Biomedical subjects

C H Shatney

Publications and source records attributed to C H Shatney.

At least 37 records · Page 2Linked to original sources

PubMed1987

Thyroid hormone alterations in patients with shock and injury.

Serum concentrations of total T3 and T4, free T4, rT3, TSH, TBG and cortisol were measured on arrival in hospital in 33 adult injured patients, 26 of whom were received directly from the accident. Serum cortisol levels and all thyroid indices, except TBG, were altered substantially by injury. Compared with values from 57 healthy volunteers, statistically significant (P less than 0.01) decreases were found in the mean serum free and total T4 concentrations and the rT3 level. Similarly significant (P less than 0.001) increases were seen in the mean serum T3, TSH and cortisol concentrations. Repeated assessment of thyroid function in six patients suggested a biphasic response to injury by TSH, T3 and rT3. The first phase was of short duration (1-2 h). Serum levels of TSH and T3 were above normal, and rT3 was decreased. These data suggest participation by the thyroid in the 'fight-or-flight' response to life-threatening stress. The second phase was fully established 6-18 h after injury and was characterized by reductions in serum TSH, T3 and total and free T4 and a rise in rT3. This pattern persisted throughout the 2-week period of measurement. Thus, as in other critical illnesses, the 'low T3' syndrome is common in severely injured patients. However, changes in thyroid hormone metabolism after injury are of greater intensity and longer duration.

Adult↗

PubMed1987

Triiodothyronine increases survival in canine hemorrhagic shock.

The euthyroid sick (low T3) syndrome occurs in shock and could influence survival. To evaluate the potential therapeutic value of triiodothyronine (T3) in circulatory collapse, 26 anesthetized, heparinized mongrel dogs were bled rapidly into a reservoir until mean arterial blood pressure (MAP) = 40 mmHg. After 60 min of hypotension, the animals were given 15 micrograms/kg of T3 i.v. (13 dogs) or an equal volume of normal saline (13 dogs), and the reservoir line was clamped for 30 min (uncompensated shock). The shed blood was then reinfused over 30 min. After 1 h of monitoring the dogs were returned to the kennel and observed for 3 days. T3 (15 micrograms/kg) or normal saline was administered i.v. on each of the first 3 postshock days. T3 administration caused significant increases during uncompensated shock in cardiac output, stroke volume, mean arterial pressure, right and left ventricular stroke work and systemic vascular resistance, with a decrease in pulmonary vascular resistance. Shortly after reinfusion of shed blood, hemodynamic values were similar in T3 and untreated animals. In the control group, 6 of 13 dogs died. However, only one of 13 T3 dogs died (P less than 0.05). Although the mechanism by which T3 enhances shock survival was not clearly identified, T3 might exert beneficial effects via the hypothalamic-pituitary-thyroid axis or by acting on cardiovascular receptors to improve hemodynamic function at a critical stage of shock. Additional studies of T3 therapy in clinical shock appear warranted.

Animals↗

PubMed1987

The reliability of excretory urography as a screening examination for blunt renal trauma.

A prospective study was designed to evaluate the reliability of excretory urography (EU) in excluding renal damage in patients with blunt abdominal trauma, using contrast-enhanced computed tomography (CECT) as the "gold standard" of diagnostic studies. Sixty patients with indications for genitourinary evaluation and with normal EU underwent CECT. Five renal injuries were demonstrated by CECT in patients with negative EU: one contusion, one subcapsular hematoma, two perirenal hematomas, and one renal laceration. All of these lesions resolved with conservative patient management. Thus, the CECT findings did not alter treatment in these five patients.

Adolescent↗

PubMed1987

Detrimental effect of reverse triiodothyronine in hemorrhagic shock.

