Search PubMed⌕ Search

Biomedical subjects

D Demetriades

Publications and source records attributed to D Demetriades.

At least 73 records · Page 4Linked to original sources
PubMed1999

Gunshot injuries to the liver: the role of selective nonoperative management.

BACKGROUND: Selective nonoperative management of blunt liver injuries has become standard practice in most trauma centers. We evaluated the role of selective nonoperative management of gunshot wounds to the liver. STUDY DESIGN: This was a retrospective review of gunshot wounds to the liver treated in a level I trauma center. Patients with peritoneal signs or hemodynamic instability were operated on without delay. Patients with a soft, nontender abdomen and no signs of heavy bleeding were selected for nonoperative management. Liver injury was diagnosed by CT scan. If peritonitis or signs of substantial internal bleeding developed, an operation was performed; otherwise the patient was discharged within a few days of admission. Analysis was restricted to the group of patients with isolated liver injuries. RESULTS: During a 42-month period, 928 patients were admitted with abdominal gunshot injuries, 152 of whom (16%) had a liver injury. In 52 patients (34% of all liver injuries), the liver was the only injured intraabdominal organ (4 patients had associated kidney or splenic injuries that did not require surgical repair). Thirty-six of the patients (69%) with isolated liver injuries had an emergent operation because of signs of peritonitis or hemodynamic instability. The remaining 16 patients (31%) were selected for nonoperative management (3 patients had associated right kidney injury). Five patients in the observed group required delayed operation because of development of signs of peritonitis (4 patients) or abdominal compartment syndrome (1 patient). The remaining 11 patients (7% of all liver injuries or 21% of isolated liver injuries) were managed successfully without operation. One patient with delayed operation developed multiple complications from abdominal compartment syndrome, and 1 patient in the nonoperative group had a biloma, which was treated with percutaneous drainage. CONCLUSIONS: Selected patients with isolated grades I and II gunshot wounds to the liver can be managed nonoperatively.

Humans↗
PubMed1999

Early thoracoscopy for the evacuation of undrained haemothorax.

OBJECTIVE: To evaluate the accuracy of radiological tests and the outcome after thoracoscopic evacuation of retained haemothorax. DESIGN: Prospective study. SETTING: Academic trauma centre, USA. SUBJECTS: Of 703 patients with thoracic injuries, 58 (8%) were evaluated for and 15 (2%) were found to have, retained haemothorax. INTERVENTIONS: Plain chest radiographs (CXR) and thoracic computed tomograms (CT) 48 hours after admission, and thoracoscopic evacuation within 3-6 days of admission. MAIN OUTCOME MEASURES: Accuracy of radiological tests, morbidity, and mortality. RESULTS: 12 patients underwent early thoracoscopy with minimal morbidity, no mortality, and appreciable clinical and radiological improvement. Three patients who were not operated on developed empyemas. CXR was inaccurate in predicting the need for thoracoscopy. CT was the only test that predicted the need for evacuation of haemothoraces. CONCLUSION: Thoracoscopic evacuation of retained haemothorax is safe and effective. The success of the procedure is assured by early intervention in appropriately selected patients. CT is the ultimate test on which to base decision-making.

Adolescent↗
PubMed1999

Predicting the need for thoracoscopic evacuation of residual traumatic hemothorax: chest radiograph is insufficient.

