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Benjamin ME, Sandager GP, Cohn EJ, Halloran BG, Cahan MA, Lilly MP, Scalea TM, Flinn WR. Duplex ultrasound insertion of inferior vena cava filters in multitrauma patients. Am J Surg 1999; 178:92-7. [PMID: 10487256 DOI: 10.1016/s0002-9610(99)00137-3] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND Techniques for placement of inferior vena cava (IVC) filters have undergone continued evolution from open surgical exposure of the venous insertion site to percutaneous insertion in most cases today. However, the required transport either to an operating room or interventional suite can be complex and potentially hazardous for the multiply injured trauma patient who may require ventilator support, controlled intravenous infusions, or skeletal immobilization. Increased experience with color-flow duplex scanning for routine IVC imaging and portability of ultrasound equipment have suggested the usefulness of duplex-guided IVC filter insertion (DGFI) in critically ill trauma and intensive care unit (ICU) patients. METHODS A total of 25 multitrauma/ICU patients were considered for DGIF. Screening color-flow duplex scans were performed on all patients, and obesity or bowel gas prevented ultrasound imaging in 2 cases, leaving 23 patients suitable for DGFI. In each case, the IVC was imaged in the transverse and longitudinal planes. The right renal artery was identified as it passed posterior to the IVC and was used as a landmark of the infrarenal segment of the IVC. All procedures were performed at the bedside in a monitored ICU setting using percutaneous placement of titanium Greenfield filters. Duplex scanning after insertion was used to document proper placement, and circumferential engagement of the filter struts in the IVC wall. An abdominal radiograph was also obtained in each case to confirm proper filter location. Duplex ultrasound imaging was repeated within 1 week of insertion to assess IVC and insertion site patency. RESULTS DGFI was successful in all cases. The filter was deployed at a suprarenal level in one case, as was recognized at the time of postprocedural scanning. Three patients died as a result of their injuries but there were no pulmonary embolism deaths. Repeat duplex scanning was obtained in 17 patients, and revealed no case of IVC or insertion site thrombosis. CONCLUSIONS Vena caval interruption can be safely performed under ultrasound guidance in a monitored, ICU environment. In selected multiply injured trauma patients, this will reduce the risk, complexity and cost of transport for these critically ill patients. DGFI also reduces procedural costs compared with an operating room or interventional suite, and eliminates intravenous contrast exposure. Preprocedural scanning is essential to identify patients suitable for DGFI, and careful attention must be paid to the known ultrasonographic anatomical landmarks.
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MESH Headings
- Adult
- Aged
- Catheterization, Peripheral
- Cause of Death
- Critical Care
- Equipment Design
- Female
- Follow-Up Studies
- Humans
- Immobilization
- Infusions, Intravenous
- Male
- Middle Aged
- Monitoring, Physiologic
- Multiple Trauma/complications
- Patient Transfer
- Radiography
- Renal Artery/diagnostic imaging
- Respiration, Artificial
- Retrospective Studies
- Titanium
- Ultrasonography, Doppler, Color
- Ultrasonography, Doppler, Duplex/economics
- Ultrasonography, Interventional/economics
- Vascular Patency
- Vena Cava Filters
- Vena Cava, Inferior/diagnostic imaging
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402
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Scalea TM, Scott JD, Brumback RJ, Burgess AR, Mitchell KA, Kufera JA, Turen C, Champion HR. Early fracture fixation may be "just fine" after head injury: no difference in central nervous system outcomes. THE JOURNAL OF TRAUMA 1999; 46:839-46. [PMID: 10338401 DOI: 10.1097/00005373-199905000-00012] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Recent reports suggest that early fracture fixation worsens central nervous system (CNS) outcomes. We compared discharge Glasgow Coma Scale (GCS) scores, CNS complications, and mortality of severely injured adults with head injuries and pelvic/lower extremity fractures treated with early versus delayed fixation. METHODS Using trauma registry data, records meeting preselected inclusion criteria from the years 1991 to 1995 were examined. We identified 171 patients aged 14 to 65 years (mean age, 32.7 years) with head injuries and fractures who underwent early fixation (< or = 24 hours after admission) (n = 147) versus delayed fixation (> 24 hours after admission) (n = 24). RESULTS Patients were severely injured, with a mean admission GCS score of 9.1, Revised Trauma Score of 6.2, Injury Severity Score of 38, median intensive care unit length of stay of 16.5 days, and hospital length of stay of 23 days. No differences between groups were found by age, admission GCS score, Injury Severity Score, Revised Trauma Score, intensive care unit length of stay, hospital length of stay, shock, vasopressors, major nonorthopedic operative procedures, total intravenous fluids or blood products, or mortality rates. In survivors, no differences in discharge GCS scores or CNS complications were found. CONCLUSION We found no evidence to suggest that early fracture fixation negatively influences CNS outcomes or mortality.
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Bozeman WP, Gaasch WR, Barish RA, Scalea TM. Trauma resuscitation/critical care fellowship for emergency physicians: a necessary step for the future of academic emergency medicine. Acad Emerg Med 1999; 6:331-3. [PMID: 10230985 DOI: 10.1111/j.1553-2712.1999.tb00397.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Emergency physicians (EPs) have long been de-facto providers of trauma resuscitation and critical care in academic and community hospital settings, and are significantly involved in out-of-hospital trauma care and trauma research. A one-year fellowship has been developed and implemented to provide advanced training in trauma resuscitation and critical care to EPs with a special interest in the field. This fellowship provides additional depth and breadth of training to prepare graduates for leadership roles in academic and specialized trauma centers. This is the first fellowship of its kind for EPs, and may serve as a model for fellowships at other institutions.
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404
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Volpe MA, Pachter EM, Scalea TM, Macchia RJ, Mydlo JH. Is there a difference in outcome when treating traumatic intraperitoneal bladder rupture with or without a suprapubic tube? J Urol 1999; 161:1103-5. [PMID: 10081847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
PURPOSE Primary bladder repair with a suprapubic tube is considered to be effective for managing intraperitoneal bladder injury. We compared the outcomes of suprapubic tube placement and no suprapubic tube for this injury. MATERIALS AND METHODS We reviewed the charts of 31 men and 3 women with a mean age of 28.5 years who required emergency operative repair without a cystogram of traumatic bladder injury from 1992 to 1997. Patient characteristics, mechanism of injury, associated injuries, and short and long-term complications were reviewed. RESULTS Penetrating and blunt trauma occurred in 28 (82%) and 5 (15%) patients, respectively, while 1 had spontaneous bladder rupture. After primary bladder repair the bladder was drained with a suprapubic tube in 18 cases (53%) and a urethral catheter only in 16 (47%). There were no significant differences between the 2 groups with respect to mechanism of injury, patient age, location of injury in the bladder, coexisting medical illnesses, stability in the field or emergency room, or the bladder repair technique. The 18 patients treated with a suprapubic tube had an associated injury that resulted in 2 deaths, while 13 of the 16 treated with urethral catheter drainage only had an associated injury and 1 died. Urological and nonurological complications in the suprapubic tube versus urethral catheter only group developed in 28 and 33 versus 19 and 19% of the cases, respectively (p <0.05). Followup ranged from 1 month to 4 years. No significant long-term morbidity was noted in either group. CONCLUSIONS These data indicate that intraperitoneal bladder injuries may be equally well managed by primary bladder repair and urethral catheter drainage only versus suprapubic tube drainage.
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405
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Scalea TM, Rodriguez A, Chiu WC, Brenneman FD, Fallon WF, Kato K, McKenney MG, Nerlich ML, Ochsner MG, Yoshii H. Focused Assessment with Sonography for Trauma (FAST): results from an international consensus conference. THE JOURNAL OF TRAUMA 1999; 46:466-72. [PMID: 10088853 DOI: 10.1097/00005373-199903000-00022] [Citation(s) in RCA: 480] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To assemble an international panel of experts to develop consensus recommendations on selected important issues on the use of ultrasonography (US) in trauma care. SETTING R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Md. The conference was held on December 4, 1997. PARTICIPANTS A committee of two co-directors and eight faculty members, in the disciplines of surgery and emergency medicine, representing four nations. Each faculty member had made significant contributions to the current understanding of US in trauma. RESULTS Six broad topics felt to be controversial or to have wide variation in practice were discussed using the ad hoc process: (1) US nomenclature and technique; (2) US for organ-specific injury; (3) US scoring systems; (4) the meaning of positive and negative US studies; (5) US credentialing issues; and (6) future applications of US. Consensus recommendations were made when unanimous agreement was reached. Majority viewpoints and minority opinions are presented for unresolved issues. CONCLUSION The consensus conference process fostered an international sharing of ideas. Continued communication is needed to advance the science and technology of US in trauma care.
