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Biomedical subjects

E E Moore

Publications and source records attributed to E E Moore.

At least 325 records · Page 18Linked to original sources
PubMed1988

Value of distal colon washout in civilian rectal trauma--reducing gut bacterial translocation.

Recent experience with civilian rectal trauma challenges the military dictum advocating routine distal colon washout. Opponents contend that septic morbidity is not influenced by perioperative removal of feces from the rectosigmoid region. In an effort to elucidate this issue, we reviewed 27 consecutive patients sustaining extraperitoneal rectal trauma over the past 5 years. One patient, exsanguinating from abdominal vascular injury, was excluded from further analysis. In the remaining 26 patients, rectal injury was due to gunshot wound in 16 (62%), pelvic fracture in 8 (31%), and stab wound in 2 (7%). The mean Revised Trauma Score was 6.9 +/- 0.4, Abdominal Trauma Index 20.9 +/- 8.1, and Injury Severity Score 28.6 +/- 11.0. Proximal colostomy was done in all patients and presacral drains were placed in 23 (88%). Broad-spectrum antibiotics were administered for a minimum of 5 days. Thirteen (50%) of the group underwent intraoperative washout of the distal rectosigmoid colon, dictated by attending surgeon's preference; the other half did not. These two groups were otherwise comparable with respect to injury mechanism, shock on arrival, rectal wound severity, associated injuries, and perioperative blood transfusions. Major complications were greater in the no-washout versus washout groups: pelvic abscess, 46% vs. 8%; rectal fistulae, 23% vs. 8%; and sepsis, 15% vs. 8%. The single death (4%) occurred in the no-washout group. Although based on a small group of patients, these trends imply that distal colon washout reduces septic morbidity following civilian rectal trauma.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1988

Prehospital venous access in an urban paramedic system--a prospective on-scene analysis.

Prehospital intravenous access has been central to the debate of paramedic intervention during management of trauma in the field. Some have suggested that excessive time requirements for IV access are detrimental to patient salvage. This prospective study objectively quantified the time required to place a peripheral IV line in our urban paramedic system. A third-party observer, nonparamedic, timed the procedure on scene with a stopwatch. Total intravenous time, including obtaining a 30-cc blood sample, was defined as the period from removal of the catheter cover until the catheter was taped. The study group included 125 patients (51 trauma and 74 nontrauma). The average total time to obtain IV access and sample blood was 2.20 +/- 0.20 and 2.71 +/- 0.18 minutes in trauma and nontrauma patients, respectively. In a subset of 63 patients in whom blood sampling time was determined separately, subtracting that from total IV time provided a net of 0.58 +/- 0.09 minutes to obtain access. Fourteen patients had a second IV line started (without blood sampling), requiring 1.25 +/- 0.38 and 0.70 +/- 0.24 minutes, respectively, for trauma and nontrauma patients. Paramedics were successful on their first IV attempt in 90% of trauma and 84% of nontrauma patients; ultimate success was 100%. This on scene study documents the time required for prehospital IV access, performed by a well-trained paramedic in an E.M.S. system with strong medical control, is less than 90 seconds.

Colorado↗
PubMed1988

The role of a regional trauma system in the management of a mass disaster: an analysis of the Keystone, Colorado, chairlift accident.

On December 14, 1985, the Teller chairlift at the Keystone, Colorado, ski area collapsed, throwing 60 of the 372 people aboard to the ground from heights up to 50 feet. Initial triage and management of the victims was carried out by the local ski patrol, the on-duty physician at the area's Snake River Health Services Clinic, and by volunteer physicians and nurses present at the scene. Thirty-three people required immediate evacuation to hospitals, most of them being transported 75 miles by helicopter air ambulance to level I and II trauma centers in the Denver metropolitan area. Eighteen of these air-evacuated patients were in serious or critical condition. Less seriously injured victims were treated at local medical facilities. The scene evacuation was carried out by helicopter and ground vehicles in accordance with an existing disaster plan coordinated by the Colorado Trauma Institute (CTI). The unique problems posed by a mass casualty incident in a remote mountain location are emphasized by this tragedy. Patient salvage due to the efficacy of a regionally organized trauma system is clearly demonstrated.