BACKGROUND: The early removal of large residual posttraumatic hemothorax by videothoracoscopy is increasingly used to avoid the late sequelae of trapped lung and empyema. Plain chest radiography (CXR) is the tool most frequently used to select such cases for operation. Our recent experience has demonstrated that what appears to be a large retained hemothorax on CXR may turn out to be intrapulmonary or extrapleural conditions not amenable to thoracoscopic removal. Our objective was to evaluate the accuracy of CXR in detecting significant residual hemothorax and compare its clinical value to thoracic computed tomography (CT) when used to select patients for thoracoscopic evacuation. METHODS: All patients requiring tube thoracostomy for traumatic hemothorax were prospectively evaluated during a 22-month period (n = 703). Patients who, on the second day after admission, demonstrated opacification on CXR involving more than the costophrenic angle were evaluated by thoracic computed tomography for the presence of undrained fluid. Second-day CXR (CXR2) results were compared with the CT findings. Incorrect interpretation was defined as a difference of more than 300 mL between the two readings. All CXR2 and CT results were reviewed in the same fashion by a radiologist blinded to the surgeon's interpretations. Data on injury mechanism, hemodynamic status, laboratory values, interventions, and outcome were collected prospectively. RESULTS: Fifty-eight patients had clinically significant opacifications on CXR2. The surgeon's and radiologist's CXR2 interpretations were incorrect in 48 and 47% of the cases, respectively. The CT interpretations by the two specialists were in agreement in 97% of the cases. Management that would have been instituted on the basis of CXR2 findings was changed in 18 cases (31%). Twelve patients (21%) required early thoracoscopic evacuation of undrained collections. There was good correlation between the CT estimation and the thoracoscopically retrieved amount of blood. CONCLUSION: Although CXR is useful as a screening tool, it cannot be used to reliably select patients for surgical evacuation of retained traumatic hemothorax. Decision-making should be based on thoracic CT findings.

Adult↗
PubMed1999

Colonic resection in trauma: colostomy versus anastomosis.

OBJECTIVES: The management of colonic trauma is well established for simple injuries with primary repair, and ileocolostomy for right-sided injuries that undergo colonic resection. Segmental colon resection for injuries to the left colon can be managed with either an end colostomy or primary anastomosis. A retrospective review was performed to evaluate the outcome and complications associated with colonic resection for trauma to determine the risk factors associated with anastomotic leakage. METHODS: A retrospective review included patients undergoing colonic resection for trauma. The patients were stratified into colostomy, ileocolostomy, and colocolostomy groups. Patient demographics and colon-related complications were collected. Comparison between the colostomy and colocolostomy groups was performed to determine the difference in outcome. The outcome of right-sided colon injuries managed by either an ileocolonic or colocolonic anastomosis was compared. Analysis was performed to identify the factors associated with an increased risk of anastomotic leakage. RESULTS: One hundred forty patients over a 66-month period were included in the analysis. Overall, 41% (57 of 140) of patients developed a colon-related complication; 28% (39 of 140) of patients developed an abscess. Overall, the anastomotic leak rate was 13% (7 of 56) in the colocolostomy group, 4% (2 of 56) in the ileocolostomy group. Right-sided colon injuries managed with a colocolonic anastomosis had a higher incidence of anastomotic leakage than ileocolonic anastomosis, i.e., 14 versus 4% respectively. Of the seven patients who developed a leak from a colocolonic anastomosis, two patients died (29%). Univariate analysis identified an Abdominal Trauma Index Score > or = 25 (p = 0.03) or hypotension in the emergency department (p = 0.001) to be associated with increased risk of developing an anastomotic leak from a colocolonic anastomosis. CONCLUSION: Colonic injuries that are managed with resection are associated with a high complication rate regardless of whether an anastomosis or colostomy is performed. Colonic resection and anastomosis can be performed safely in the majority of patients with severe colonic injury, including injuries to the left colon. For injuries of the right colon, an ileocolostomy has a lower incidence of leakage than a colocolonic anastomosis. For injuries to the left colon, there remains a role for colostomy specifically in the subgroups of patients with a high ATI or hypotension, because these patients are at greater risk for an anastomotic leak. The role of resection and primary anastomosis versus colostomy in colonic trauma requires further investigation.

Adult↗
PubMed1999

Multiple organ failure: by the time you predict it, it's already there.