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406
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West M, Spadaro M, Sclafani SJ, Scalea TM. Internal carotid artery nasopharyngeal fistula treated with coil embolization. THE JOURNAL OF TRAUMA 1998; 45:162-4. [PMID: 9680033 DOI: 10.1097/00005373-199807000-00036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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407
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Shetty PC, Dicksheet S, Scalea TM. Emergency department repair of hand lacerations using absorbable vicryl sutures. J Emerg Med 1997; 15:673-4. [PMID: 9348057 DOI: 10.1016/s0736-4679(97)00147-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The use of absorbable suture material has a number of potential advantages when compared to nonabsorbable suture. We conducted a 5-year retrospective study of 102 patients with hand lacerations and compared the quality of scar formation and healing in these patients. Those patients who did not have tendon, nerve, or bone injury were included in the study. Lacerations were repaired with either 5-0 Vicryl or nylon. There were no reported complications or infections in any study group patient. The quality of scar, when compared visually and by palpation, was the same at the end of 6 months. In addition, there was no difference in the incidence of scar retraction. We conclude that the use of absorbable suture material is an acceptable alternative in the repair of hand lacerations.
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408
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Abstract
This article focuses on some general principles of care and then discusses devastating pelvic injury secondary to both blunt and penetrating trauma. The authors describe the current approach to the mangled extremity and discuss indications for primary amputation.
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409
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Shetty PC, Moradia VJ, Patel MR, Scalea TM. Transverse bayonet dislocation of the distal interphalangeal joint--a case report. J Emerg Med 1997; 15:197-200. [PMID: 9144062 DOI: 10.1016/s0736-4679(96)00347-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Transverse bayonet dislocation of an interphalangeal joint is an unstable injury caused by the disruption of both collateral ligaments. This injury pattern in proximal interphalangeal joint was first described by Patel et al. (Clin Orthop Rel Res. 1978;133:219), who coined the term "bayonet dislocation" to describe this particular type of injury. The case of a distal interphalangeal transverse dislocation is presented. This dislocation was successfully treated by closed reduction and immobilization with an aluminum splint and buddy taping to the adjacent finger.
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410
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Hoffer EK, Sclafani SJ, Herskowitz MM, Scalea TM. Natural history of arterial injuries diagnosed with arteriography. J Vasc Interv Radiol 1997; 8:43-53. [PMID: 9025038 DOI: 10.1016/s1051-0443(97)70514-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
PURPOSE To evaluate the natural history of untreated arterial injuries identified at arteriography. MATERIALS AND METHODS The medical charts and radiographs were reviewed for all patients with arterial injuries identified during arteriography who were managed by means of nonoperative observation and underwent follow-up arteriography. RESULTS Eighty-six nonrandomized patients with 105 arterial injuries were identified. These included 33 narrowed segments, two dilated segments, 23 intimal defects, 13 occlusions, 12 false aneurysms, 13 arteriovenous fistulas (AVFs), and five extravasations. Four vessels initially considered normal were subsequently found to have injuries. The average duration of observation was 23.5 days (range, 1-1,900 days). Forty-two arterial abnormalities healed spontaneously without other intervention. Thirty-eight "minimal" injuries improved or healed, whereas 25 worsened. Thirteen transmural injuries improved, whereas 12 progressed. There was no significant morbidity or mortality due to the delay involved with sequential studies. CONCLUSIONS The natural history of these abnormalities was variable and unpredictable. Nonocclusive "minimal" injuries rarely cause ischemic or hemorrhagic complications. Although symptomatic AVFs have a low probability of spontaneous resolution, asymptomatic lesions may close and the risks associated with a few months of observation are minimal. Close follow-up is essential if a nonoperative approach is undertaken.
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411
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Sclafani SJ, Scalea TM, Wetzel W, Henry S, Dresner L, O'Neill P, Patterson L. Internal carotid artery gunshot wounds. THE JOURNAL OF TRAUMA 1996; 40:751-7. [PMID: 8614074 DOI: 10.1097/00005373-199605000-00011] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To review a series of patients who sustained internal carotid artery (ICA) gunshot wounds. DESIGN, MATERIALS, AND METHODS We retrospectively studied the demographics and clinical presentation, angiographic findings, methods of treatment, and outcome of 38 consecutive patients who had ICA injury identified by angiography. RESULTS Thirty-four of 38 patients were symptomatic with neck hematomas (32 patients), active hemorrhage (12 patients), and/or neurologic deficit (10 patients). Angiography showed active bleeding in 22 patients and occlusion in 16 patients. Twelve patients were treated operatively by ligation (seven patients), repair (four patients), or intracranial/extracranial bypass (one patient). Twenty-six patients were managed nonoperatively either by angioplasty (one patient), embolotherapy (17 patients), or observation alone (eight patients). Percutaneous balloon catheters were also used in three patients for vascular control of the ICA before operative repair or as a method of assessing intracranial collateral circulation. The mortality of 18.4% was largely related to strokes. CONCLUSIONS Penetration of the ICA is a very severe injury with a high mortality. The major cause of death in this series was related to neurologic damage associated with carotid injury and shock. However, neurologic deficit among the survivors was uncommon and often resulted from emboli. Interventional radiology can play an important role in the management of these wounds and often obviates the need for operative exploration.
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412
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Mikulaschek A, Henry SM, Donovan R, Scalea TM. Serum lactate is not predicted by anion gap or base excess after trauma resuscitation. THE JOURNAL OF TRAUMA 1996; 40:218-22; discussion 222-4. [PMID: 8637069 DOI: 10.1097/00005373-199602000-00008] [Citation(s) in RCA: 87] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVE The inability to normalize lactate predicts death after trauma, but lactate may not be immediately available in every center. We postulated that, in a normal acid-base environment, lactate would correlate with the anion gap and the base excess of an arterial blood gas. METHODS We studied 52 consecutive, invasively monitored patients with trauma admitted directly to the intensive care unit (ICU) from the emergency department or operating room in our level I center to determine whether base excess and anion gap could predict lactate. Lactate, base excess, and anion gap were recorded upon admission to the ICU and 8, 16, 24, 36, and 48 hours after admission. Correlation coefficients (r2) were calculated for the total patients, the 43 survivors, and the nine non-survivors. RESULTS Serum lactate was significantly higher in nonsurvivors at 16 hours after post ICU admission (4.0 +/- 1.69 vs. 2.84 +/- 1.49, p < 0.05), and this trend persisted; the greatest difference was seen at 48 hours after admission (2.92 +/- 1.47 vs. 1.76 +/- 0.57, p < 0.001). There were no differences in base excess or anion gap between survivors and nonsurvivors. We found no consistent correlation between lactate versus anion gap, lactate versus base excess, or anion gap versus base excess. CONCLUSIONS There is no correlation between lactate, base excess, and anion gap after initial resuscitation. Neither anion gap nor base excess was capable of predicting lactate; therefore, lactate must be directly measured. The lack of correlation of anion gap with base excess or lactate suggests the presence of unmeasured anions, an impairment in acid-base regulation after injury and resuscitation, or both.
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413
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Abstract
Acute blood loss is a common, but often challenging, problem facing emergency physicians. Inadequate or delay in treatment can lead to morbidity or mortality. Standard classifications to quantify blood loss, as well as vital signs alone, are inadequate for guiding therapy. Mechanism of injury, base deficit and blood lactate, central venous oxygen saturation, and oxygen transport parameters should all play a role in deciding the need for further diagnostic studies and resuscitation. Extreme care must be taken to evaluate and resuscitate those with decreased physiologic reserve adequately, such as the elderly. Once bleeding has been identified, expeditious control of bleeding should be accomplished, either operatively or angiographically. Care must be individualized, but adherence to these general guidelines will improve outcome.