To examine whether reverse triiodothyronine (rT3), generally considered devoid of biological activity, could influence outcome in circulatory collapse, 23 anesthetized mongrel dogs were subjected to hemorrhagic shock. In 10 dogs, 15 micrograms/kg of rT3 were administered iv 30 min before hemorrhage. In 13 other dogs, an equal volume of saline was injected. The dogs were bled rapidly to a mean arterial pressure of 40 mm Hg, and after 60 min the reservoir line was clamped for 30 min. The shed blood was then reinfused over 30 min. After one hour of hemodynamic monitoring, the dogs were returned to the kennel and observed for at least 3 days. During shock there were few significant intergroup hemodynamic-metabolic differences. In the control group, six of 13 dogs died, whereas nine of ten dogs given rT3 died (p less than .03). This study strongly suggests that rT3 exerts detrimental biological activity in canine hemorrhagic shock. Hence, rT3 may play a causative role in the euthyroid sick ("low T3") syndrome.

Animals↗

PubMed1987

Beneficial effect of thyroidectomy in canine hemorrhagic shock.

To further evaluate the relationship between plasma thyroid hormone concentrations and mortality in shock, 10 thyroidectomized and 9 normal dogs were bled rapidly to a mean arterial pressure of 40 mm Hg. After 60 min of hypotension, the reservoir line was clamped for 30 min. The shed blood was then reinfused. Thyroidectomy produced a hypodynamic, hypometabolic state. During shock, these animals exhibited fewer major hemodynamic derangements than the control group. Only one thyroidectomized dog died, whereas 5 of 9 control animals died (p less than 0.05). Thus, circulating thyroid hormones are not determinants of survival in canine hemorrhagic shock. We hypothesize that thyroidectomy, perhaps by modulating catecholamine metabolism or stimulating liberation of thyrotropin releasing hormone, promotes salutary hemodynamic-metabolic effects during circulatory collapse and enhances survival.

Animals↗

PubMed1987

Feeding jejunostomy (versus gastrostomy) passes the test of time.

The authors previously reported a higher incidence of early postoperative complications after feeding gastrostomy compared to jejunostomy, prompting the recommendation of jejunostomy for chronic enteral feeding. Long-term follow-up has since been obtained on these 31 patients and an additional 25 patients undergoing surgical feeding procedures. The 26 feeding gastrostomies were 16 Stamm, eight permanent mucosal-lined, and two Witzel. The 30 feeding jejunostomies consisted of 19 Roux-en-Y, nine Stamm, and two Witzel. Patients with gastrostomy have had a mean follow-up of 100 days. Adverse events have occurred in 15/26 (58%), including 9 patients with pulmonary aspiration (35%), two of which were fatal. Twenty-three additional patients have died of underlying diseases. All 11 patients with tube jejunostomy died of underlying diseases within 4 months of surgery. The complication rate was 36%, including pulmonary aspiration in both patients with Witzel jejunostomy. The 19 patients with Roux-en-Y jejunostomy have had mean follow-up of 169 days. Complications have occurred in 9 patients (47%); 16/19 patients (mean age 55 years) have died of underlying disease. The mean age of the patients still alive is 35 years. Feeding jejunostomy has a lower incidence of complications, especially pulmonary aspiration, than gastrostomy. Stamm jejunostomy should be used for enteral feeding in older patients and in patients with short life expectancy. In younger patients requiring lifelong enteral feeding, Roux-en-Y jejunostomy should be used.

Enteral Nutrition↗

PubMed1987

Massive rectal bleeding from jejunal diverticula.

During a ten year interval, four patients with extensive rectal bleeding from jejunal diverticula were treated in a city of 750,000 people. Patient ages ranged from 54 to 66 years. All of the patients presented with bright red rectal bleeding. Bleeding scans demonstrated a source of blood loss high in the small intestine in two patients who had jejunal diverticula at exploratory laparotomy. In another patient, the results of preoperative evaluation did not reveal the site of hemorrhage. Jejunal diverticula were found at exploratory laparotomy. These three patients underwent jejunal resection and have since remained free of gastrointestinal bleeding. In the fourth patient, mesenteric arteriography revealed extravasation from a jejunal diverticulum. After angiography, the patient experienced no further hemorrhage, and surgical treatment was not performed. This patient remained asymptomatic and died of myocardial infarction five years later. The successful nonoperative management of this patient belies the high reported incidence of recurrent hemorrhage associated with jejunal diverticula. Thus, patients with rectal bleeding who are found to have jejunal diverticula should undergo removal of the involved jejunum, even if preoperative evaluation results implicate another source. The results of this study suggest that jejunal diverticula are a more frequent cause of extensive rectal bleeding than heretofore appreciated, particularly in the elderly.