OBJECTIVE: Validate an at-risk population to study multiple organ failure and to determine the importance of organ dysfunction 24 hours after injury in determining the ultimate severity of multiple organ failure. METHODS: We evaluated 105 patients admitted to five academic trauma centers during a 1-year period who survived for more than 24 hours with Injury Severity Scores > or = 25 and who received 6 or more units of blood. Organ dysfunction was scored daily with a modified multiple organ failure scoring system made up of individual adult respiratory distress syndrome score, renal dysfunction, hepatic dysfunction, and cardiac dysfunction scores. Multiple organ failure (MOF) severity was quantitated using the maximum daily multiple organ failure score and the cumulative sum of daily multiple organ failure scores for the first 7 days (MOF 7) and 10 days (MOF 10). Independent variables included markers of tissue injury, shock, host factors, physiologic response, therapeutic factors, and organ dysfunction within the first 24 hours after admission. Data were subjected to a conditional stepwise multiple regression analysis, first excluding and then including 24-hour MOF as an independent variable. RESULTS: Of the 105 high-risk patients, 69 (66%) developed a maximum daily multiple organ failure score > or = 1; 50 (72%) did so on day 1 one and 60 (87%) did so by day 2. In multiple regression models, the multiple correlation coefficient increased from 0.537 to 0.720 when maximum MOF was the dependent variable, from 0.449 to 0.719 when maximum daily MOF was the dependent variable, from 0.519 to 0.812 when MOF 7 was the dependent variable, and from 0.514 to 0.759 when MOF 10 was the dependent variable. CONCLUSION: We have confirmed that the population of patients with Injury Severity Scores > or = 25 who received 6 or more units of blood represent a high-risk group for the development of multiple organ failure. Our data also indicate that multiple organ failure after trauma is established within 24 hours of injury in the majority of patients who develop it. It appears that multiple organ failure is already present at the time when most published models are trying to predict whether or not it will occur.

Adult↗
PubMed1999

Bactericidal/permeability-increasing protein (rBPI21) in patients with hemorrhage due to trauma: results of a multicenter phase II clinical trial. rBPI21 Acute Hemorrhagic Trauma Study Group.

BACKGROUND: Infection and organ failure are the most common causes of death or serious complication in trauma patients surviving initial resuscitation and operation. Of the many possible causes of these complications, bacterial translocation and release of harmful cytokines and oxygen free radicals may play an important role in the pathogenesis of the complications associated with traumatic hemorrhage. Recombinant human bactericidal/permeability-increasing protein (rBPI21) has antibacterial and antiendotoxin properties, reduces cytokine levels, and increases survival in animal models of hemorrhagic shock. The primary objective of this study was to evaluate the safety and efficacy of prophylactic rBPI21 infusion in patients with hemorrhage due to trauma. METHODS: This was a phase II, multicenter, randomized, double-blind, placebo-controlled trial. Patients who required at least 2 U of blood were randomized to receive rBPI21 (4 mg x kg(-1) x d(-1) for 2 consecutive days) or an equivalent volume of placebo by continuous infusion within 12 hours of injury. The primary efficacy end point was mortality or serious complication occurring during the first 15 days of the study. Safety was monitored clinically and by laboratory panels during the study period. RESULTS: A total of 401 patients were treated (202 in the rBPI21 group and 199 in the placebo group). The composite end point rate of mortality or serious complication through day 15 was 46% in the placebo group and 39% in the rBPI21 group (hazard ratio = 0.79; p = 0.13). Secondary analysis, which adjusted for age, mechanism of injury, Injury Severity Score (1990 version), and units of blood received before study drug infusion showed similar results (hazard ratio = 0.79; p = 0.14). The proportion of patients who developed at least one serious organ dysfunction was 22% in the placebo group and 16% in the rBPI21 group (hazard ratio = 0.71; p = 0.14). The proportion of patients who developed either pneumonia or acute respiratory distress syndrome was 32% in the placebo group and 22% in the rBPI21 group (hazard ratio = 0.66; post hocp = 0.03). The beneficial trends of rBPI21 were observed in both blunt and penetrating trauma and were generally observed across different age groups, Injury Severity Scores, and units of blood transfused. No treatment difference was observed in mortality or resource utilization in this phase II study. CONCLUSION: rBPI21 was well-tolerated and demonstrated a favorable trend in reducing the composite primary end point of mortality or serious complication through day 15, especially respiratory complications, in patients with hemorrhage due to trauma. A phase III study is currently in progress.

Adolescent↗
PubMed1999

Value of complete cervical helical computed tomographic scanning in identifying cervical spine injury in the unevaluable blunt trauma patient with multiple injuries: a prospective study.