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414
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Sclafani SJ, Scalea TM, Hoffer EK, Herskowitz MM, Pevsner P. Interventional radiology in the treatment of internal carotid artery gunshot wounds. J Vasc Interv Radiol 1995; 6:857-61. [PMID: 8850660 DOI: 10.1016/s1051-0443(95)71202-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
PURPOSE To review the indications for and techniques and results of interventional radiology in the management of internal carotid artery gunshot wounds. PATIENTS AND METHODS The demographics, clinical presentations, angiographic findings, methods of treatment, and outcomes were reviewed in 20 patients who underwent 21 interventional procedures. RESULTS Seventeen coil embolizations were successful in controlling hemorrhage. One intimal flap was compressed with balloon angioplasty, with subsequent nonoperative healing. Temporary balloon occlusions were used as a method of preoperative assessment of intracranial collateral circulation or of preoperative vascular control in three patients. There were no complications. The mortality rate was 20%. CONCLUSION Penetration of the internal carotid artery is a very severe injury with a high mortality rate due to neurologic sequelae. Interventional radiology plays an important role in the management of these wounds, and it often obviates surgical exploration.
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415
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Sclafani SJ, Shaftan GW, Scalea TM, Patterson LA, Kohl L, Kantor A, Herskowitz MM, Hoffer EK, Henry S, Dresner LS. Nonoperative salvage of computed tomography-diagnosed splenic injuries: utilization of angiography for triage and embolization for hemostasis. THE JOURNAL OF TRAUMA 1995; 39:818-25; discussion 826-7. [PMID: 7473996 DOI: 10.1097/00005373-199511000-00004] [Citation(s) in RCA: 198] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVES The aims of this study were to determine if angiographic findings can be used to predict successful nonoperative therapy of splenic injury and to determine if coil embolization of the proximal splenic artery provides effective hemostasis. METHODS Splenic injuries detected by diagnostic imaging between 1981 and 1993 at a level I trauma center were prospectively collected and retrospectively reviewed after management by protocol that used diagnostic peritoneal lavage, computed tomography (CT), angiography, transcatheter embolization, and laparotomy. Computed tomography was performed initially or after positive diagnostic peritoneal lavage. Angiography was performed urgently in stabilized patients with CT-diagnosed splenic injuries. Patients without angiographic extravasation were treated by bed rest alone; those with angiographic extravasation underwent coil embolization of the proximal splenic artery followed by bed rest. RESULTS Patients (172) with blunt splenic injury are the subject of this study. Twenty-two patients were initially managed operatively because of associated injuries or disease (11 patients) or because the surgeon was unwilling to attempt nonoperative therapy (11 patients) and underwent splenectomy (17 patients) or splenorrhaphy (5 patients). One hundred fifty of 172 consecutive patients (87%) with CT-diagnosed splenic injury were stable enough to be considered for nonoperative management. Eighty-seven of the 90 patients managed by bed rest alone, and 56 of 60 patients treated by splenic artery occlusion and bed rest had a successful outcome. Overall splenic salvage was 88%. It was 97% among those managed nonoperatively, including 61 grade III and grade IV splenic injuries. Sixty percent of patients received no blood transfusions. Three of 150 patients treated nonoperatively underwent delayed splenectomy for infarction (one patient) or splenic infection (two patients). CONCLUSIONS (1) Hemodynamically stable patients with splenic injuries of all grades and no other indications for laparotomy can often be managed nonoperatively, especially when the injury is further characterized by arteriography. (2) The absence of contrast extravasation on splenic arteriography seems to be a reliable predictor of successful nonoperative management. We suggest its use to triage CT-diagnosed splenic injuries to bed rest or intervention. (3) Coil embolization of the proximal splenic artery is an effective method of hemostasis in stabilized patients with splenic injury. It expands the number of patients who can be managed nonoperatively.
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416
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Jurkovich GJ, Hoyt DB, Moore FA, Ney AL, Morris JA, Scalea TM, Pachter HL, Davis JW. Portal triad injuries. THE JOURNAL OF TRAUMA 1995; 39:426-34. [PMID: 7473903 DOI: 10.1097/00005373-199509000-00005] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVE Injuries to the portal triad are a rare and complex challenge in trauma surgery. The purpose of this review is to better characterize the incidence, lethality, and successful management schemes used to treat these injuries. DESIGN A retrospective review of the experience of eight academic level I trauma centers over a combined 62 years. RESULTS A retrospective review of the experience of eight anatomical structures of the portal hepatis: 118 injuries to the anatomical structures of the portal hepatis: 55 extrahepatic portal vein injuries, 28 extrahepatic arterial injuries, and 35 injuries to the extrahepatic biliary tree. Sixty-nine percent of the injuries were by penetrating mechanism and 31% were by blunt mechanism. All patients had associated injuries with a mean Injury Severity Score of 34 in blunt trauma patients. Overall mortality was 51%, rising to 80% in patients with combination injuries. Sixty-six percent of deaths occurred in the operating room, primarily from exsanguination; 18% of deaths occurred within 48 hours of injury from refractory shock, coagulopathy, or cardiac arrest; 16% occurred late. Ten percent of patients undergoing portal vein ligation survived, compared to 58% managed by primary repair. Survival after hepatic artery ligation was 42%, compared to 14% after primary repair. Survival after biliary-enteric anastomosis as treatment of extrahepatic bile duct injury was 89%, compared to 50% after primary repair and 100% after ligation of lobar bile duct injuries. Missed bile duct injuries had a high (75%) severe complication rate. CONCLUSIONS Injuries to the anatomical structures of the portal triad are rare and often lethal. Intraoperative exsanguination is the primary cause of death, and hemorrhage control should be the first priority. Bile duct injuries should be identified by intraoperative cholangiography and repaired primarily or by enteric anastomosis; lobar bile ducts can be managed by ligation.
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417
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Scalea TM, Sinert R, Duncan AO, Rice P, Austin R, Kohl L, Trooskin SZ, Talbert S. Percutaneous central venous access for resuscitation in trauma. Acad Emerg Med 1994; 1:525-31. [PMID: 7600399 DOI: 10.1111/j.1553-2712.1994.tb02547.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVE To determine the safety of percutaneous central venous access when used for trauma resuscitation and whether the initial hemodynamic status of the patient or the site of placement affects the ease or success of line placement. METHOD Consecutive major-trauma patients were managed using a resuscitation protocol guiding intravenous line use. Percutaneous peripheral venous access was initially attempted in all patients. If this approach was unsuccessful or proved to be inadequate for volume resuscitation, venous access was attempted using central venous catheter-introducer sets. The site of the central venous access was determined by protocol. For thoracic injury, access was via the ipsilateral subclavian vein (SCV), the ipsilateral internal jugular vein (IJV), or the femoral vein. For suspected mediastinal injury, access was via the contralateral SCV or IJV, or the femoral vein. For abdominal or flank injury, access was via the SCV or IJV only. Multiple central venous access sites were used at the discretion of the trauma team. RESULTS Central venous access was successful at 144 of 147 sites (99%) used in 122 patients during the study period. There was only one major complication (rate = 0.7%; 95% CI 0.0-3.8%). Mean catheter placement time was 1.9 minutes, and cannulation occurred with a mean of 1.8 needle passes. Most patients (81/122) were hypotensive (blood pressure < or = 90 torr) at the time of line placement, including 44 who were in cardiac arrest and four awake patients who had no obtainable blood pressure. Neither the access site nor the presence of hypotension was associated with the mean time to obtain central venous access, the mean number of attempts, or the complication rate. CONCLUSION Percutaneous central venous access is relatively safe and reliable for gaining intravenous access when resuscitating trauma patients, when used in a center where physicians are experienced in the technique. Consideration should be given to expanding the use of central venous access in trauma resuscitation.
