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Biomedical subjects

A C Beall

Publications and source records attributed to A C Beall.

At least 55 records · Page 3Linked to original sources
PubMed1988

Delayed diagnosis of injuries to the diaphragm after penetrating wounds.

During a 9-year period, 16 patients with a delay in diagnosis of an injury to the diaphragm after a penetrating wound were treated. The left hemidiaphragm was involved in 15 of 16 patients, and the delay in diagnosis from the time of arrival in the emergency center immediately after injury ranged from 16 hours to 14 years. In the patients in the Acute Group (delay of hours to days), three patients had diaphragmatic defects missed at the time of laparotomy, three patients had chest X-rays not immediately suggestive of diaphragmatic defects, two patients had false-negative lavages, and one patient treated elsewhere did not have a chest X-ray in the emergency room. In the patients in the Chronic Group (hernias presenting months to years after injury), four of seven patients had misreading of a recent chest X-ray or failure to have a chest X-ray performed during numerous return visits to the emergency center. Despite a variety of diagnostic maneuvers, these defects and hernias continue to be diagnosed after a delay. Careful review of early and late followup chest X-rays appears to be the easiest mechanism to avoid significant delays in diagnosis.

Adult↗
PubMed1987

Management of injuries to the suprarenal aorta.

During a 12 year period, 79 patients with a diagnosis of a penetrating wound to the suprarenal aorta were treated. An analysis of the records of these patients has led to the following conclusions: With a midline penetrating wound and presence of a supramesocolic hematoma or hemorrhage, injury to the suprarenal aorta should be suspected. If a midline supramesocolic hematoma is present or if hemorrhage can be controlled by direct pressure, a lateral approach with medial mobilization of the intraabdominal viscera on the left side allows rapid vascular control. Although lateral aortorrhaphy is preferred, patch grafting, and end-to-end anastomosis, or insertion of a prosthetic graft was required in 46 percent of the patients who underwent repair. As in all previous series, the insertion of synthetic patches or prostheses was not complicated by infection. The average survival rate for injuries to the suprarenal aorta in series reported since 1974 is 33 percent. Finally, the continuing problem of irreversible shock suggests the need for rapid transport from the field to the hospital for victims of penetrating wounds to the abdomen.

Aorta, Abdominal↗
PubMed1987

Primary aortoduodenal fistula caused by Salmonella aortitis.

We report the management and follow-up of two cases of primary aortoduodenal fistulas caused by Salmonella aortitis. The origin, presentation, diagnosis, and results of operative therapy for patients with primary aortoduodenal fistulas, especially patients with positive aortic wall cultures, are reviewed. Successful therapeutic principles included early intervention, primary duodenal repair, aneurysm resection, aortic reconstruction with an in situ Dacron graft, and prolonged courses of bactericidal antibiotics.

Adult↗
PubMed1986

Liberal use of emergency center thoracotomy.

Emergency center thoracotomy is a heroic technique of resuscitation and treatment which was revived in the 1960s to improve the survival of patients presenting with cardiac wounds. With excellent survival rates attained in such patients, the technique was extended to victims of trauma with other mechanisms and locations of injury. At present, the technique has a survival rate ranging from 3 to 20 percent; however, most recent series of unselected patients show a survival rate of 8 to 10 percent. In this series, there were no survivors when emergency center thoracotomy was utilized after a period of prehospital cardiopulmonary resuscitation. Patients with isolated stab wounds to the thorax, especially those with cardiac injuries, had the best survival rate of any subgroup in the series. If emergency center thoracotomy was utilized for patients with some vital signs on admission and with neck or truncal gunshot wounds, blunt trauma, or abdominal trauma, the survival rate decreased to 2 to 4 percent; however, the small but constant survival rate in all of these groups justifies its continued use.

Adult↗
PubMed1986

Management of injuries to the superior mesenteric artery.

From 1978 through 1984, 22 patients with 20 penetrating and two blunt injuries to the proximal superior mesenteric artery were treated. Patients presented with exsanguinating hemorrhage (19), midline hematomas (two), or 'black bowel' (one). Two other patients developed 'black bowel' during operation. Direct cutdown through the mesentery was the approach in 11 patients, and three survived; a Mattox maneuver was used in ten patients, and five survived. Complex bypass or grafting procedures were performed in nine patients, and two survived. Ten of 15 deaths were secondary to hemorrhagic shock; two of five late deaths were related to problems with the vascular repair in patients with multiple injuries. Interposition grafting near a major pancreatic injury may lead to catastrophic postoperative problems. Bypass grafts from the distal aorta should have retroperitoneal tissue coverage of the suture line.