Aged↗

PubMed1987

Resuscitation and evaluation of victims of blunt multisystem trauma.

The initial management of hemodynamically unstable polytrauma patients can be challenging. Although there are other possible causes of hypotension, such as tension pneumothorax, CNS injury and hemopericardium, in the vast majority of blunt trauma victims shock is due to blood loss. Whereas the diagnosis of circulatory collapse is clearcut, the rapid identification and control of the bleeding source may not be a straightforward matter. Such patients often have injuries to several body systems and thus have numerous potential sites of hemorrhage. Ideally, the injury pattern should be defined during resuscitation. The use of a trauma team and standardized protocols facilitate patient management. Clearly, airway patency and adequacy of ventilation must have top priority. Cervical spine immobilization should be maintained until a fracture has been ruled out. In concert with respiratory management, other members of the trauma team should secure adequate vascular access, resuscitate the patient and perform a physical examination. Physical findings dictate the order of further diagnostic and therapeutic maneuvers. In unstable patients the potential need for urgent surgical intervention must not be overlooked.

Emergency Medical Services↗

PubMed1987

Complications of splenectomy.

During the last three decades it has become clear that removal of the spleen, for any reason, is not a benign procedure. In both adults and children splenectomy places the patient at significantly higher risk of overwhelming infection, compared to the normal population. The risk of the post-splenectomy septic syndrome is lifelong and is not eliminated by the administration of polyvalent pneumococcal vaccine. Thus far, the reported rate of overwhelming sepsis in asplenic individuals has ranged from 2.5-13.5%. As more long-term follow-up data become available, it is likely that the true incidence will be 5-10%. In addition to this late complication, splenectomy increases the frequency of adverse events, including death, in the immediate postoperative period. Infections, particularly pulmonary and abdominal sepsis, constitute the majority of the complications. The mortality rate from postoperative sepsis is substantial. Atelectasis, pancreatitis/fistula, pulmonary embolism and bleeding at the operative site are also relatively common occurrences following splenic removal. These alarming statistics have spurred surgeons to change their attitudes concerning splenectomy for trauma, both accidental and iatrogenic. Nonoperative management of hemodynamically stable patients with isolated splenic injury and splenorrhaphy in patients requiring laparotomy are now firmly entrenched in the surgical armamentarium. Patients in whom splenectomy is necessary are given polyvalent pneumococcal vaccine and are instructed to seek early medical attention for febrile illnesses. Splenic autotransplantation and lifelong prophylactic antibiotic therapy have been used in some centers, but their clinical value remains to be proven.

Bacterial Infections↗

PubMed1987

Diagnostic and therapeutic aspects of rectal trauma. Blunt versus penetrating.

In the last 6 years, nine patients with blunt and 16 with penetrating rectal injuries were treated at University Hospital, Jacksonville, Florida. Blunt trauma was caused by vehicular accidents in seven patients and crush injuries in two. Penetrating rectal trauma was due to gunshot wounds in ten patients and foreign body insertion in six. All patients with blunt injury had bright red rectal bleeding, which led to diagnostic sigmoidoscopy. Rectal injury was identified at sigmoidoscopy in 12 patients who had penetrating wounds and at laparotomy in four patients. Thirteen patients who had penetrating rectal trauma had injury to only the rectum or to one additional organ. In contrast, all patients who had blunt rectal trauma had at least three associated injuries. In the penetrating group, 13 patients were treated by colostomy and mucus fistula; three patients with mucosal injury were managed nonoperatively. The only death occurred in a patient whose rectal injury was initially missed. Patients who had blunt rectal trauma were managed with colostomy and mucus fistula. Three patients died postoperatively, two of pelvic bleeding and one of head injury. Hemodynamic stabilization, colostomy and mucus fistula, presacral drainage, and rectal washout constitute proper treatment of patients with blunt or penetrating rectal trauma. Because of the greater number and severity of associated injuries, morbidity and mortality are higher after blunt rectal trauma.