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418
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Scalea TM, Maltz S, Yelon J, Trooskin SZ, Duncan AO, Sclafani SJ. Resuscitation of multiple trauma and head injury: role of crystalloid fluids and inotropes. Crit Care Med 1994; 22:1610-5. [PMID: 7924373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVES To determine the hemodynamic responses to blunt trauma with a closed-head injury and to investigate the effect that volume resuscitation has on intracranial pressure. DESIGN Prospective study with retrospective analysis of patient data and hemodynamic responses. SETTING Surgical intensive care unit at an inner-city, Level I trauma center. PATIENTS Consecutive patients (n = 30) who sustained multiple system injury, including a closed-head injury that was severe enough to require intracranial pressure monitoring but not a craniotomy. INTERVENTIONS All patients underwent invasive hemodynamic monitoring with percutaneous arterial and pulmonary arterial catheters. Serum lactate concentrations and hemodynamic and oxygen transport variables were measured every 4 hrs. Intracranial pressures and vital signs were recorded each hour. Attempts were made to achieve a state of nonflow-dependent oxygen consumption and a normal serum lactate concentration. MEASUREMENTS AND MAIN RESULTS Despite being normotensive and neither tachycardiac nor oliguric, 80% of patients had evidence of inadequate tissue perfusion. Only 50% of the remaining patients had an adequate response to volume. The other 50% received vasodilating inotropic agents. Despite volume loading and the administration of inotropic agents, intracranial pressure did not increase. This observation was found in patients who showed clinically important intracranial pathology on computed tomography scan, as well as in all other patients. Intracranial pressure did not correlate with the amount of fluid or blood infused or with hemodynamic performance, but intracranial pressures did correlate with serum lactate concentrations. CONCLUSIONS Many patients with diffuse blunt trauma closed-head injuries, even when they are normotensive, have evidence of impaired peripheral perfusion. Volume infusion and vasodilating inotropic support improve oxygen transport without increasing intracranial pressure. The observed relationship between intracranial pressure and the serum lactate concentration requires further study.
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419
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Low RB, Scalea TM. Statewide trauma systems: the bottom line. Acad Emerg Med 1994; 1:206-7. [PMID: 7621196 DOI: 10.1111/j.1553-2712.1994.tb02429.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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420
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Scalea TM, Trooskin SZ, Wait RB. Critical care training makes trauma care more attractive as a career. THE JOURNAL OF TRAUMA 1994; 36:548-53; discussion 553-4. [PMID: 8158718 DOI: 10.1097/00005373-199404000-00015] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
One recent report has prompted concern that surgical residents are no longer concerned in providing trauma care as a significant portion of their careers. In 1986, we linked our trauma and critical care services. We surveyed all chief residents who finished in the past 10 years, comparing the 5 years before the linking of trauma and critical care to the period since. Between 1982 and 1987, 3 of the 45 finishing residents (7%) pursued trauma fellowships, then trauma care as a career. Since 1987, 12 finishing residents (30% of the total and 33% of those pursuing fellowship training) trained in trauma/critical care. Nine currently pursue trauma care as a career. Two others are academic trauma surgeons without fellowship training and one other practices general surgery with trauma care as a main focus. Thus 12 of the 41 residents (30%) practice trauma care and 14 residents (34%) practice critical care. Residents finishing since 1987 were significantly more likely to respond that they are interested in trauma care, feel trauma care was attractive, and wish to have trauma care be a major portion of their careers. Those who chose not to pursue trauma care cited reasons similar to those described by Richardson and Miller. Other specialty interests were the most important factor in both time periods. Residents finishing after 1987 described the link between trauma care and critical care with a designated ICU service as strong positive influences. The understanding of resuscitation physiology gained in the ICU, including nonsurgical therapy, was felt to enhance trauma care, making it more attractive.(ABSTRACT TRUNCATED AT 250 WORDS)
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Abou-Khalil B, Scalea TM, Trooskin SZ, Henry SM, Hitchcock R. Hemodynamic responses to shock in young trauma patients: need for invasive monitoring. Crit Care Med 1994; 22:633-9. [PMID: 8143473 DOI: 10.1097/00003246-199404000-00020] [Citation(s) in RCA: 160] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVE To determine whether early invasive monitoring is necessary in young trauma patients. DESIGN A prospective study. SETTING Surgical intensive care unit (ICU) at an inner-city, Level I trauma center. PATIENTS Thirty-nine patients < 40 yrs of age, who required operative therapy for penetrating trauma and who received > 6 units of intraoperative blood. INTERVENTIONS Invasive hemodynamic monitoring, with percutaneous insertion of arterial and pulmonary artery catheters. Vital signs, hemodynamic and oxygen transport values, and laboratory tests were obtained at 1, 8, and 24 hrs postoperatively. Oxygen delivery was increased until a normal serum lactate concentration and a state of nonflow-dependent oxygen consumption were achieved. MEASUREMENTS AND MAIN RESULTS Despite normal heart rate, blood pressure, and urine output, only five (15%) patients achieved an optimized state at 1 hr postoperatively. Of the other 34 patients, two patients achieved an optimized state with volume infusion alone and 32 (82%) patients required inotropes. Five (12%) patients never achieved an optimized state and died within hours of their arrival to the ICU. Two other patients achieved an optimized state but died of sepsis and organ failure. The other 32 (82%) patients achieved an optimized state within 24 hrs and survived. The hemodynamic values of survivors at 1 hr postoperatively showed a significantly lower pulmonary vascular resistance and serum lactate concentration, and a significantly higher oxygen delivery and mixed venous oxygen saturation, when compared with the values of nonsurvivors. At 24 hrs postoperatively, survivors also had a significantly lower pulmonary vascular resistance and serum lactate concentration, and significantly higher oxygen delivery than nonsurvivors. Survivors' oxygen consumption was also higher than the oxygen consumption of nonsurvivors. CONCLUSIONS Our data demonstrate that young trauma patients have substantial but clinically occult myocardial depression after shock, and most of these patients require inotropes to optimize and clear circulating lactate. Early invasive monitoring is necessary to precisely define the adequacy of the cardiac response and to individually tailor therapy. Patients who do not optimize and clear their lactate within 24 hrs may not survive.
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422
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Scalea TM, Mann R, Austin R, Hirschowitz M. Staged procedures for exsanguinating lower extremity trauma: an extension of a technique--case report. THE JOURNAL OF TRAUMA 1994; 36:291-3. [PMID: 8114158 DOI: 10.1097/00005373-199402000-00032] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Packing and temporary closure have been used in various clinical scenarios to control nonsurgical bleeders in the abdomen. We present a case where we have extended that technique and successfully utilized it in a patient with an exsanguinating lower extremity vascular injury.
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Zipnick RI, Scalea TM, Trooskin SZ, Sclafani SJ, Emad B, Shah A, Talbert S, Haher T. Hemodynamic responses to penetrating spinal cord injuries. THE JOURNAL OF TRAUMA 1993; 35:578-82; discussion 582-3. [PMID: 8411282 DOI: 10.1097/00005373-199310000-00013] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Although the hemodynamic response to blunt spinal cord injury has been well described, much less is known about the responses to penetrating spinal cord injuries. In order to elucidate any differences, we reviewed the last 75 patients treated over the past 12 years with penetrating spinal cord injuries. There were 67 men and eight women; the mean age was 26.2 years (range, 15-59 years); 73 patients suffered 120 gunshot wounds; one patient was injured with an ice pick; one was stabbed twice. The offending missile causing spinal cord injury entered the neck in 24%, the thorax in 56%, and the abdomen in 20%. Nine patients (12%) were complete quadriplegics and 49 patients (65%) were complete paraplegics; 69 patients (92%) had no rectal tone; 17 patients (22%) had incomplete injuries. Despite the high proportion of complete spinal injury (78%), only 18 patients (24%) were hypotensive in the field. Five additional patients became hypotensive in the ED. Of the 23 patients with hypotension, 18 (74%) had significant blood loss to explain their low blood pressure. The mean HR was 100 beats/minute in the field (range, 50-130 beats/minute) and 90 beats/minute in the ED. Only five patients (7%) demonstrated the classic presentation of neurogenic shock (hypotension and bradycardia). This classic presentation of neurogenic shock is rare following penetrating spinal cord injury. Despite evidence of a complete spinal cord injury on initial physical examination, hypotension is usually secondary to blood loss in these patients. A careful search for sources of blood loss is mandatory before ascribing hypotension to spinal injury.
