surgical repair. We therefore retrospectively reviewed 353 patients with nontrivial blunt abdominal trauma. All patients underwent abdominal evaluation as part of our routine trauma protocol within the first minutes of arrival at our emergency center. Hemoperitoneum and intraperitoneal parenchymal damage were correctly identified by US with a sensitivity of 92.8%, and a specificity of 100%. Accuracy was 99.4%, the positive predictive value was 100%, and the negative predictive value was 99.4% (prior probability of disease was 7.65%). We believe that abdominal US should be considered an important tool and an integral part in the work-up of major trauma victims.

ISSN:0022-5282    

出版商:OVID    

年代:1993

数据来源: OVID

摘要:

We retrospectively reviewed the medical records and cervical films, computed tomographic (CT) scans, and tomographic studies of 216 consecutive patients with cervical injuries. A trauma series of roentgenograms—a cross-table lateral (CTL), a supine anteroposterior, and an open-mouth odontoid view—was performed in 100%; CT scanning was performed in 100%; and tomography was done in 9% of cases. We determined what percentage of the patients were asymptomatic initially in the emergency department; the total numbers of fractures, subluxations, and dislocations of the cervical spine in these patients; and what percentage of the cervical injuries were not detected with the plain films. Of the 216 patients in the series, 188 (87%) had known signs or symptoms of cervical injury; however, 28 (13%) of the patients were initially asymptomatic with no neurologic deficit. Of these 28, 17 were intoxicated or had mild closed head injuries; however, in 11 (5%) there was no clinical clue to their cervical injury other than a known injury mechanism. Prospectively, 67% of the fractures and 45% of the subluxations and dislocations were not detected by the CTL films, and 32% of the patients, over half of whom had unstable cervical injuries, were falsely identified as having normal spines. Prospectively, the trauma series improved the sensitivity of plain films for detecting cervical injuries but still did not detect 61% of the fractures and 36% of the subluxations and dislocations, and falsely identified 23% of the patients, half of whom had unstable cervical injuries, as having normal cervical spines. We conclude that cervical roentgenography cannot be relied upon either to definitively determine the true extent and severity of cervical injuries in trauma victims or to exclude cervical injuries in these patients. In trauma victims for whom the plain films are positive for injury and in those in whom the plain films are negative for injury but there is a high clinical suspicion of cervical injury, CT scanning should be liberally employed for a more definitive evaluation of the cervical spine.

ISSN:0022-5282    

出版商:OVID    

年代:1993

数据来源: OVID

摘要:

In hypotensive blunt trauma patients with a diminished level of consciousness, it may be difficult to decide whether to proceed with immediate head CT scanning or urgent laparotomy or thoracotomy. The purpose of this study was to determine the frequency of emergency craniotomy and urgent laparotomy or thoracotomy in a group of 734 blunt trauma patients with initial hypotension (BP < 90 mm Hg systolic) admitted to the eight level I and II trauma centers in North Carolina. The mean initial systolic blood pressure was 64 ± 26 mm Hg, and the mean Trauma Score was 8 ± 5.8. Serious head injury (AIS head ≥ 3) was present in 40% (293 of 734). Of 734 patients studied, 9.4% (69 of 734) died in the emergency department. Head CT scanning was performed on 47% (344 of 734) and produced positive results for 26% (202 of 734). Emergency craniotomy for intracranial hemorrhage was performed on 2.5% (18 of 734) (ten subdurals, three epidurals, and five other intracranial hemorrhages). Twenty-one percent (154 of 734) underwent urgent laparotomy, thoracotomy, or both. Overall hospital mortality for hypotensive blunt trauma patients was 36% (263 of 734). Although serious head injury occurs commonly (40%) in hypotensive blunt trauma patients, frequency of urgent laparotomy (21%) is 8.5 times greater than emergency craniotomy for intracranial hemorrhage (2.5%). This information may be used by trauma teams in prioritizing care for hypotensive blunt trauma patients.

ISSN:0022-5282    

出版商:OVID    

年代:1993

数据来源: OVID

摘要:

We sought to determine the reliability of the Glasgow Coma Scale (GCS) when used by emergency physicians and paramedics. We performed a prospective sequential trial in a classroom setting, with subjects blinded to others' scoring. Nineteen university-affiliated emergency physicians and 41 professional paramedics from an urban EMS system voluntarily participated. Participants viewed four videotaped scenes in which a patient is assessed by a paramedic. The first three scenes represented severe, intermediate, and no/mild alteration in level of consciousness (LOC). The findings in the fourth scene were identical to the first, allowing determination of intrarater reliability. The Kappa statistic was used to determine interrater reliability; the reliability coefficient determined intrarater reliability. Kappa was significant (p < 0.0001) for severe (k = 0.48), intermediate (K = 0.34), and no/mild (k = 0.85) conditions. Intrarater reliability (r1,2) for emergency physicians was 0.66 (p < 0.01) and for paramedics was 0.63 (p < 0.01). The GCS shows statistically significant reliability (i.e., significant agreement) between emergency physicians and emergency medical technician-paramedics. It also has a significant level of interpreter reliability.

ISSN:0022-5282    

出版商:OVID    

年代:1993

数据来源: OVID

摘要:

In elderly women with proximal femur fractures, plasma cortisol levels are still elevated 2 weeks after injury. We have now measured the concentrations of adrenocorticotrophin (ACTH) and its precursor peptides (pro-opiomelanocortin plus pro-ACTH) in blood samples obtained in the morning and afternoon from such patients and from old and young control subjects. In healthy subjects, aging had no effect on these variables. Compared with healthy elderly women, the injured women had elevated cortisol but not ACTH concentrations; at both times of day their precursor peptide concentration was increased but probably not enough to affect cortisol secretion substantially. There were no correlations between the concentrations of cortisol, ACTH, and precursor peptides. We have also studied adrenocortical sensitivity after giving dexamethasone overnight. The cortisol responses to graded doses of ACTH did not differ between injured and healthy elderly women, suggesting that their higher cortisol concentrations were the result of stimuli acting independently of ACTH.

ISSN:0022-5282    

出版商:OVID    

年代:1993

数据来源: OVID

摘要:

Forty-two patients with subtrochanteric fractures were treated from 1987 through 1990. Of these, 31 patients above 70 years of age (average, 81.9) had nonpathologic low-energy fractures that were internally fixed with a sliding screw-plate device. Subtrochanteric fractures with an associated intertrochanteric component were the most common type. Interfragmentary compression was used in long oblique and spiral fractures and those with large butterfly fragments. Patients were mobilized early and allowed partial weightbearing for 6–8 weeks. There was a 29% mortality rate within 3 months of injury. Of the remaining cases, followed for a minimum of 6 months (average, 11.8 months), 20 (91%) united satisfactorily. There was loss of fixation in one case and one instance of plate fracture. We found, given the special circumstances in elderly patients, that the device was suitable not only for subtrochanteric fractures with an intertrochanteric element but also for four-part fractures and two-part spiral fractures. The sliding screw-plate permitted passage of interfragmentary screws and facilitated medial displacement and collapse, which are valuable in cases with medial comminution in reducing the bending moment on theplate. These factors may help reduce the incidence of plate failure and, coupled with familiarity with its use, make it a reliable implant for such difficult fractures in elderly patients.

ISSN:0022-5282    

出版商:OVID    

年代:1993

数据来源: OVID