Adolescent↗
PubMed1988

Total enteral nutrition versus total parenteral nutrition after major torso injury: attenuation of hepatic protein reprioritization.

Reprioritization of hepatic protein synthesis, a process involving accelerated production of acute-phase proteins at the expense of constitutive proteins, accompanies major trauma. The impact of isocaloric, isonitrogenous total enteral nutrition (TEN) versus total parenteral nutrition (TPN) on hepatic reprioritization was investigated in a prospective, randomized trial. Of the 59 patients with an abdominal trauma index (ATI) greater than 15 but not more than 40, 45 evaluable patients were followed. Results from 36 (18 TEN, 18 TPN) evaluable patients revealed that mean serum levels of acute-phase proteins increased, whereas mean serum levels increased to a greater extent in the TPN group. The maximal increase from baseline for the acute-phase response in both groups occurred at postinjury day 5 and was significantly higher for alpha 1-antitrypsin (alpha 1AT, p = 0.03) and orosomucoid (p = 0.02) in the TPN group. Nonacute-phase proteins reached a nadir at day 10 in the TPN group and increased in the TEN group; significant differences between TEN and TPN groups appeared for albumin (p = 0.004) and retinol-binding protein (RBP, p = 0.03); alpha 2-macroglobulin (alpha 2M) approached significance at day 10 (p = 0.07). When change from baseline values was compared, day 10 increases in alpha 2M were significantly higher (p = 0.04) in the TEN group. These data suggest that postinjury TEN attenuates reprioritization of hepatic protein synthesis in patients sustaining major trauma.

Abdominal Injuries↗
PubMed1988

Emergency department tracheostomy.

Emergency Department tracheostomy is performed in the rare instances of extensive laryngeal trauma in the adult and emergent airway access in the infant. This article reviews indications, anatomy, technique, and complications of this challenging life-saving procedure.

Adult↗
PubMed1988

Graded experimental myocardial contusion: impact on cardiac rhythm, coronary artery flow, ventricular function, and myocardial oxygen consumption.

Current management of myocardial contusion is based on experience with ischemic heart disease, but the mechanism responsible for cardiac dysfunction may be quite different. The purpose of this study was to characterize the pathophysiology of myocardial contusion in a controlled animal model. Sprague-Dawley rat hearts were prepared on a standard Langendorff apparatus, and myocardial function (DP, + dP/dT, - dP/dT) measured via a left ventricular balloon. Bipolar atrial and ventricular leads were placed to define conduction changes. Coronary sinus effluent was sampled for pO2, pH, creatine phosphokinase (CPK), and lactic dehydrogenase (LDH). The hearts were freeze-clamped to measure phosphocreatine (PC) and adenosine triphosphate (ATP). Myocardial contusion was produced by a single blow with a weighted pendulum. Hearts were divided into control (n = 5), moderate impact--Group I (n = 5), and major impact--Group II (n = 5). Group I sustained a 25% decrease in function after an impact of 78 +/- 5 mJoules/gm, and Group II a 50% deficit after 87 +/- 7 mJoules/gm. Impact resulted in complete electrical arrest, followed by sequential ventricular, atrial, and AV nodal recovery; recovery time correlated directly with degree of injury. Coronary flow at 2 min postinjury was decreased (p less than 0.05) in Group I (12.8 +/- 0.8 ml/min) and Group II (11.5 +/- 1.3) compared to control (17.2 +/- 0.5), and returned to baseline levels at 20 min. LDH and CPK levels were twice as high in Group II as in Group I. The PC/ATP ratio in Group II increased from 1.63 at baseline to 2.54 (p less than 0.05) at 25 min, confirming ischemic reperfusion.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗
PubMed1988

Severe hepatic trauma: a multi-center experience with 1,335 liver injuries.