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Abramson D, Scalea TM, Hitchcock R, Trooskin SZ, Henry SM, Greenspan J. Lactate clearance and survival following injury. THE JOURNAL OF TRAUMA 1993; 35:584-8; discussion 588-9. [PMID: 8411283 DOI: 10.1097/00005373-199310000-00014] [Citation(s) in RCA: 526] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Previous reports cite optimization of O2 delivery (DO2) to 660 mL/min/m2, O2 consumption (VO2) to 170 mL/min/m2, and cardiac index (CI) of 4.5 L/min as predicting survival. We prospectively evaluated 76 consecutive patients with multiple trauma admitted directly to the ICU from the operating room or emergency department. Patients had serum lactate levels and oxygen transport measured on ICU admission and at 8, 16, 24, 36, and 48 hours. Patients were analyzed with respect to survival (S) versus nonsurvival (NS), lactate clearance to normal (< or = 2 mmol/L) by 24 and 48 hours, hemodynamic optimization as defined above, as well as Injury Severity Score (ISS), ICU stay (LOS), and admission blood pressure. All patients achieved non-flow-dependent VO2. There was no difference in CI, DO2, VO2, or ISS when S was compared with NS. All 27 patients whose lactate level normalized in 24 hours survived. If lactate levels cleared to normal between 24 and 48 hours, the survival rate was 75%. Only 3 of the 22 patients who did not clear their lactate level to normal by 48 hours survived. Ten of the 25 nonsurvivors (40%) achieved the above arbitrary optimization criteria. Fifteen of the survivors never achieved any of these criteria. Optimization alone does not predict survival. However, the time needed to normalize serum lactate levels is an important prognostic factor for survival in severely injured patients.
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Baron BJ, Scalea TM, Sclafani SJ, Duncan AO, Trooskin SZ, Shapiro GM, Phillips TF, Goldstein AM, Atweh NA, Vieux EE. Nonoperative management of blunt abdominal trauma: the role of sequential diagnostic peritoneal lavage, computed tomography, and angiography. Ann Emerg Med 1993; 22:1556-62. [PMID: 8214835 DOI: 10.1016/s0196-0644(05)81258-2] [Citation(s) in RCA: 29] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
STUDY OBJECTIVE To determine the usefulness of sequential nonoperative diagnostic studies in the evaluation and treatment of stable patients after blunt abdominal trauma. DESIGN AND SETTING Retrospective review of a prospective treatment plan in a large urban Level I trauma center. PARTICIPANTS Fifty-two patients deemed stable after initial evaluation following blunt abdominal trauma. INTERVENTIONS Patients with a positive diagnostic peritoneal lavage for red blood cells underwent abdominal computed tomography (CT) scanning. If CT demonstrated a visceral injury, it was followed by diagnostic angiography. Attempts were made to treat on-going bleeding by transcatheter embolization. RESULTS Fifteen patients had negative CT scans and were successfully observed. In the other 37 patients, CT identified 17 liver, 16 splenic, and eight kidney injuries; eight extra-peritoneal bleeds; and one mesenteric hematoma. Six of these patients were observed. Thirty underwent diagnostic angiograms. Twelve had no active bleeding, and all were observed successfully. Seventeen underwent successful embolization of the bleeding site(s). One had injuries not controllable by embolization and required exploration. Six patients required laparotomy later in their course, but none had intra-abdominal bleeding or a missed intestinal injury. Despite being performed after diagnostic peritoneal lavage, CT missed only two injuries. There was one main complication, delayed recognition of a diaphragmatic injury. Three patients died, two from multiple organ failure and one from a pulmonary embolus; none was believed to be related to this technique. With our algorithm, 45 patients (86%) were spared laparotomy. CONCLUSION Diagnostic peritoneal lavage and CT are complementary when evaluating blunt abdominal trauma. Diagnostic peritoneal lavage is an effective screening tool. CT may be reserved for stable patients with a positive diagnostic peritoneal lavage to specify the organs injured. Bleeding often may be treated by embolization, limiting the rate of surgery.
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Toporoff B, Scalea TM, Abramson D, Scalafani SJ. Ureteral laceration caused by a fall from a height: case report and review of the literature. THE JOURNAL OF TRAUMA 1993; 34:164-6. [PMID: 8437188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Ureteral rupture is an uncommon lesion in adults following blunt trauma. We report a case of an adult who sustained a ureteral injury in a fall from a height. To our knowledge this is the first time this has been reported following this mechanism of injury. The diagnosis was made from a CT scan. Prompt surgical repair yielded an excellent result.
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427
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Yelon JA, Scalea TM. Venous injuries of the lower extremities and pelvis: repair versus ligation. THE JOURNAL OF TRAUMA 1992; 33:532-6; discussion 536-8. [PMID: 1433399 DOI: 10.1097/00005373-199210000-00008] [Citation(s) in RCA: 57] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Many surgeons advocate repair of venous injuries to prevent the sequelae of venous ligation. Since 1986, we have treated 74 patients with 79 venous injuries of the lower extremity or pelvis. There were 68 men and six women with a mean age of 29.2 years (range, 16-62 years). The mechanisms of injury were gunshot wounds in 61 patients, stab wounds in 11 patients, and shotgun wounds and blunt trauma in one patient each. Forty-eight injuries were treated by ligation; 31 injuries were treated by repair. Repairs included two interposition grafts, eight end-to-end repairs, 16 venorrhaphies, and five vein patches. In addition, we developed a venous injury staging system (VIS), which ranged from grade I (less than 50% laceration) to grade IV (complete interruption with soft-tissue injury). Patient age, mechanism, location of injury, associated injuries, and incidence of arterial injury were not different between the patients treated by ligation and those treated by repair. Patients treated with venous ligation had a greater VIS (mean, 3.45 vs. 2.0), a greater incidence of shock (71% vs. 39%), and higher transfusion requirements (9.23 vs. 4.82 units). Postoperative morbidity rates were identical, however. There was no increase in the need for fasciotomy in patients treated with venous ligation. Eighty-six percent of the patients treated by ligation were totally free of edema at discharge. The others had only mild edema that did not interfere with daily activities at discharge and follow-up. Ligation is a safe alternative to repair in patients with injuries to the lower extremities or pelvis.(ABSTRACT TRUNCATED AT 250 WORDS)
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428
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Scalea TM, Donovan R. Amrinone as an inotrope in managing hypermetabolic surgical stress. THE JOURNAL OF TRAUMA 1992; 32:372-8; discussion 378-9. [PMID: 1548727 DOI: 10.1097/00005373-199203000-00016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Dobutamine is the standard inotrope used as cardiac support for hyperdynamic hypermetabolic patients following acute surgical stress. Amrinone has been utilized in medical patients with heart failure, but its use in hyperdynamic patients to our knowledge has never been reported. We now report the results of a trial of amrinone versus dobutamine in this setting. Over a 3-month period, we compared 28 trials of dobutamine and 27 trials of amrinone in 47 patients. Attempts were made to achieve non-flow-dependent oxygen consumption. Values are expressed as pre/post inotrope. Student's two-tailed t test was used for evaluation. [table: see text] Patients treated initially with dobutamine were slightly younger (mean, 46 vs. 57 years). They required slightly higher doses of dobutamine (mean, 12.9 vs. 12.2 micrograms/kg/min) and a slightly longer treatment period (mean, 11.3 vs. 9.8 hours) to achieve the desired effect. Of the 47 trials with dobutamine, six (13%) failed to achieve non-flow-dependent oxygen consumption. All then responded somewhat to amrinone. The failure rate for amrinone was 10%. No patient developed hypotension when treated with either drug. Amrinone is an effective inotrope useful in the cardiovascular support of hyperdynamic patients following surgical stress. Hypotension is not a problem with adequate intravascular volume loading. It should become part of the standard drug regimen in the surgical ICU.