OBJECTIVE: To evaluate the role of routine helical computed tomographic (CT) scan of the entire cervical spine in high-risk patients with multiple injuries. METHODS: Prospective study of patients with severe blunt multiple injuries, requiring intensive care unit admission and CT scan of another body area besides the cervical spine. All patients were evaluated by means of standard cervical spine radiography. A complete cervical spine CT scan was performed during the same trip to the scanner in which other body areas were evaluated. The plain films and the CT scans were read by a radiologist in a blinded manner. RESULTS: Fifty-eight patients fulfilled the criteria for inclusion in the study. The mean Glasgow Coma Scale score was 8.9 and the mean Injury Severity Score was 24.1. Twenty patients (34.4%) had cervical spine injuries (12 stable and 8 unstable injuries). Plain radiography missed eight injuries (including three unstable) and its sensitivity was 60%, specificity 100%, positive predictive value 100%, and negative predictive value 85.1%. The helical CT scan missed two spinal injuries (both stable) and its sensitivity was 90%, specificity was 100%, positive predictive value = 100%, negative predictive value = 95%. CONCLUSION: There is a high incidence of cervical spine injuries in the severe, blunt, multiple-injury, unevaluable patients requiring intensive care unit admission. Plain radiography alone is not reliable in diagnosing many cervical spine injuries. Complete cervical spiral computed tomography is superior to plain radiography. It is suggested that in this selected group of patients, both plain radiography and spiral computed tomography should be performed.

Adolescent↗
PubMed1999

High-frequency percussive ventilation improves oxygenation in patients with ARDS.

STUDY OBJECTIVES: To evaluate changes in respiratory and hemodynamic function of patients with ARDS and requiring high-frequency percussive ventilation (HFPV) after failure of conventional ventilation (CV). DESIGN: Retrospective case series. SETTING: Surgical ICU (SICU) and medical ICU (MICU) of an academic county facility. MEASUREMENTS AND RESULTS: Thirty-two consecutive patients with ARDS (20 from SICU, 12 from MICU) who were unresponsive to at least 48 h of CV and were switched to HFPV were studied. Data on respiratory and hemodynamic parameters were collected during the 48 h preceding and the 48 h after institution of HFPV and compared. Between the period of CV and the period of HFPV, the ratio of PaO2 to the fraction of inspired oxygen (F(IO2)) increased ([mean+/-SE] 130+/-8 vs. 172+/-17; p = 0.027), peak inspiratory pressure (PIP) decreased (39.5+/-1.7 vs. 32.5+/-1.9 mm Hg; p = 0.002), and mean airway pressure(MAP) increased (19.2+/-1.2 vs. 27.5+/-1.4 mm Hg; p<0.001). The rate of change of PaO2/F(IO2) per hour was also significantly improved between the two periods. The same changes in PaO2/F(IO2), PIP, and MAP were observed when the last value recorded while the patients were on CV was compared with the first value recorded after 1 h of HFPV. This improvement was sustained but not amplified during the hours of HFPV. The patterns of improvement in these three parameters were similar in SICU and MICU patients as well as in volume-control and pressure-control patients. There were no changes in hemodynamic parameters. CONCLUSION: The HFPV improves oxygenation by increasing MAP and decreasing PIP. This improvement is achieved soon after institution of HFPV and is maintained without affecting hemodynamics.

Adult↗
PubMed1999

Abdominal computed tomography scan in pediatric blunt abdominal trauma.

The purpose of this study was to evaluate the role of abdominal CT scans in pediatric patients and correlate the findings with the clinical examination. A 2-year retrospective review of 88 patients with an abdominal CT scan after blunt trauma was performed. Seventy-two patients were identified with complete clinical examination data available. In its ability to predict the need for surgery, the CT scan had a sensitivity of 67 per cent and a negative predictive value of 98.7 per cent. The combination of the clinical examination and the CT scan findings did not miss any significant injuries. No patient with a soft, nontender abdomen and a negative CT scan required an abdominal operation. We conclude that the CT scan alone may miss clinically significant injuries. In blunt abdominal trauma in the pediatric population, the CT scan findings should be coupled with the clinical examination to ensure that no significant abdominal injuries are missed.

Abdominal Injuries↗
PubMed1999

Complex repair for the management of duodenal injuries.

