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Biomedical subjects

E E Moore

Publications and source records attributed to E E Moore.

At least 343 records · Page 19Linked to original sources
PubMed1987

Venous bullet embolism: rationale for mandatory extraction.

Venous missile embolism is a rare complication of penetrating trauma which poses controversial management options. We report a case of hepatic vein bullet embolism treated by percutaneous transvenous basket relocation and extraction via femoral vein cutdown. A review of 102 reported bullet emboli since 1930 indicates that the morbidity of a retained projectile is substantial (25%), while removal using modern techniques has few complications. Salient features of early extraction include: 1) prevention of proximal migration, 2) transvenous relocation of the missile to an accessible vein, and 3) peripheral surgical removal. Delayed recognition of an asymptomatic bullet embolus demands further judgment in guiding selective operative removal. A management scheme based on time of recognition, patient status, and embolus characteristics is presented for this unusual problem.

Adult↗
PubMed1987

Presumptive antibiotics for penetrating abdominal wounds.

The optimal antibiotic agent or agents for penetrating abdominal injuries remains undetermined. During the two year period ending April 1985, 150 consecutive patients undergoing celiotomy for penetrating abdominal trauma were prospectively randomized to receive either mezlocillin (4 grams every six hours) or clindamycin (600 milligrams every six hours) and gentamicin (loading dose of 2.0 milligrams per kilogram, then 1.5 milligrams per kilogram every eight hours). Antibiotics were begun in the emergency department with duration of coverage based upon the injury pattern--colon, five days; other hollow visceral injury, two days, and all others, one day. Ten patients were excluded due to breach in protocol and other patients died within 48 hours of presentation. The two study groups, comprised of the remaining 130 patients, were comparable with respect to age, sex, injury mechanism, incidence of colonic injuries, intraoperative blood replacement and abdominal trauma index. Overall incidence of septic morbidity was similar among the groups; ten of the 61 patients receiving mezlocillin and nine of those receiving clindamycin and gentamicin had infection develop. There was no significant difference with respect to extensive abdominal infection (10 versus 3 per cent). The pattern of postoperative infection and offending pathogens were similar in the study groups. Enterobacteriaceae, enterococcus and Bacteroides species were most frequently isolated. Infection was due to an organism resistant to the initial study regimen in one of the ten failures with mezlocillin and in two of the nine failures with clindamycin and gentamicin. Mezlocillin, a single agent broad spectrum penicillin, achieved comparable results with more expensive potentially toxic combination therapy for penetrating wounds.

Abdominal Injuries↗
PubMed1986

Penetrating wounds to the anterior chest. Analysis of thoracotomy and laparotomy.

This study of the records of 193 consecutive patients admitted for penetrating anterior chest wounds was carried out to specifically define the need for emergent thoracotomy or laparotomy. The mechanism of injury was a stab wound in 119 patients and a gunshot wound in 74 patients. Seventy-three of the patients (38 percent) required either early thoracotomy (21 percent) or laparotomy (17 percent). In the upper chest region, 83 percent of the operations were thoracotomies, whereas in the lower chest region, 81 percent were laparotomies. Pericardial tamponade, chest tube output, and hypovolemic shock comprised 91 percent of the decisive signs for thoracotomy. The predominant reason for laparotomy was diagnostic peritoneal lavage (63 percent of patients). Plain abdominal roentgenograms were helpful to confirm diaphragmatic missile traverse. Our findings support selective operative management of anterior chest wounds as guided by injury mechanism and entrance location.

Adult↗
PubMed1986

Fibrin glue as a biologic vascular patch--a comparative study.

Fibrin glue is a biologic two component hemostatic adhesive. Fibrin glue acts as an effective vascular plus after arterial injury without suture at pressures twice systolic. It is also effective on vein at physiologic pressures, however, venous distensibility precludes its efficacy beyond these limits. Recent studies have documented its utility as a preclot material on vascular grafts and as a seal for sutured vascular anastomoses. This study was designed to characterize the glue's sealant ability when applied to open arterial and venous injuries, and to compare its efficacy with currently available hemostatic agents. Segments of canine peripheral artery and vein were isolated and perforated with a 16-gauge needle. This injury was treated by random application of either fibrin sealant (FS), oxidized cellulose (OC), microcrystalline collagen (MC), or MC plus thrombin (MCT). Five minutes after patch application, intralumenal pressure was increased progressively with saline infusion to ascertain bursting threshold. The arterial bursting threshold was significantly higher for FA (250 +/- 59.7 mm Hg) than for OC (12.5 +/- 6.1 mm Hg), MC (17.2 +/- 21.9 mm Hg) or MCT (10.8 +/- 13.8 mm Hg) (P less than 10(6)). The bursting threshold of FS applied to vein (17.5 +/- 11.7) was not significantly different from other agents (P less than 0.05).