The experience of six regional trauma centers with severe hepatic trauma was reviewed to identify trends in management, mortality, and postoperative complications. During the 5-year period ending June 1987, 210 complex liver injuries were identified at laparotomy. There were 92 Class III, 59 Class IV, and 59 Class V injuries. Mechanism of injury was blunt in 101 (48%) patients and penetrating in 109 (52%). Shock was observed in 38%, 46%, and 85% of Class III, IV, and V patients, respectively. Emergency department thoracotomy was performed in 31 patients. There was only one (3%) survivor. Resuscitative operating room thoracotomy was performed in 34 patients with three (9%) survivors. Class III injuries were most frequently treated with hepatotomy and individual vessel ligation (41%) and deep liver suturing (25%). Class IV injuries were most often managed by resectional debridement (36%). Class V injuries required caval shunt placement in 38 (64%) patients. There were only four (10%) survivors after caval shunt placement. There were 20 (59%) survivors of 34 patients treated with packing placed as an adjunct after hepatic injury repair. There was no significant increase in the incidence of abscess formation after perihepatic packing. Routine peritoneal drainage was used in 94% of patients. Overall mortality rates for Class III, IV, and V injuries were 25%, 46%, and 80%, respectively (p less than 0.01). Death rates due to the liver injury in Class III, IV, and V patients were 7%, 30%, and 66%, respectively (p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1988

Trauma angiography: the use of clinical findings to improve patient selection and case preparation.

Two-hundred eighty angiographic studies performed for suspected acute arterial trauma were reviewed to evaluate the relationship between the clinical findings and arterial injury. Extremity injury occurred in 237 cases. The proximity of a penetrating injury or a fracture to a major vascular structure was the sole indication for angiographic study in 136. No major arterial injury was discovered in either group. Exclusion of these patients would have improved the extremity angiographic yield from 25% to 58% while missing no patients with major arterial injury. We conclude, based on the negligible yield, that clinical observation of these patients is a safe alternative if adequate followup is assured; elective angiography may be performed if followup is questionable. Nineteen of 20 (95%) patients with an absent distal pulse and clinical signs of extremity ischemia had a major arterial injury. All extremity arterial injuries occurred within 5 cm of bullet fragments, bone fragments, entrance wound, or exit wound. Given the virtual assurance of finding major arterial injury, patients with unifocal injury and a threatened limb may proceed directly to the operating room to minimize ischemic time.

Adolescent↗
PubMed1987

Traumatic popliteal and trifurcation vascular injuries: determinants of functional limb salvage.

Forty-seven patients with 64 popliteal or trifurcation arterial injuries were analyzed to elucidate the influence of associated limb trauma on ultimate functional recovery. Nerve, bone, and soft tissue injuries appeared to be critical risk factors. Two or more risk factors were present in 60 percent of 30 blunt injuries, compared with 17 percent of 18 penetrating injuries. All limbs with less than two of these risk factors recovered to a functional state, whereas none of the limbs with all three risk factors had a good outcome, and 7 of 13 limbs (54 percent) were amputated. Vascular reconstruction was successful in 90 percent of the 48 limbs, and patency was 100 percent among the 27 limbs with less than two risk factors. Patients with all three risk factors should be considered for early amputation. We believe reports of peripheral vascular trauma must delineate associated limb injuries to facilitate analysis of patients stratified by relative risk.

Adolescent↗
PubMed1987

Fetomodulin: marker surface protein of fetal development which is modulatable by cyclic AMP.