The management of duodenal injuries is a subject of ongoing debate. In this study we attempt to describe duodenum-related morbidity (DRM) after primary repair or complex repair (CR) and to identify risk factors for development of complications. The medical records of 145 consecutive patients admitted to Los Angeles County + University of Southern California Medical Center with duodenal injuries between January 1991 and December 1997 were reviewed. Fifty-four (37%) died within 24 hours of admission because of associated injuries. The remaining 91 were subjected to univariate and multivariate analysis. Of them, 66 (72.5%) developed complications and 3 (3%) died. CR was used in 32 (35%) patients and with increasing frequency as the grade of duodenal injury increased. DRM rate was overall low (9%) and not different between low-grade and high-grade duodenal injuries. This occurred despite a significant increase in Injury Severity Score and abdominal Abbreviated Injury Score in patients with more severe duodenal injuries. Patients with overall complications had higher Injury Severity Scores, higher abdominal Abbreviated Injury Scores, and more severe duodenal injuries. We conclude that duodenal injuries are frequently associated with other highly lethal injuries. Liberal use of CR in patients with more severe duodenal injuries prevents DRM.

Abdominal Injuries↗
PubMed1999

Determinants of survival after inferior vena cava trauma.

Inferior vena cava (IVC) injuries continue to be associated with mortality rates of 21 to 66 per cent despite advances in prehospital, surgical, and critical care. The purpose of this study was to evaluate outcome of patients with IVC injury after treatment at a major urban trauma center and to identify factors predictive of survival. Between 1989 and 1995, 158 patients presented to the Los Angeles County + University of Southern California Medical Center with IVC injuries. One hundred thirty-six patient records were available for review, and 69 data points were collected and analyzed. Mean age was 26 years (range, 6-54), and 122 (90%) patients were male. Mechanism of injury included gunshot in 88 (65%) patients, stab in 23 (17%) patients, shotgun in 7 (5%) patients, and blunt trauma in 18 (13%) patients. The mean Injury Severity Score was 25. Seventy (52%) patients were hypotensive. Eleven (8%) patients died before surgical intervention, and 25 (18%) patients died before operative repair. Repair (79), ligation (20), or observation (1) was accomplished in 100 (74%) patients. Overall survival was 48 per cent and 65 per cent in the 100 patients surviving to operative repair, including 5 of 20 patients requiring IVC ligation. Significant differences (P<0.001) between survivors and nonsurvivors included Injury Severity Score, Glasgow Coma Score, hematocrit, hypotension, emergent thoracotomy, blood loss, level of injury, tamponade, and associated aortic injury. Logistic regression analysis identified hypotension, anatomic level of injury, and associated aortic injury as significant predictors of outcome (P = 0.001). Survival is predominantly determined by severity and anatomic accessibility of the IVC injury and by the absence of associated major vascular injuries. Ligation may control otherwise exsanguinating injuries and should be considered early in the management of complex injuries.

Adolescent↗
PubMed1999

The "seat belt mark" sign: a call for increased vigilance among physicians treating victims of motor vehicle accidents.

The use of seat belts is shown to cause a specific pattern of internal injuries. Skin bruise corresponding to the site of the seat belt is known as the "seat belt mark" (SBM) sign and is associated with a high incidence of significant organ injuries. No study has yet defined the exact incidence of injuries requiring intervention at the presence of this sign. The objective of this study was to find the incidence of surgically correctable injuries in belted car occupants with a SBM sign and to define strategies of early detection and treatment of such injuries. The prospective study included consecutive patients involved in road traffic accidents who were admitted at an academic Level I trauma center. Of 650 car occupants, 410 (63%) were restrained and 77 (12%) had a SBM across the abdomen, chest or neck. The injuries of these 77 patients were compared with the injuries of belted patients without an SBM sign. Of patients with SBMs, 9 per cent had neck bruises, 32 per cent had chest bruises, 40 per cent had abdominal bruises, and 19 per cent had bruises in multiple sites. No significant neck injuries were detected. Three patients were found to have myocardial contusion, and 10 patients had intra-abdominal injuries (predominantly bowel and mesenteric lacerations) requiring laparotomy. There was a near 4-fold increase in thoracic trauma (22.5% versus 6%; P=0.01) and a near 8-fold increase in intra-abdominal trauma (23% versus 3%; P < 0.0001) between the groups of patients with and without SBMs. The presence of the SBM sign should alert the physician to the high likelihood of specific internal injuries. Routine laparotomy or mandatory evaluation by specific diagnostic tests is not justified; rather, a high index of suspicion with a low threshold for appropriate diagnostic evaluation and/or surgical exploration should be maintained for the optimal management of such patients.