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Scalea TM, Sclafani SJ, Henry SM, John J, Shaftan GW, Trooskin SZ, Vieux EE, Talbert SJ, Davis R. Trauma versus critical care: it is time to end the debate. THE JOURNAL OF TRAUMA 1992; 32:1. [PMID: 1732558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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430
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Scalea TM, Sclafani SJ. Angiographically placed balloons for arterial control: a description of a technique. THE JOURNAL OF TRAUMA 1991; 31:1671-7. [PMID: 1749041 DOI: 10.1097/00005373-199112000-00018] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Obtaining proximal and distal control is essential in the repair of arterial injuries. Occasionally, the location of the injury makes this difficult, risks excessive blood loss, or requires wide exposure to obtain control. Recently, we have used percutaneously placed balloons as an aid to vascular control in 11 patients who had arterial injuries identified angiographically. The balloon is placed under fluoroscopic guidance and is then deflated. The balloon is reinflated intraoperatively at the time vascular control is needed. Five balloons were placed for inflow control in patients with very proximal subclavian artery injuries. All were then able to undergo successful repair through a limited supraclavicular incision without sternotomy or thoracotomy. Two were placed in the internal carotid artery to obtain distal control in injuries located at the base of the skull. Both injuries were then repaired without problems. Two patients had balloons placed for external iliac artery injuries located at the inguinal ligament, one for proximal and one for distal control. Both injuries were then repaired through a limited incision. Two additional patients who had arterial injuries identified began to bleed massively while in the angiography suite. Balloons were placed proximally to control bleeding during transport and dissection. There were no complications from balloon placement. All balloons functioned well, greatly limited blood loss, and allowed for repair through a limited incision. We feel this is a technique that can be utilized in selected cases of angiographically identified arterial injuries in which operative exposure is likely to be difficult, cause significant blood loss, or require an extensive incision and dissection.
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Sclafani SJ, Weisberg A, Scalea TM, Phillips TF, Duncan AO. Blunt splenic injuries: nonsurgical treatment with CT, arteriography, and transcatheter arterial embolization of the splenic artery. Radiology 1991; 181:189-96. [PMID: 1887032 DOI: 10.1148/radiology.181.1.1887032] [Citation(s) in RCA: 108] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The management and outcome of blunt splenic injury diagnosed with computed tomography (CT) were studied in 44 consecutive patients who were hemodynamically stable or whose condition stabilized rapidly with resuscitation. Celiac and splenic arteriography was used in the triage of patients for nonsurgical treatment or for hemostasis. Patients without arterial extravasation of contrast material at arteriography were treated with bed rest only (group 1, n = 19); patients who had such extravasation were treated with bed rest after percutaneous transcatheter coil occlusion of the proximal splenic artery (group 2, n = 17). Abdominal exploration without angiography or embolotherapy was begun if the patient or attending surgeon did not agree with the treatment protocol (group 3, n = 8). Treatment with bed rest alone was successful in 18 patients. Clinical control of hemorrhage was accomplished in all patients in group 2 and one patient in group 1. Thus, exploratory laparotomy was avoided in 34 of 36 patients (94%) in whom nonoperative management was attempted; splenic salvage was achieved in 35 of 36 patients (97%).
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432
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Scalea TM, Hartnett RW, Duncan AO, Atweh NA, Phillips TF, Sclafani SJ, Fuortes M, Shaftan GW. Central venous oxygen saturation: a useful clinical tool in trauma patients. THE JOURNAL OF TRAUMA 1990; 30:1539-43. [PMID: 2258969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
An accurate method of estimating acute blood loss is essential in the evaluation of injured patients. Central venous oxygen (CVO2) saturation has been shown to be a sensitive and reliable correlate of blood loss in an animal model but its clinical validity is unproven. We evaluated 26 consecutive patients with an injury mechanism suggesting blood loss but who were deemed stable after initial evaluation. Vital signs (pulse, blood pressure, pulse pressure, urine output, CVP) and CVO2 saturation were serially measured. Blood loss was estimated by direct intracavitary collection or serial hematocrits and acute transfusion requirements. Despite stable vital signs, ten patients (39%) had CVO2 saturations under 65%. These patients had more serious injuries, significantly larger estimated blood losses, and required more transfusions than those patients with CVO2 saturation greater than 65%. Linear regression analysis demonstrated the superiority of CVO2 saturation to predict blood loss with a p value less than 0.005 relative to any of the normally followed parameters. CVO2 saturation is a reliable and sensitive method for detecting blood loss. It is a useful tool in the evaluation of acutely injured patients.
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433
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Scalea TM, Simon HM, Duncan AO, Atweh NA, Sclafani SJ, Phillips TF, Shaftan GW. Geriatric blunt multiple trauma: improved survival with early invasive monitoring. THE JOURNAL OF TRAUMA 1990; 30:129-34; discussion 134-6. [PMID: 2304107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Geriatric trauma survival rates are reported to approach 85%, but no series to our knowledge has included a predominance of multiply injured patients. In 1985, we treated 60 patients more than 65 years of age who sustained blunt multiple trauma, excluding burns and minor falls. A pedestrian-motor vehicle mechanism, initial BP less than 150 mm Hg, acidosis, multiple fractures, and head injuries all predicted mortality. To investigate this, in 1986, we began invasive monitoring in all patients with any of these risk factors and modified this in 1987 to emergent monitoring, postponing all but the most critical diagnostic studies. All patients included were hemodynamically stable after initial evaluation. Attempts were made to optimize all patients with volume, inotropes, and afterload reduction as needed. There was no difference between 1986 and 1987 in patient age, injury severity, or per cent of patients requiring operation. In 1986, mean time from ED admission to monitoring was 5.5 hours. Eight of 15 patients had an initial cardiac output (CO) less than 3.5 L/M and/or mixed venous saturation (MVO2) less than 50%. All developed progressive pump failure despite therapy and died within 24 hours. The other seven had an initial CO between 3.4-5.5 L/M, but five had an MVO2 less than 50%. All augmented their CO with therapy over 6-12 hours to a mean CO of 6.8 L/M and resolved their MVO2, but six died from MOF. Survival was 7%. In 1987-88, we reduced time to monitoring to 2.2 hours by limiting diagnostic tests. Thirteen of 30 patients treated had an initial CO less than 3.5 L/M.(ABSTRACT TRUNCATED AT 250 WORDS)
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Atweh NA, Vieux EE, Ivatury R, Scalea TM, Duncan AO, Gordon J, Sclafani SJ, Dresner L, Phillips TF, Stahl W. Indications for barium enema preceding colostomy closure in trauma patients. THE JOURNAL OF TRAUMA 1989; 29:1641-2. [PMID: 2593193 DOI: 10.1097/00005373-198912000-00009] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
The need for a barium enema (BE) preceding colostomy closure is controversial. In the process of evaluating the usefulness of BE before closure of colostomies performed for colorectal injuries, we reviewed our experience with 84 trauma patients who underwent BE before colostomy closure. Patients who had their colonic injuries repaired or diverted during the initial procedure did not benefit from the precolostomy closure contrast study. In this group of patients artifacts on BE had to be ruled out by endoscopy or repeat radiography in 9.5% of patients. Barium enema was found beneficial in evaluating colorectal injuries below the peritoneal reflection in one out of 20 patients. However, since the rectal injuries are not usually explored and repaired during the initial procedure, investigation by endoscopy and contrast studies may still be indicated preceding colostomy closure.