Animals↗
PubMed1986

Role of the observation unit in the management of thoracic trauma.

Use of the observation unit in the management of 150 consecutive patients sustaining blunt or penetrating thoracic trauma, and initially presenting with stable vital signs, normal physical examination findings, and normal chest x-ray studies, was reviewed. All patients requiring admission declared themselves within six hours, with the exception of one asymptomatic patient whose repeat x-ray study was slightly delayed. Of the 150 patients, 129 (86%) were spared hospital admission, and no increased morbidity or mortality could be associated with our policy of selective hospital admission.

Adult↗
PubMed1986

Delayed presentation of traumatic diaphragmatic hernia.

More than 111 patients with traumatic diaphragmatic hernia (TDH) were treated in a 5 1/2-year period; eight (7.2%) were first recognized more than 30 days postinjury. All were men, and their average age was 33.4 years. Seven injuries were on the left side; one was on the right side. The mechanism of injury was equally divided between penetrating and blunt trauma. Chest roentgenographic abnormalities were seen in all patients. Visceral reduction and diaphragmatic repair, despite strangulation in four patients, was accomplished without mortality and with minimal morbidity. Delayed presentation of TDH is reviewed, emphasizing diagnostic features encountered in the emergency department (ED).

Acute Disease↗
PubMed1986

Peritoneovenous shunt in the management of the hepatorenal syndrome.

The hepatorenal syndrome (HRS) is a terminal complication of severe liver disease associated with a mortality of 80 to 90%. Although the renal functional abnormalities in the HRS suggest prerenal azotemia, volume expansion with saline, albumin or ascitic fluid rarely results in reversal of the HRS because fluid redistributes from the vascular space. Since the peritoneovenous (PV) shunt causes sustained central volume expansion, it has been advocated for the treatment of the HRS. We prospectively compared the PV shunt (N = 10) to Medical Therapy (MED) (N = 10) on renal function and mortality in 20 patients with the HRS associated with alcoholic liver disease. The HRS was diagnosed on the basis of clinical, hemodynamic, and laboratory criteria. The insertion of a PV shunt resulted in an increase in pulmonary capillary wedge pressure (4.2 +/- 1.1 vs. -1.5 +/- 1.0 mm Hg, P less than 0.01) and in cardiac index (0.8 +/- 0.3 vs. -0.2 +/- 0.3 1/min/m2, P less than 0.05). After 48 to 72 hours, weight (+3.1 +/- 1.1 kg) and serum creatinine (3.9 +/- 0.5 to 5.5 +/- 0.7 mg/dl, P less than 0.001) were increased with MED therapy and decreased (weight: -3.7 +/- 0.7 kg; serum creatinine: 3.6 +/- 0.4 to 3.0 +/- 0.5, P less than 0.05) with the PV shunt. Despite improvement in renal function, only one patient with the PV shunt had prolonged survival (210 days). In the remainder, survival was 13.8 +/- 2.2 days compared to 4.1 +/- 0.6 days with MED therapy. We conclude that the PV shunt often stabilizes renal function, but does not prolong life in patients with the HRS.

Adult↗
PubMed1986

Delayed staple penetration of the heart: transthoracic migration with late tamponade.

Most foreign bodies in the chest do their damage at the time of injury. While needle-like objects may migrate (6), delayed intrathoracic injury is rare. Delayed transthoracic penetration of the heart by a staple is reported, and is felt to be unique because acute hemopericardium resulted 30 days after the time of initial injury. The principles of recognition of pericardial tamponade, initial stabilization with periocardiocentesis, and immediate exploration are emphasized.

Adult↗
PubMed1986

Natural history of untreated inferior vena cava injury and assessment of venous access.

Conventional policy mandates exploration of retroperitoneal hematomas presumed to contain penetrating injuries of the inferior vena cava (IVC). In clinical practice this maneuver frequently results in torrential blood loss, suggesting the injury may be best managed without exploration and IVC suturing. The present study was undertaken to define the natural history of untreated IVC perforations, and to assess venous access with such injuries. Twelve adolescent Hampshire pigs (20-25 kg) underwent halothane anesthesia and laparotomy. The infrarenal IVC was isolated temporarily and a posterior cruciate incision, equivalent to 50% of the IVC circumference, made via anterior venotomy. Animals were resuscitated with Ringer's lactate. Technetium sulfur colloid was injected 20 min postlaparotomy closure via either a jugular or femoral venous cannula, and count activity measured over the IVC injury site using a mobile gamma camera. The procedure was repeated via the counterpart limb. Background from the first injection was subtracted, and count ratios integrated from 16 to 19 min postinjection. Extravasation following lower extremity infusion was not significantly different from that following central venous administration. One pig succumbed to cryptogenic peritonitis one wk postinjury. The remaining animals were killed at periods ranging from 3 to 12 wk. No animal had clinical evidence of delayed bleeding, pulmonary embolus, or other venous sequelae during the observation period. At autopsy all vena cavae were normal caliber without evidence or pseudoaneurysm of thrombosis. This swine study confirms the efficacy of lower extremity venous access with contained IVC injury, and suggests that isolated retroperitoneal IVC injuries may be treated nonoperatively in very selected patients.