Abdominal Injuries↗
PubMed1998

Routine helical computed tomographic evaluation of the mediastinum in high-risk blunt trauma patients.

BACKGROUND: The indications and method of evaluation of the mediastinum in blunt deceleration trauma are controversial and vary among centers. Most centers practice a policy of angiographic evaluation only in the presence of an abnormal mediastinum on chest radiography. Routine aortography in the absence of any mediastinal abnormality is not widely practiced. Helical computed tomographic (CT) scan has been successfully used in recent studies in the evaluation of the thoracic aorta. OBJECTIVE: To determine the role of routine helical CT scan evaluation of the mediastinum in patients involved in high-speed deceleration injuries, irrespective of chest radiographic findings. DESIGN: A prospective study over a 1-year period. Included in the study were patients with high-speed deceleration injuries who required CT evaluation of the head or abdomen. This group of patients underwent routine helical CT evaluation of the mediastinum irrespective of chest radiographic findings. SETTING: Large, urban, academic level I trauma center. RESULTS: A total of 112 trauma patients fulfilled the criteria for study inclusion. Overall, there were 9 patients (8.0%) with aortic rupture. Four (44.4%) of these patients had a normal mediastinum on the initial chest x-ray film and the diagnosis was made by CT scan. The CT scan was diagnostic in 8 of the aortic ruptures (intimal tear or pseudoaneurysm) and was suggestive of aortic injury but not diagnostic in 1 patient with brachiocephalic artery injury. In 42 patients (37.5%), there was a widened mediastinum: an aortic rupture was diagnosed in 5 of them (11.9%) and a spinal fracture in 9 (21.4%). One patient had both aortic rupture and spinal injury. CONCLUSIONS: The incidence of aortic injury in patients with high-speed deceleration injury is high. A significant proportion of patients with aortic injury have a normal mediastinum on the initial chest radiograph. There is a high incidence of spinal injuries in the presence of a widened mediastinum. We recommend that all trauma patients with high-risk deceleration injuries undergo routine helical CT evaluation of the mediastinum irrespective of chest radiographic findings.

Accidental Falls↗
PubMed1998

Is there a limit to massive blood transfusion after severe trauma?

OBJECTIVE: To examine the hypothesis that the futility of short-term care for trauma patients requiring emergency operation can be determined based on the number of units of blood transfused and associated risk factors. DESIGN: A 4-year retrospective review of a cohort of critically injured patients who underwent an emergency operation. SETTING: A large-volume, academic level I, urban trauma center. PATIENTS: One hundred forty-one consecutive patients received massive blood transfusions of 20 U or more of blood during preoperative and intraoperative resuscitation (highest, 68 U). There were 43 survivors (30.5%) and 98 nonsurvivors (69.5%). MAIN OUTCOME MEASURES: Mortality. RESULTS: The number of blood units transfused did not differ between survivors and nonsurvivors (mean +/- SD, 31 +/- 11 vs 32 +/- 10; P = .52). Stepwise multiple regression analysis identified 3 independent variables associated with mortality: need for aortic clamping, intraoperative use of inotropes, and intraoperative time with a systolic blood pressure of 90 mm Hg or less. However, blood usage was not different among the subgroups of patients who had 1 or more of these risk factors. When patients were stratified according to the amount of massive blood transfusion (20-29, 30-39, 40-49, and 50-68 U), the incidence of risk factors was not different across the 4 subgroups. Survival in the presence of risk factors was not affected by the amount of blood transfused. CONCLUSIONS: Although mortality among critically injured patients requiring operation and massive blood transfusion can be correlated with independent risk factors, discontinuation of short-term care cannot be justified based on the need for massive blood transfusion of up to 68 units.

Adult↗
PubMed1998

Transpelvic gunshot wounds: routine laparotomy or selective management?

