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Biomedical subjects

D J Muckart

Publications and source records attributed to D J Muckart.

At least 37 records · Page 2Linked to original sources
PubMed1996

Routine daily chest radiography is not indicated for ventilated patients in a surgical ICU.

OBJECTIVE: To determine a) if clinical examination can accurately predict radiological change and b) if routine chest radiography is efficacious. DESIGN: All mechanically ventilated patients admitted to the Surgical Intensive Care Unit over a 4-week period were enrolled into the study. A physical examination was undertaken by two clinicians to predict significant (radiographic features which alter management) and insignificant (radiographic features which do not alter management) changes. The radiographs were then reviewed by a radiologist who noted any changes from previous radiographs. The clinical findings were then correlated with the radiographical findings. SETTING: The study was conducted in a 16-bedded Surgical Intensive Care Unit which admits approximately 800 patients per year. The majority of these patients require mechanical ventilation. PATIENTS AND PARTICIPANTS: All patients who required mechanical ventilation were included. Thirty-four patients were studied. The patients were young adults admitted primarily following trauma with a low incidence of pre-existing disease. INTERVENTIONS: There were no interventions in this study. MEASUREMENTS AND RESULTS: One hundred sixty-four radiographs were evaluated. Both examiners were efficient in predicting significant changes (sensitivity of 93 and 97%), but less efficient at predicting insignificant changes (sensitivity of 74 and 70%). Two significant radiographical changes were missed on clinical examination: one catheter malposition and one pneumothorax, representing a yield from radiography of 1%. A 52% reduction in the number of radiographs would have resulted if the need for radiography had been determined by clinical examination. CONCLUSIONS: Clinical examination can effectively predict the need for radiography. Routine chest radiography is, therefore, not indicated for ventilated patients in our Surgical Intensive Care Unit.

Adult↗
PubMed1995

The changing pattern of penetrating torso trauma in KwaZulu/Natal--a clinical and pathological review.

The number of patients who sustained penetrating torso trauma and were admitted to King Edward VIII Hospital and the surgical intensive care unit were reviewed over 10- and 5-year periods respectively. For the last 4 months of 1992, a comparison was made between victims of trauma admitted to hospital and those whose bodies were taken directly to the South African Police medicolegal laboratories in Gale Street, Durban, where the majority of medicolegal autopsies in the Durban metropolitan area are performed. The total number of hospital admissions has not changed during the last decade, but the aetiology of injury has altered considerably. Stab wounds have declined by 30% whereas gunshot wounds have increased by more than 800%. The ratio of stab to gunshot wounds admitted to the intensive care unit reversed within the 5-year period 1987-1992. Direct admission to the mortuary was three times as common in cases of gunshot compared with stab wounds. The hospital mortality rate for gunshot wounds was 8 times that for stab wounds. The establishment of dedicated trauma centres is essential for the treatment of these injuries, and strategies to control the use of firearms are vital.

Abdominal Injuries↗
PubMed1994

Adverse events in a surgical intensive care unit--a cause of increased mortality.

The incidence and nature of and the outcome following adverse events were studied prospectively in a surgical intensive care unit over a period of 1 year. From a total of 657 patients, 229 (34.8%) suffered 369 adverse events. The number of adverse events per patient ranged from 1 (58.1%) to a maximum of 4 (6.1%). The overall mortality rate was 23.4%. Eighty-seven deaths (20.3%) occurred in patients not suffering an adverse event and 67 (29.3%) in those whose treatment was complicated by an adverse event (P < 0.02). There was no significant difference in mortality between patients with single or multiple events. Twenty-two patients died as a direct result of the event, the commonest reason being loss of airway control. Adverse events contribute significantly to mortality in critically ill patients.

Critical Care↗
PubMed1992

Prediction of acute renal failure following soft-tissue injury using the venous bicarbonate concentration.