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435
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Duncan AO, Phillips TF, Scalea TM, Maltz SB, Atweh NA, Sclafani SJ. Management of transpelvic gunshot wounds. THE JOURNAL OF TRAUMA 1989; 29:1335-40. [PMID: 2810408 DOI: 10.1097/00005373-198910000-00007] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The records of 98 patients with transpelvic gunshot wounds from 1983 to 1988 were reviewed: 22 patients were admitted in shock and required aggressive resuscitation and immediate exploration, and 76 patients were normotensive and were evaluated with diagnostic peritoneal lavage, angiography, cystography, proctoscopy, CT scan, and contrast-enhanced CT enema in various combinations as indicated. Using this approach, 40 stable patients were observed without operation and discharged without complications. Fifty-eight patients were explored: 20 had both arterial and hollow viscus injuries. Thirty-nine major vascular injuries were evaluated: 27 were ligated and 12 repaired. Other injuries were colon, 27; including seven rectal perforations, multiple small bowel perforations, five bladder, one ovarian, four ureteral, three caval, three renal, and two distal aortic injuries. Colon injuries associated with vascular injuries were treated with colostomy and ligation of the vessel with extra-anatomic bypass when revascularization was required. Overall 12 patients died as a result of their injuries, a mortality of 12.2%. However, 50% of the patients who were admitted in shock died. Two external iliac artery injuries and two ureteral injuries were missed at initial operation. Penetrating trauma to the pelvis presents a serious challenge because of the complex anatomy of the region. Patients in shock have a high incidence of vascular injury and subsequent exsanguination, and associated visceral injuries may complicate their management. However, stable patients may be managed without operation, when appropriate diagnostic techniques fail to demonstrate an injury. Arterial ligation and extra-anatomic bypass should be considered for vascular injury with gross fecal contamination.
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436
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Duncan AO, Scalea TM, Sclafani SJ, Phillips TF, Bryan D, Atweh NA, Vieux EE. Evaluation of occult cardiac injuries using subxiphoid pericardial window. THE JOURNAL OF TRAUMA 1989; 29:955-9; discussion 959-60. [PMID: 2746706 DOI: 10.1097/00005373-198907000-00008] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
During 1987, we performed diagnostic subxiphoid pericardial windows on all stable patients with juxta-cardiac penetrating injuries. This excluded any patient with clinically diagnosed tamponade or shock. Fifty-one patients underwent subxiphoid diagnostic pericardiotomy for suspected cardiac injuries. Forty patients were normotensive on presentation and 11 experienced transient hypotension. All patients were easily resuscitated in the Emergency Department. The time from admission to operation ranged from 20 minutes to 6 hours (average, 2.5 hours). Twelve patients (23.5%) had hemopericardium at the time of subxiphoid diagnostic pericardiotomy (SDP), and cardiac injury was confirmed at sternotomy in all. Two patients (16%) in the positive group were admitted with systolic blood pressures less than 100 mm Hg compared to nine (23%) in the negative group. One patient had a systolic to diastolic pressure gradient less than 30. Central venous pressures in this group of patients ranged from 8 to 23 cm H2O. Nine patients who had pericardial window solely on the basis of location of the injury had positive findings. All nine patients were normotensive on admission, had CVP's less than 12, and had no other overt clinical signs of injury. This represents an overall occult injury rate of 17.6%. At sternotomy, there were eight ventricular, two pulmonary artery, one aortic root, and one atrial injury, all repaired. Two patients in this group had associated abdominal injuries as did 11 in the negative group, all of whom required operation, and may have explained the hypotension in negative patients. There were no complications of SDP and all negative patients were discharged on the second hospital day.(ABSTRACT TRUNCATED AT 250 WORDS)
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437
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Brunicardi FC, Scalea TM, Bernstein MO, Sclafani SS, Phillips TF. Air embolism during pulsed saline irrigation of an open pelvic fracture: case report. THE JOURNAL OF TRAUMA 1989; 29:700-1. [PMID: 2724391 DOI: 10.1097/00005373-198905000-00030] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Air embolism is a rare but potentially lethal complication of surgical procedures. We report an air embolus that occurred during pulsed saline lavage of a perineal laceration in a patient with an open pelvic fracture. Treatment consisted of aspiration of air from central venous lines and the patient recovered without sequelae.
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438
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Sclafani SJ, Weiss K, Glanz S, Scalea TM, Duncan AO, Atweh N. Posttraumatic impotence: resulting from transcatheter embolization. UROLOGIC RADIOLOGY 1988; 10:156-9. [PMID: 3206744 DOI: 10.1007/bf02926560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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439
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Fuortes M, Blank MA, Scalea TM, Pollock TW, Jaffe BM. Release of vasoactive intestinal peptide during hyperdynamic sepsis in dogs. Surgery 1988; 104:894-8. [PMID: 3187902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Vasoactive intestinal peptide (VIP) is a potent vasodilator that has been reported to be a mediator of the hemodynamic changes in endotoxin-induced hypodynamic septic shock. We investigated the release of VIP in a hyperdynamic model of sepsis in awake, conscious dogs similar to that of sepsis in human beings. Sepsis was induced by intraperitoneal implantation of a fibrin clot containing live Escherichia coli (0.9 +/- 0.2 X 10(9) organisms per kilogram of body weight). All dogs developed hyperdynamic sepsis with increased cardiac output and decreased systemic vascular resistance. During the first 24 hours of sepsis, VIP was released without a concomitant decrease in blood pressure, suggesting that during septic shock it was released by a direct mechanism rather than as a result of hypotension. During peak VIP release (2 to 4 hours after induction of sepsis) no decreases in systemic vascular resistance or mean arterial pressure were observed. This suggests that mediators other than VIP may be responsible for the vasodilation observed during sepsis. The precise role of VIP during sepsis is therefore yet to be clarified.
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Fuortes M, Pollock TW, Holman MJ, McMillen MA, Jaffe BM, Scalea TM. Changes in extravascular lung water and fatty acids in a hyperdynamic canine model of sepsis. THE JOURNAL OF TRAUMA 1988; 28:1455-9. [PMID: 3050145 DOI: 10.1097/00005373-198810000-00008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Several mediators, including fatty acids, have been postulated to induce the increase in permeability of the pulmonary endothelium and subsequent accumulation of extravascular lung water (EVLW) which are generally considered to be among the first events in the development of adult respiratory distress syndrome. In a canine model of hyperdynamic sepsis (hemodynamically similar to human sepsis) changes in EVLW and in concentrations of different fatty acids in the aortic and pulmonary arterial blood were measured. Two days after induction of sepsis, EVLW increased from 6.6 +/- 0.6 to 9.2 +/- 1.0 ml/kg, and the pulmonary arterial concentration of oleic acid increased from 52 +/- 4 to 73 +/- 5 mg/dl. Three days after induction of sepsis, EVLW increased further to 14.4 +/- 3.8 ml/kg and the mean concentration of oleic acid increased to 74 +/- 7 mg/dl. Twenty-four hours later, both EVLW and the mean pulmonary arterial concentration of oleic acid were not different from basal. We postulate that oleic acid, a known inducer of experimental ARDS, is one of the mediators of endothelial damage of the lung during sepsis.