A novel cell surface marker of fetal development was identified in both in vivo and in vitro systems of the mouse using monoclonal antibodies against a glycoprotein of an apparent size of 133,000 Da. Two independent clones of hybridomas were isolated by fusing murine myeloma cells, NS-1, with spleen cells of a rat which was immunized with murine 3T3 fibroblast. The analysis of molecular size and tryptic peptides of the immunoprecipitate indicated that fibroblast and putative parietal endoderm cells, which were derived by induced differentiation of F9 embryonal carcinoma cells with retinoic acid and cyclic AMP, expressed apparently the same protein. Undifferentiated F9 cells and F9 cells which were treated with retinoic acid or cyclic AMP alone had little or no immunoprecipitable proteins. Analogously, parietal endoderm of in vivo embryos tested positive for this protein but visceral endoderm and embryonic ectoderm did not. The amount of this surface protein was increased in fibroblast and differentiated F9 cells by elevation of intracellular cyclic AMP concentrations. These results are consonant with a hypothesis that this surface protein plays a role in fetal development via a quantitative modulation by cyclic AMP.

Animals↗
PubMed1987

Prehospital advanced trauma life support for critical blunt trauma victims.

The ability of paramedics to deliver advanced trauma life support (ATLS) in an expedient fashion for victims of trauma has been strongly challenged. In this study, the records of 114 consecutive victims of blunt trauma who underwent laparotomy or thoracotomy were reviewed. Prehospital care was rendered by paramedics operating under strict protocols. The mean response time (minutes +/- SEM) to the scene was 5.6 +/- 0.27. On-scene time was 13.9 +/- 0.62. The time to return to the hospital was 8.0 +/- 0.4. On-scene time included assessing hazards at the scene, patient extrication, spine immobilization (n = 98), application of oxygen (n = 94), measurement of vital signs (n = 114), splinting of 59 limbs, and the following ATLS procedures: endotracheal intubation (n = 31), IV access (n = 106), ECG monitoring (n = 69), procurement of blood for tests including type and cross (n = 58), and application of a pneumatic antishock garment (PASG) (n = 31). On-scene times were analyzed according to the number of ATLS procedures performed: insertion of one IV line (n = 46), 14.8 +/- 1.03 minutes; two IV lines (n = 28), 13.4 +/- 0.92; one IV line plus intubation (n = 7), 14.0 +/- 2.94; two IV lines plus intubation (n = 9), 17.0 +/- 2.38; and two IV lines plus intubation plus PASG (n = 13), 12.4 +/- 1.36. Of the 161 IV attempts, 94% were completed successfully. Of 36 attempts at endotracheal intubation, 89% were successful.(ABSTRACT TRUNCATED AT 250 WORDS)

Emergency Medical Services↗
PubMed1987

Selective management of blunt abdominal trauma in children--the triage role of peritoneal lavage.

The evolution of selective laparotomy in children sustaining blunt abdominal trauma has been highly controversial. This report describes our experience and policy change during this transitional period. Emergency laparotomies performed in the pediatric age group (less than 14 yr) between 1980 and 1984, based on peritoneal lavage, were reviewed. Of 16 such patients, six (37.5%) had injuries identified at laparotomy necessitating operation, (four greater than Grade III spleen, one hepatic vein, one small bowel). The remaining ten patients (67.5%) had injuries which probably could have been managed nonoperatively (eight less than or equal to Grade II spleen, two less than or equal to Grade II liver). We additionally reviewed 46 peritoneal lavages done in children during 1984, and noted a 100% sensitivity but 86% specificity when considering essential laparotomies. Based on these data, we established a selective management protocol and initiated a prospective study in January 1985. The protocol consisted of: 1) routine peritoneal lavage (DPL) in children at high risk for abdominal injury, 2) immediate laparotomy for DPL positive for blood in conjunction with hemodynamic instability, 3) selective laparotomy for DPL positive for blood in a stable child, additionally evaluated by abdominal CT scan (major mechanism) or liver/spleen scan (minor mechanism), and 4) mandatory laparotomy for DPL effluent positive by criteria other than blood. This policy reduced unnecessary laparotomy, otherwise warranted by DPL, to 18% (2/11); both patients had Grade II splenic injuries. Five children sustaining low-energy trauma were managed nonoperatively following peritoneal aspiration of gross blood with L-S scan confirming minor solid visceral injury.(ABSTRACT TRUNCATED AT 250 WORDS)

Abdominal Injuries↗
PubMed1987

Intraoperative hypogastric artery embolization for life-threatening pelvic hemorrhage: a preliminary report.