Sixty-four patients with soft-tissue injuries were studied prospectively to determine whether an initial venous bicarbonate concentration (VBC) of less than 17 mmol/L would predict the development of myoglobin-induced acute renal failure. The VBC was > 17 mmol/L in 59 patients, seven of whom had myoglobinuria. All recovered without renal complications. The remaining five patients all had VBC < 17 mmol/L and four had myoglobinuria. Acute renal failure developed in four patients (p < 0.001). The VBC on hospital arrival was the most accurate predictor of these patients' risk for the development of acute renal failure following soft-tissue injury.

Acute Kidney Injury↗
PubMed1991

Trauma--the malignant epidemic.

Trauma is the commonest cause of death in children and young adults in the USA and the UK and the incidence of both accidental and non-accidental injury continues to increase. In the Western world more pre-retirement years of life are lost annually from trauma than malignant disease, heart disease, and AIDS combined, and by the beginning of the last decade injury deaths outnumbered deaths from all other causes combined in those under 35 years of age. In South Africa, although infectious diseases continue to exact their toll, a similar pattern is emerging. Alcohol and speed are responsible for the majority of motor vehicle accidents, while the increasing ownership of firearms directly parallels the homicide rates from these weapons. Stricter application of the legislation governing alcohol, driving and firearm control is required and a regionalised trauma care programme is desperately needed to contain this epidemic.

Age Factors↗
PubMed1991

Evaluation of diagnostic peritoneal lavage in suspected penetrating abdominal stab wounds using a dipstick technique.

The total protein content (g/l) and white blood cell count (cells/mm3) diagnostic peritoneal lavage was assessed using a urine dipstick in 46 patients with suspected penetrating abdominal stab wounds and equivocal physical examination. Those patients with a protein content greater than or equal to 1 g/l and white blood cell count of greater than 500 cells/mm3 were submitted to laparotomy while those with lower values underwent observation and repeat physical examination. In all, 26 patients had a positive lavage and significant injuries were found in 23 of these. Of 18 patients with a negative lavage, 17 were managed successfully without operation while one patient died from complications related to central venous catheterization. In two patients the lavage results were equivocal. One underwent a negative laparotomy and the remaining patient recovered uneventfully. The test has a 100 per cent sensitivity and 86 per cent specificity and provides an accurate, cheap, and rapid means of diagnosis of intra-abdominal injury in penetrating trauma.

Abdominal Injuries↗
PubMed1991

Unreliability of standard quantitative criteria in diagnostic peritoneal lavage performed for suspected penetrating abdominal stab wounds.

Thirty-five patients with abdominal stab wounds in whom clinical examination was equivocal on 2 separate occasions underwent diagnostic peritoneal lavage (DPL) prior to laparotomy. The red and white blood cell counts (cells/mm3) of the lavage effluent were compared with the operative findings. There were 26 positive and 9 unnecessary laparotomies, the latter consisting of 4 negative and 5 non-therapeutic operations. Use of the standard quantitative criteria for red cells in DPL failed to identify significant injury in eight patients (31%), while the standard white cell count missed six injuries (23%). Their combined use resulted in three missed injuries (12%). Two false-positive results occurred using the red cell count alone and four using the white cell count alone, producing a combined false-positive result in four patients (11%). Reducing the cell threshold level to exclude missed injuries would increase dramatically the rate of unnecessary laparotomies. Although the standard quantitative criteria for DPL are superior to clinical assessment in patients with equivocal findings, their use in penetrating trauma does not achieve the same diagnostic accuracy as in blunt abdominal trauma.

Abdominal Injuries↗
PubMed1991

Undetected injuries: a preventable cause of increased morbidity and mortality.

A prospective audit of trauma patients managed at the discretion of six different general surgical units was performed over a 6-month period. Eighteen patients were identified in whom diagnostic delay or injuries undetected at operation contributed to increased morbidity and mortality. Failure to perform investigations as indicated by the nature of the trauma was the main reason for delay in diagnosis in seven patients. Incomplete exploration at laparotomy resulted in seven undetected injuries, while unexplored retroperitoneal hematomas accounted for the remaining four. Fourteen patients (78%) required management in the intensive care unit. Eight patients died (44%) as a result of ongoing sepsis and multiple organ failure. Seven of the deaths occurred in patients in whom surgical treatment was inadequate. Delays in diagnosis and undetected injuries, although uncommon, are a readily preventable cause of phase 3 trauma deaths. Strict adherence to standard surgical protocols as employed in dedicated trauma care centers does much to reduce unnecessary morbidity and mortality.