Accidents, Traffic↗

PubMed1987

Maximum surgical blood order schedule reduces hospital costs.

The maximum surgical blood order schedule (MSBOS) is a viable option for reducing unnecessary crossmatching and achieving significant cost savings in the blood bank. A MSBOS specifies, and thus limits, the amount of blood normally crossmatched for elective surgical procedures. During the first 10 months after introducing MSBOS at our hospital, there was a 33 per cent drop in the number of units of blood crossmatched for elective surgical procedures. The 712 crossmatches that were avoided saved the hospital blood bank more than $6000. Patient care was not adversely affected. Institution of MSBOS can be accomplished without difficulty by gaining input from surgeons and anesthesiologists. After implementation, follow-up is advisable to attain optimal blood use.

Blood Banks↗

PubMed1986

Thyrotropin-releasing hormone increases survival in canine hemorrhagic shock.

In our previous work thyroidectomy significantly improved survival in canine hemorrhagic shock. This finding, coupled with the reported beneficial hemodynamic effects of thyrotropin-releasing hormone (TRH) in circulatory collapse, led to the present study. Anesthetized, heparinized dogs were bled rapidly into a reservoir until MAP = 40 mm Hg. After 60 min of hypotension (E60) the reservoir line was clamped for 30 min (E90). In 10 dogs three doses of TRH (2 mg/kg) were administered iv at 10-min intervals during clamping. In 11 other animals equivalent volumes of saline were given. At E90 the reservoir line was unclamped, and shed blood was reinfused over 30 min. After 1 hr of monitoring (E180) the dogs were returned to the kennel and observed for at least 3 days. Among 11 control dogs, 6 died. In the TRH group only 1 of 10 dogs died (P less than 0.05). During uncompensated shock (E60-E90), TRH-treated dogs had significantly higher mean arterial pressure, cardiac index, stroke index, and right and left ventricular stroke work indexes, and arterial pH than control animals. At the conclusion of the acute experiment (E180) there were few intergroup hemodynamic-metabolic differences. The significant enhancement of 3-day survival by TRH in canine hemorrhagic shock might be related to hemodynamic improvement at a critical stage of circulatory collapse (E60-E90). Direct or indirect neuromodulatory actions of TRH on the CNS could also explain our results. These findings lend further support to the potentially key role of hypothalamic-pituitary-thyroid interrelationships in shock.

Animals↗

PubMed1986

Upper-airway obstruction as a complication of oral anticoagulation therapy.

We treated a patient for warfarin-induced sublingual hematoma causing upper-airway obstruction. This complication of oral anticoagulation therapy is rare; only three other cases have been reported in the English literature. All reported patients developed acute respiratory embarrassment necessitating emergency airway establishment. Sublingual hematomas usually resolve spontaneously, and surgical drainage is rarely necessary.

Airway Obstruction↗

PubMed1986

Acute rupture of the diaphragm in blunt trauma: analysis of 60 patients.

During a 9-year period, 60 patients with acutely ruptured diaphragms following blunt trauma were treated in our institution. Diaphragmatic injury was detected within 24 hours of hospital admission in all but two patients. The diagnosis was suggested by upright chest X-ray in 40% of the patients. Diaphragmatic tears were discovered at laparotomy for hemoperitoneum in the remaining patients. At initial evaluation hypotension was present in 67% of the patients, and respiratory distress was evident in 52%. In contrast to traditional teaching, there was a 30% incidence of right hemidiaphragmatic disruption. One patient experienced bilateral diaphragmatic rupture, and two had isolated tears of the pericardial diaphragm. Intra-abdominal organs were herniated through the diaphragmatic defect in only 32% of the patients. There was a 90% incidence of associated intra-abdominal injuries. The diaphragmatic tear was repaired via the abdomen in 53 patients, through a thoracoabdominal incision in five patients, and through the chest in only two cases. All defects were closed primarily. Twelve patients also required thoracotomy for resuscitation and/or correction of intrathoracic injury. Atelectasis was the most frequent postoperative complication, occurring in 65% of the patients. The mortality was 26.7% and was related to associated injuries in all cases.