Mandatory exploration is the standard method for managing patients with gunshot wounds to the abdomen and back. This policy is associated with a high incidence of unnecessary laparotomies and significant morbidity. Reports from our center have shown that a policy of selective management, based on clinical findings, is safe in such patients. Patients with bullet trajectories that carry a high likelihood for intraabdominal organ injury may constitute a subgroup at particular risk. The need for routine or selective exploration in similar patients must be assessed. Therefore we decided to analyze patients with transpelvic gunshot wounds. The objective of the study was to examine if a policy of selective management of patients with transpelvic gunshot wounds is safe. This prospective study was conducted at an academic level I trauma center. We admitted 37 patients with transpelvic gunshot wounds over a 12-month period. All patients were managed according to a protocol that dictated laparotomy in the presence of significant clinical findings (peritoneal signs, hemodynamic instability, gross hematuria, rectal bleeding) and observation in the absence of the above. Additional diagnostic workup was performed only in appropriate cases rather than routinely. Nineteen (51.3%) patients were immediately operated on the basis of clinical findings. Sixteen of these laparotomies were therapeutic. Eighteen (48.6%) patients were initially observed. Subsequently, three of them underwent exploration for development of abdominal tenderness. All three laparotomies were nontherapeutic. The remaining 15 (40.5%) patients were successfully managed nonoperatively. There were no delays in diagnosis or missed injuries. Clinical examination had a sensitivity of 100% and specificity of 71.4% in detecting the need for laparotomy. A policy of selective management is thus safe, even for patients who suffer gunshot wounds with a high likelihood for intraabdominal organ injury. Clinical examination, supported by additional studies in appropriate cases, is the main method of selecting patients for operation or nonoperative treatment.

Abdominal Injuries↗
PubMed1998

Timing of fracture fixation in blunt trauma patients with severe head injuries.

BACKGROUND: Early fracture fixation in blunt trauma patients is suggested to decrease postoperative morbidity by allowing early mobilization and reducing the release of harmful inflammatory mediators. Some studies have challenged this concept in the presence of severe associated injuries, and especially head trauma. METHODS: The records of 47 consecutive blunt trauma patients with severe head injuries, as defined by a Glasgow Coma Score (GCS) < or =8 and a head Abbreviated Injury Score (AIS) > or =3, and long bone fractures requiring surgical fixation were reviewed. The study population was divided into the early fixation (EF) group, consisting of 22 patients who underwent fracture fixation within 24 hours of admission (mean time 17 +/- 8.5 hours); and the late fixation (LF) group, consisting of 25 patients, who had orthopedic repair at a later time (mean 143 +/- 178 hours). RESULTS: The two groups were similar in terms of overall injury severity, neurologic injuries, hemodynamic and neurologic status on admission, and operations received. Patients in the EF group had a higher injury severity of extremity fractures (extremity AIS: 2.9 +/- 0.2 versus 2.4 +/- 0.5, P = 0.0002) and a higher incidence of open fractures (72% versus 36%, P = 0.02). There was no difference in intraoperative and postoperative hypoxic and hypotensive episodes. Neurologic, orthopedic, and general complications were the same between the two groups. The mean GCS on discharge was 12 +/- 3 for both groups with equal distribution among patients. Although there was a trend toward longer hospital stay (25 +/- 17 versus 17 +/- 10 days, P = 0.057) among LF patients, mechanical ventilation days, length of stay, and mortality were not different. CONCLUSIONS: Timing of fracture fixation in this group of blunt trauma patients with severe head injuries did not influence morbidity, mortality, or neurologic outcome.

Adolescent↗
PubMed1998

Penetrating neck trauma.

Penetrating neck trauma can pose significant diagnostic and therapeutic challenges for emergency physicians. Factors contributing to these problems are complex anatomy, proximity of vital structures, and potential for rapid deterioration of airway, vascular, or neurologic injuries. Other contributing factors are the lack of consensus in the literature regarding appropriate evaluation and management of penetrating neck injuries, and insufficient resources or experienced personnel at some institutions. This review focuses on the key components of the history and physical examinations that allow for an assessment of the severity and type of structures involved. In addition, current methods of airway management, as well as ways to manage penetrating neck trauma efficiently and cost effectively, are discussed.

Airway Obstruction↗