Abdominal Injuries↗
PubMed1991

Pigment-induced nephropathy after sjambok injuries.

During a 12-month period, 42 patients required admission to hospital after sjambok beatings. Eighteen showed no abnormality of serum electrolyte values or renal function but urinary pigment precipitation was present in 9 patients. A further 16 patients demonstrated abnormalities of serum urea and electrolyte values, the commonest of which was a subnormal venous carbon dioxide content, in conjunction with urinary pigment precipitation in 14 cases. The remaining 8 patients presented with, or developed, varying degrees of renal failure. In 4 of these patients, the sole initial biochemical abnormality was a subnormal venous carbon dioxide level. Based on the initial laboratory findings, four groups of patients may be identified with gradations of soft-tissue injury. Recognition of those patients at risk of developing crush syndrome is facilitated and appropriate treatment may be instituted at an early stage thereby reducing morbidity and mortality.

Acute Kidney Injury↗
PubMed1990

Selective conservative management of abdominal gunshot wounds: a prospective study.

A prospective study of 111 patients with low velocity gunshot wounds of the abdomen was conducted to determine whether a policy of selective conservative management based on repeated physical examination is a safe form of treatment. Laparotomy was undertaken in 89 patients (80 per cent), seven of which were negative. Of the patients 22 (20 per cent), eight of whom were considered to have peritoneal penetration, underwent conservative management. None required delayed laparotomy. Eight patients (7 per cent) died, all deaths occurring in the positive laparotomy group. The incidence of significant intra-abdominal injury if the peritoneal cavity had been penetrated was 89 per cent. Selective conservative management may be applied safely to a limited group of patients with gunshot wounds of the abdomen.

Abdominal Injuries↗
PubMed1990

Penetrating visceral injuries of the neck: results of a conservative management policy.

A study of the conservative treatment of 109 patients with penetrating neck injuries was carried out over 3 years. Patients with clinical or radiological evidence of injury to the oesophagus or trachea were included in the study while nine patients with major vascular trauma were explored immediately and excluded. Three late vascular operations were performed. The remaining 106 patients were treated conservatively. There were two deaths, both from associated injuries. The remaining 104 patients were treated successfully with only three cases of minor wound sepsis. We conclude that oesophageal and tracheal injuries after stab injuries and low velocity gunshot wounds can be treated successfully by non-operative treatment.

Adolescent↗
PubMed1989

Protein electrophoresis of diagnostic peritoneal lavage in penetrating abdominal trauma: a marker of significant injury.

Protein electrophoresis of diagnostic peritoneal lavage fluid has been shown in experimental work to be a marker of hollow viscus injury. In order to ascertain the value of this investigation in penetrating abdominal trauma, we conducted a prospective study, over a 4-month period, involving 35 patients with stab wounds to the abdomen whose initial clinical examination was equivocal. The results of electrophoresis were compared with the standard quantitative criteria for diagnostic lavage and the operative findings. Protein electrophoresis was found to be a more sensitive and specific marker of significant intra-abdominal injury than the standard quantitative criteria.

Abdominal Injuries↗
PubMed1989

Pancreatic pseudocyst haemorrhage presenting as a bleeding duodenal ulcer.

We present a case of upper gastrointestinal haemorrhage where the preoperative endoscopic findings suggested a duodenal ulcer as the cause. Although at operation this proved to be the site of bleeding, the source was found to be the splenic artery in the base of a pancreatic pseudocyst.

Blood Transfusion↗
PubMed1989

Diaphragmatic disruption in blunt trauma.

A patient group, which has sustained blunt abdominal injury in a predominantly non-driver-related manner, was reviewed. The incidence of diaphragmatic rupture was half that expected from other reported series. It is concluded that the mechanism for diaphragm rupture is related to forces produced in front-seat passengers during motor vehicle accidents.

Adolescent↗