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Scalea TM, Phillips TF, Goldstein AS, Sclafani SJ, Duncan AO, Atweh NA, Shaftan GW. Injuries missed at operation: nemesis of the trauma surgeon. THE JOURNAL OF TRAUMA 1988; 28:962-7. [PMID: 3398094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Injuries missed at initial operation have the potential to cause the most disastrous complications in trauma patients. Over the past 5 years, 12 patients have required re-operation for 14 injuries missed at initial laparotomy and/or thoracotomy. Six missed injuries were vascular, two each in the thorax, pelvis, and retroperitoneum. The other eight were visceral: three small bowel (one patient), two pancreatic, and one each of the heart, ureter, and diaphragm. Five patients (42%) died, three with missed vascular and two with missed visceral injuries. Three died due to complications directly related to their missed injuries, while the unrecognized injury did not play a significant role in the other two. Indications for re-operation in patients with vascular injuries were hypotension in two patients, persistent output from drains in three, and refractory acidosis in one. Re-exploration in visceral injuries was for clinical sepsis in three patients, DIC in one, cardiac tamponade in one, and persistent chest tube drainage in one. Eleven of the 12 patients presented to the E.D. in shock. All patients had multiple injuries with a mean of 3.25 organ systems injured. Hypotension, coagulopathy, and/or hypothermia (T less than 92 degrees) were felt to have contributed to missing the injury in five of the patients with vascular, and three of the patients with visceral injuries. In the four other patients, injuries were missed due to inadequate exploration or a low index of suspicion in the presence of multiple injuries.(ABSTRACT TRUNCATED AT 250 WORDS)
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Scalea TM, Holman M, Fuortes M, Baron BJ, Phillips TF, Goldstein AS, Sclafani SJ, Shaftan GW. Central venous blood oxygen saturation: an early, accurate measurement of volume during hemorrhage. THE JOURNAL OF TRAUMA 1988; 28:725-32. [PMID: 3385813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Accurate and relatively simple monitoring is essential in managing patients with multiple injuries, and becomes particularly important when there is substantial occult blood loss. Tachycardia, said to occur following a 15% blood loss, is generally regarded as the first reliable sign of hemorrhage. However, heart rate is a nonspecific parameter which is affected by factors other than changing intravascular volume. The purpose of this study was to evaluate available means of monitoring volume status and to identify the parameter which is the earliest and most reliable indication of blood loss. Sixteen mongrel dogs were anesthetized and bled by increments of 3% of their total blood volume until the onset of sustained hypotension or a 25% blood loss. All dogs were monitored with a Swan-Ganz catheter and an arterial line. Vital signs, full hemodynamic parameters, and arterial and mixed venous blood gases were measured after each 3% blood loss. Statistical analysis of the data demonstrated that only Cardiac Index and Mixed Venous Oxygen Saturation showed linearity as function of measure blood loss. Linear regression analysis generated r values that ranged from 0.85-0.99 with a mean of 0.95 for Mixed Venous Oxygen Saturation; r values for Cardiac Index ranged from 0.39-0.98 with a mean of 0.85. Furthermore, all dogs had increased tissue oxygen extraction after 3-6% blood loss. Because Central Venous Blood Oxygen Saturation mirrors Mixed Venous Oxygen Saturation and is easily and rapidly measured, we extended our study by repeating all of the previously measured parameters, with the addition of CVP blood gases in an unanesthetized animal model.(ABSTRACT TRUNCATED AT 250 WORDS)
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Vitelli CE, Scalea TM, Philips TF, Sclafani SJ, Duncan AO. A technique for controlling injuries of the iliac vein in the patient with trauma. SURGERY, GYNECOLOGY & OBSTETRICS 1988; 166:551-2. [PMID: 3287666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
This has become our preferred way to control deep pelvic hypogastric vein injuries and we have found it to be particularly useful in the patient with multiple nonvascular injuries. It is rapid, entails little ongoing blood and allows for direct exposure of the injury. It minimizes the chances of creating additional iatrogenic injuries from blind clamping or dissection. Thus, this technique should not be used routinely but should be reserved for situations when attempts to obtain proximal and distal control are unsuccessful.
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Sclafani SJ, Florence LO, Phillips TF, Scalea TM, Glanz S, Goldstein AS, Duncan AO, Shaftan GW. Lumbar arterial injury: radiologic diagnosis and management. Radiology 1987; 165:709-14. [PMID: 3685349 DOI: 10.1148/radiology.165.3.3685349] [Citation(s) in RCA: 65] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Injury of the lumbar arteries is a cause of potentially life-threatening retroperitoneal hemorrhage. Twelve patients who sustained massive hemorrhage of the lumbar arteries associated with lumbar spinal fractures and/or pelvic fractures are described. Computed tomography (CT) was helpful by revealing a distinct separation of the lumbar hemorrhage from the hematomas associated with pelvic fracture. On arteriograms, stasis within lumbar extravasation was manifested as globular or streaky accumulations of contrast medium, pseudoaneurysms or diffuse "staining," or opacification of a fracture site. Multiple lumbar bleeding sites were seen frequently. Embolization with pledgets of absorbable gelatin sterile sponge controlled bleeding in ten patients. Abdominal aortography should be an essential part of the arteriographic evaluation of retroperitoneal hematomas associated with pelvic fractures, especially when there are lumbar fractures. Selective lumbar arteriography should be performed for confirmation when there is suspicion of lumbar artery injury on the basis of aortographic findings. Embolization with pledgets of surgical gelatin is effective in controlling hemorrhage from these injuries.
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Duncan A, Phillips TF, Sclafani SJ, Goldstein AS, Lipkowitz G, Scalea TM, Golueke PJ, Panetta T, Shaftan GW. Intussusception following abdominal trauma. THE JOURNAL OF TRAUMA 1987; 27:1193-9. [PMID: 3682031 DOI: 10.1097/00005373-198711000-00001] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
We reviewed the charts of 21 patients on the Trauma Service who were operated on for intestinal obstruction for the years 1983 through 1985. Six (28.6%) of the 21 patients had intussusception as the cause of their obstruction post-laparotomy for trauma. All were males ages 17 to 25 years. The mechanisms of injury were gunshot wounds in three, stab wounds in two, and blunt trauma in one. Five patients were hypotensive on admission with systolic BP less than 70, and two patients received uncrossmatched blood preoperatively. Injuries at exploration included liver laceration (six patients), gastric perforation (two patients), and diaphragmatic lacerations, splenic laceration, renal injury, and ventricular injury, one each. No patient suffered small intestinal injuries and we cannot explain the occurrence of intussusception. Intussusception occurred in the first 8 postoperative days in four patients and at 21 days, and 10 months, in the remaining two. The diagnosis was made twice by CT scan preoperatively. Jejunojejunal intussusception was common (five patients), jejunoileal in one and ileocolic in one (who also had a jejunojejunal intussusception). All patients were treated with manual reduction alone and none recurred. There were no postoperative complications and all patients were discharged by the eighth postoperative day. Our study suggests that early postoperative obstruction is caused by intussusception with unexpected frequency in trauma patients, and can be diagnosed by CT scan in some cases. Treatment with operative reduction has an excellent prognosis.
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Savino JA, Dawson JA, Agarwal N, Moggio RA, Scalea TM. The metabolic cost of breathing in critical surgical patients. THE JOURNAL OF TRAUMA 1985; 25:1126-33. [PMID: 4068066 DOI: 10.1097/00005373-198512000-00002] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Twenty ventilator-dependent patients, 14 male and six female, age 47.9 +/- 14, status post polytrauma (14), emergency surgery (three), and coronary artery bypass (three) were evaluated to compare measured energy expenditure (MEE) between the intermittent mandatory ventilation mode (IMV) and assist mode ventilation (AMV) utilizing indirect calorimetry. The MEE was then compared to the predicted basal energy expenditure (PEE) utilizing the Harris-Benedict equation (HBE) and appropriate correction factors dependent on disease and injury status (mean 1.65 +/- 0.24). The mean oxygen consumption (VO2) (IMV) was 347.5 +/- 54.6 ml/min; (VO2) (AMV) was 307.1 +/- 51.4 ml/min (p less than 0.001). The mean MEE (IMV) was 2,380 +/- 369 kcal/day; MEE (AMV) was 2,128 +/- 342 kcal/day (p less than 0.05). The mean predicted energy expenditure (PEE) was 2,731 +/- 416 kcal/day. The IMV mode required 11.6% more pulmonary work when compared to AMV (VO2 IMV - VO2 AMV). The PEE overestimated caloric needs in ventilator-dependent patients by 12.8% on IMV and 22.1% on AMV. The MEE (IMV) required 10.7% more energy than MEE (AMV). Assist mode ventilation resulted in decreased work of breathing and decreased energy expenditure, and the (HBE) inaccurately predicted caloric needs in ventilator dependent patients.
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Abstract
Because it is difficult to diagnose, acalculous cholecystitis in critically ill patients is treated frequently in an advanced stage. Three of 1600 cardiac surgery ICU admission cases and five of 500 general surgical ICU admission cases were analyzed retrospectively to determine which variables expedited diagnosis and might have encouraged earlier surgery. Vague right upper quadrant physical findings and nonspecific changes in liver function chemistries led frequently to radiologic evaluations. Noninvasive diagnostic procedures such as ultrasound and hepatobiliary scans were helpful but frequently inconclusive. Of the eight patients, the five survivors were diagnosed while still in the hyperdynamic hemodynamic state of early sepsis. Cholecystostomy performed early under local anesthesia was the safest procedure in this group of critically ill patients. After other sources of sepsis such as suppurative phlebitis, yeast septicemia, catheter sepsis, and other extra-abdominal sources such as soft-tissue, urinary, and pulmonary infections have been ruled out, hemodynamic data obtained from pulmonary artery catheters inserted during the early phase of sepsis increase diagnostic accuracy and should expedite surgical exploration.
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