Abdominal Injuries↗
PubMed1985

Management of traumatic injuries to the extrahepatic biliary ducts.

From 1978 through 1984, 13 patients with traumatic injuries to the extrahepatic biliary ducts were treated. Twelve of the 13 patients had penetrating wounds, and associated intraabdominal injuries were uniformly present. Multiple types of operative repair were successfully utilized, with the choice dictated by the patient's condition and the location and extent of the ductal injury. In stable patients with partial tears or small through-and-through injuries, lateral repair with or without T-tube stenting was used successfully. With ductal transections, an end-to-end anastomosis or a bilioenteric anastomosis was used. The Whipple procedure was reserved for complex periampullary injuries. Morbidity was related to the complexity of the ductal repair, whereas mortality (4 of 13 patients, 31 percent) was related to associated injuries.

Adolescent↗
PubMed1985

Combined tracheoesophageal injuries.

From 1974 through 1984, 23 patients with combined tracheoesophageal injuries from penetrating wounds were treated. Physical examination, endoscopy, a barium swallow, or a combination of these techniques confirmed the diagnosis preoperatively in 19 patients. A variety of operative techniques were used, with 20 of 23 repairs involving some type of primary repair of the trachea and esophagus, such as side repair or end-to-end anastomosis, with or without a tracheostomy. Major complications occurred in 74 percent of the patients and included eight cases of pneumonia, eight esophageal leaks, six tracheoesophageal fistulas, five mediastinal abscesses, four wound infections, and two carotid artery blowouts. To decrease the number of complications, several refinements in operative technique have been suggested.

Adolescent↗
PubMed1985

Clamp/repair: a safe technique for treatment of blunt injury to the descending thoracic aorta.

Debate exists with regard to the use of pump bypass, shunt bypass, or clamp/repair techniques in treating injuries to the descending thoracic aorta. The objective in using any of these techniques is to minimize the complications of paraplegia and renal failure, while achieving the lowest possible mortality. During an eighteen-year period, 45 patients were seen with acute blunt injury to the descending thoracic aorta. The shunt bypass method of repair was used in 1; pump bypass in 8; and clamp/repair in 23. There were desperate unsuccessful attempts to resuscitate and control hemorrhage in 13 patients, 1 of whom was placed on portable pump bypass. Thirty-two patients survived resuscitation and operation, and 26 were long-term survivors. Among surviving patients with permanent paraplegia, 2 underwent pump bypass and 1, the clamp/repair technique. Four other patients were seen with paraplegia or paresis and had reversal of the paralysis. The clamp/repair technique was used in these patients with clamp times ranging from 35 to 62 minutes (mean, 47.4 +/- 13.3 minutes). Renal failure did not occur in any patient, despite clamp times of up to 62 minutes (mean, 37.5 minutes). Excluding patients seen in a moribund condition, mortality most often was secondary to neurological or multisystem injury. Debate continues concerning intraoperative management of this highly lethal vascular injury. The data presented here support the historical composite experience that clamp/repair is a safe and efficacious technique that minimizes paraplegia and mortality.

Adolescent↗
PubMed1985

Cardiac evaluation following heart injury.

Both penetrating and blunt cardiac injuries require urgent management. Delayed sequelae and complications have been reported to occur in 4 to 56% of survivors and frequently required secondary surgical corrections. Between January 1980 and June 1984, 204 patients presented with heart injuries. One hundred twenty-eight of these patients survived. Of the 90 undergoing cardiorrhaphy in the operating room, 78 survived. Two-dimensional (2-D) and pulsed-Doppler echocardiography (echo) and/or cardiac catheterization were performed in 40 patients for suspected significant residual injury. Eight of the 40 required secondary cardiac operations. Two-dimensional echo demonstrated pericardial effusion, abnormal chamber enlargement, abnormal cardiac wall motion, intracardiac missile, and intracardiac and pleural thrombus. Pulsed-Doppler findings included ventricular septal defect, tricuspid insufficiency and right ventricular turbulence secondary to arteriovenous fistulae. Cardiac catheterization detected lesions undetected by 2-D echo in one patient with a gunshot wound. It is concluded that in the absence of cardiac bullets seen on routine chest X-ray, 2-D with pulsed-Doppler echo is an excellent screening technique. With a positive echo study or a residual bullet overlying the cardiac silhouette, cardiac catheterization is indicated in selected patients.

Adolescent↗
PubMed1984

Reevaluation of early evacuation of clotted hemothorax.