Percutaneous pelvic embolization has become a useful adjunct in the management of life-threatening hemorrhage from pelvic trauma. However, this approach may be preempted by the need for emergency laparotomy. The surgeon is then confronted with a hemodynamically unstable patient with an expanding hematoma in the face of other life-threatening injuries. Bilateral hypogastric artery ligation has failed in this scenario due to extensive collateralization of the pelvic circulation. We present our experience with intraoperative hypogastric artery embolization used in the management of four patients, and review the available literature on the subject.

Embolization, Therapeutic↗
PubMed1987

Emergency trauma angiography: accuracy, safety, and pitfalls.

The accuracy, safety, pitfalls, and limitations of trauma angiography were determined by comparing the findings of 280 arteriograms performed for suspected arterial trauma with the patients' surgical findings and clinical courses. Trauma angiography was accurate, with a sensitivity for detecting major arterial injury of 98.3%, specificity of 98.5%, positive predictive value of 95.0%, and negative predictive value of 99.5%. Angiography was effective in eliminating the need for surgical arterial exploration in 203 cases (73%). These emergency procedures were associated with a 5% morbidity; all complications were minor. Sixteen percent of the studies were technically compromised. Common factors included poor vessel opacification with aortic contrast injection, over-penetrated films, mistimed lower extremity studies, and overlapped structures obscuring the vessels. In most cases, the field of study can be limited to a region 5 cm beyond the most distant fracture fragment, bullet fragment, and entrance or exit wound. Emergency trauma angiography is an ideal technique for evaluating injured patients with suspected arterial trauma. It is safe to perform and accurately separates patients who may be spared surgical exploration from those who require vascular intervention.

Adolescent↗
PubMed1987

Angiography in patients with arterial trauma: correlation between angiographic abnormalities, operative findings, and clinical outcome.

The arteriograms and clinical course of 280 consecutive patients with suspected arterial trauma were reviewed to correlate the angiographic abnormalities with operative findings and to assess the impact of these findings on surgical management and prognosis. Major angiographic abnormalities were found in 77 patients. Arterial occlusion (46 patients) was caused by intimal flap injury or arterial transection with subsequent thrombosis and frequently presented with an acutely ischemic extremity (27 patients, three of whom required subsequent amputations). Intraluminal defects typical for intimal flaps (20 patients) were the most difficult pathologic entity to diagnose, accounting for two false-positive angiograms and the sole false-negative examination. Focal luminal widening (five patients) corresponded with a partial-thickness injury of the arterial wall. Major angiographic extravasation of contrast material (19 patients) was caused by arterial laceration or transection and usually presented with clinical signs of acute hemorrhage; massive pelvic hemorrhage was the cause of death in three patients. Acute arteriovenous fistulas (four patients) were from arterial laceration with venous communication. Arterial narrowing with a smooth margin (50 patients) was a finding associated with a benign clinical course, except when combined with slowed arterial flow--a characteristic finding of compartment syndrome (six of 13 patients). An irregular beaded pattern of arterial narrowing (23 patients) was associated with severe injuries, subsequent poor fracture healing, and wound infection. A detailed angiographic map is of considerable value in planning surgical management. The absence of major angiographic abnormalities usually eliminates the need for surgical exploration; the location of injury and routes of distal blood flow affect the feasibility of conservative therapy; the length of occlusion influences the necessity of saphenous vein harvesting; the location of arterial extravasation determines the advisability of surgical ligation or transcatheter embolization; and the need for fasciotomy may be suggested first by the angiographic features of compartment syndrome.

Angiography↗
PubMed1987

Trauma in pregnancy.

Care of the pregnant trauma patient requires knowledge of the mechanism of injury, understanding the physiological changes of pregnancy, assessing fetal maturity and stability, and close teamwork among emergency, trauma, obstetric and pediatric services.

Cesarean Section↗