Diaphragm↗

PubMed1986

Splenic injuries in adults: selective nonoperative management.

Although nonoperative management is the standard initial treatment in children with splenic injury, this therapeutic option has been exercised infrequently in adults. Over the past two years we have hospitalized and observed 11 hemodynamically stable adults with splenic trauma and no other significant injury. Ten patients sustained blunt trauma localized to the left upper quadrant, and one patient was stabbed in the left flank. Eight patients were normotensive on hospital arrival, while three had an initial systolic blood pressure of 90 to 98 mm Hg. All patients remained normotensive after receiving 2 liters of crystalloid fluid IV. Nine patients had an initial hemoglobin level of 11.1 to 14.0 gm/dl, and two a level of less than 10 gm/dl. Liver-spleen scan done in ten patients yielded true-positive results in eight, false-positive results in one, and false-negative results in one. In the 11th patient, a celiac arteriogram showed a splenic defect. Three patients had laparotomy 27 to 43 hours after hospitalization, owing to a decreasing hemoglobin concentration; one required partial splenectomy. Eight patients were successfully managed nonoperatively; only one required blood transfusion, and all tolerated oral alimentation by the second hospital day. All patients were discharged by the 12th hospital day. Nonoperative management can be successfully applied to adults with isolated splenic trauma.

Adult↗

PubMed1985

The management of venous injuries in blunt extremity trauma.

Data on venous injury in blunt extremity trauma are scarce. The nature of injury and results of therapy in 22 patients presenting with blunt venous extremity injury at MIEMSS and KUMC in a 10-year period are presented. Comparisons of the outcome with venous ligation and repair, the use of anticoagulants, and the use of fasciotomy, led to the development of guidelines for the therapy of blunt venous injury in both upper and lower extremity trauma.

Adolescent↗

PubMed1985

Feeding gastrostomy. Assistant or assassin?

Following several deaths from pulmonary aspiration in severely ill or chronically debilitated patients receiving nasogastric tube feedings, a study was undertaken to determine the incidence of aspiration pneumonitis in patients with feeding gastrostomies. During a 15-month interval, 22 feeding gastrostomies and nine feeding jejunostomies were performed. In the former group, eight patients experienced aspiration pneumonitis, with two deaths. Six patients with Stamm gastrostomies and two patients with permanent mucosal-lined gastrostomies experienced pulmonary aspiration. In contrast, aspiration pneumonia did not occur in our small series of patients with feeding jejunostomies. The high incidence of pulmonary aspiration in patients with feeding gastrostomies strongly suggests that, for chronic enteral nutrition in patients who are unable to protect their airway, a feeding jejunostomy is preferable to a feeding gastrostomy.

Adult↗

PubMed1985

Endogenous opioid activity in clinical hemorrhagic shock.

Plasma beta-endorphin, cortisol and total opioid-like activities were measured upon arrival at the hospital in ten patients with extensive trauma and in a state of shock and 11 patients with minor injury. Patients in a state of shock had significantly (p less than 0.01) higher mean plasma beta-endorphin immunoreactivity than patients with minor trauma (128.8 +/- 24.8 picomolars versus 31.7 +/- 5.6 picomolars). There were no significant intergroup differences in the mean plasma cortisol concentration (27.7 +/- 4.7 micrograms per deciliter versus 20.6 +/- 2.7 micrograms per deciliter) or opioid ligand activity (2.28 +/- 0.62 nanomolars versus 3.17 +/- 0.99 nanomolars). These data are consistent with the hypothesis that certain endogenous opioids may be physiopathologic factors in hemorrhagic shock but provide no proof of a cause and effect relationship.

Accidents, Traffic↗