During an 181/2 year period, we encountered 14,300 patients with blunt or penetrating thoracic or thoracicoabdominal trauma. In 155 patients, residual clotted hemothorax or empyema developed later. Thirty-nine patients underwent early evacuation of clotted hemothorax with no mortality and an average hospital stay of only 10 days. When progression to empyema occurred, the mortality rate increased to 9.4 percent and the average hospital stay to 37.9 days. The most common related event in the development of empyema was concurrent injury to intraabdominal organs and the inevitable bacterial contamination of the thorax. In a small number of patients, tube thoracostomy drainage is inadequate and results in residual clotted hemothorax. Despite recent pleas for conservative, expectant management, it is our experience that early evacuation of clotted hemothorax is not only cost-effective, it is also associated with lower morbidity, lower mortality, and reduces the chance of development of empyema.

Abdominal Injuries↗
PubMed1984

Civilian trauma in the 1980s. A 1-year experience with 456 vascular and cardiac injuries.

During 1982, 312 patients with 408 vascular injuries and 48 cardiac injuries were seen. Two or more vascular or cardiac injuries were present in 34% of patients. Over 87% of injuries were secondary to gunshot wounds, stab wounds, or shotgun wounds. Vascular injuries were most commonly seen in the extremities (39.9%) or abdomen (31.9%). The most common arterial injuries occurred in the brachial artery (39 patients), while the most common venous injuries occurred in the internal jugular vein (26 patients). Arterial injuries were treated by the insertion of substitute vascular conduits (33.9%), ligation (22.6%), lateral arteriorrhaphy (18.6%), or end-to-end anastomosis (15.4%). Venous injuries were treated by lateral venorrhaphy (63.7%) or ligation (25.1%). In the 272 patients admitted with only vascular injuries, survival was 84.2%. Cardiac injuries in 38 patients most commonly occurred in the right ventricle (50%) and right atrium (25%). In the 34 patients who had only cardiac injuries and less than 4 minutes of prehospital cardiopulmonary arrest prior to arrival in the emergency center, survival was 64.7%.

Adult↗
PubMed1984

Lymphangiomyomatosis with chylous effusions.

We report two cases of lymphangiomyomatosis with pleural and peritoneal chylous effusions, one without pulmonary involvement. The first patient died after seven years. The second received external irradiation to control the chylous ascites and remains alive 12 years later. The disease appears to be estrogen-dependent, and bilateral oophorectomy has been recently reported for palliative treatment.

Adult↗
PubMed1982

Carotid artery injuries.

One-hundred twenty-nine patients with carotid artery injuries were analyzed to compare the results of revascularization with those of ligation or occlusion. In patients who present with central neurologic deficit short of coma (Grades 1 to 4), revascularization is clearly the operative method of choice. Revascularization in patients with preoperative coma (Grade 5) is also indicated when ischemia has only been present for a short period of time before surgery. Controlling cerebral edema and minimizing infarct size in patients with severe deficits may be essential to optimize the chance of recovery of these patients.

Adolescent↗
PubMed1982

Pulmonary embolectomy for acute massive pulmonary embolism.

During the period from 1961 to 1981, 40 pulmonary embolectomies were performed in 39 patients who were in extremis at the time of initiation of cardiopulmonary bypass. In a 460-bed hospital with more than 17,000 acute admissions and 4,000 operations per year, this small number represents the few patients who are potentially salvageable by urgent embolectomy. Preoperative angiography was performed in 57% of the cases, and in another ten patients suspected of having pulmonary emboli, angiography prevented unnecessary thoracotomy. Despite their moribund condition, 43% of the embolectomy patients lived. Excluding two patients with tumor occlusion of the pulmonary arteries and three patients with chronic cor pulmonale from old pulmonary emboli, the survival rate was 50%. Ten patients died because of hypoxemia and hypotension prior to initiation of cardiopulmonary bypass, and seven died of myocardial depression of multiple etiologies. Portable cardiopulmonary bypass affords the possibility of survival in moribund patients with acute massive pulmonary embolism. Preoperative angiography is recommended to guide appropriate surgical management.

Cardiopulmonary Bypass↗
PubMed1982

Innominate vascular injury.

Survivors of innominate and other major cardiovascular injuries are being seen with increasing frequency. Penetrating injuries more frequently involve the distal innominate artery and innominate veins. Associated subclavian and carotid artery injuries are more frequent following penetrating trauma. Blunt trauma typically involves the proximal innominate artery. A variety of operative exposures is useful but the selection of incision frequently depends upon the presence or absence of associated mediastinal injuries. Partial or complete median sternotomy in combination with various cervical and thoracic extensions is advised. Successful management of innominate artery injury can be performed without the aid of cardiopulmonary bypass or arterial shunts.

Blood Vessel Prosthesis↗