Animals↗
PubMed1986

Successful management of cardiac impalement: the result of an integrated EMS-trauma system.

A case of cardiac impalement is presented and the general principles of torso impalement discussed. Leaving the impaling object in situ is desirable but when this requires substantial time, the patient's clinical status and the difficulties of resuscitation due to the object may necessitate prompt removal. Emergency department assessment and resuscitation should be brief and preoperative studies minimal.

Emergencies↗
PubMed1986

Pericardial tamponade: a critical determinant for survival following penetrating cardiac wounds.

Previous studies have emphasized injury mechanism, wound site, and presenting vital signs as critical determinants for survival following penetrating cardiac injury. Our experience suggests pericardial tamponade is another crucial factor and is the basis for this study. Prognostic features were reviewed in 100 consecutive, unselected patients with acute cardiac injuries. Mechanism was stab wound in 57, and gunshot injury in 43. Location included right ventricle in 55, left ventricle in 49, right atrium in 16, and left atrium in seven. Overall salvage was 31%,; 27 (47%) of 57 stab wounds, four (9%) of 43 gunshot wounds, 22 (49%) of 45 right, and nine (23%) of 39 left heart wounds. The presence or absence of pericardial tamponade was documented in 77 patients. Patients with tamponade had a survival of 73% (24/33) compared to 11% (5/44) in those without its protective effect. The presence of tamponade improved survival (p less than 0.05) following stab injuries (77% vs. 29%), gunshot wounds (57% vs. none), right heart wounds (79% vs. 28%), left heart injuries (71% vs. 12%), and overall in patients arriving with vital signs (96% vs. 50%). Multivariant discriminant analysis by logistic regression demonstrated cardiac tamponade was a critical independent factor in patient survival, and suggested that it may be more influential than presenting vital signs in determining outcome.

Adolescent↗
PubMed1986

Benefits of immediate jejunostomy feeding after major abdominal trauma--a prospective, randomized study.

Benefits of immediate postinjury nutritional support remain ill defined. Seventy-five consecutive patients undergoing emergent celiotomy with an abdominal trauma index (A.T.I.) greater than 15 were randomized prospectively to a control group (no supplemental nutrition during first 5 days) or enteral-fed group. The enteral patients had a needle catheter jejunostomy (N.C.J.) placed at laparotomy with the constant infusion of an elemental diet (Vivonex HN) begun at 18 hours and advanced to 3,000 ml/day (3,000 kcal, 20 gm N2) within 72 hours. Control and enteral-fed groups were comparable with respect to demographic features, trauma mechanism, shock, colon injury, splenectomy, A.T.I., and initial nutritional assessment. Twenty (63%) of the enteral patients were maintained on the elemental diet greater than 5 days; four (12%) needed total parenteral nutrition (T.P.N.). Nine (29%) of the control patients required T.P.N. Nitrogen balance was markedly improved (p less than 0.001) in the enteral-fed group. Although visceral protein markers and overall complication rate were not significantly different, septic morbidity was greater (p less than 0.025) in the control group (abdominal infection in seven and pneumonia in two) compared to the enteral-fed patients (abdominal abscess in three). Analysis of patients with A.T.I. 15-40 disclosed sepsis in seven (26%) of the control versus one (4%) of the enteral-fed group (p less than 0.01). Our clinical experience demonstrates the feasibility of immediate postoperative enteral feeding via N.C.J. after major abdominal trauma, and suggests this early nutrition reduces septic complications in critically injured patients.

Abdominal Injuries↗
PubMed1986

Traumatic bilateral renal artery occlusion: successful outcome without surgical intervention.

Traumatic bilateral renal artery thrombosis is rare, and attempts to reestablish life-sustaining renal function have had dismal results. This case describes a successful outcome of such an injury, the gradual return of adequate renal function without surgical intervention. This experience raises an argument against both strict limitation of the acceptable time interval between injury and revascularization, and early nephrectomy.

Adult↗
PubMed1986

Hemorrhage associated with major pelvic fracture: a multispecialty challenge.

Definitive treatment of life-threatening hemorrhage associated with blunt pelvic fracture remains controversial. To elucidate this issue, we reviewed 538 consecutive patients admitted with acute pelvic fracture during a 5-year period. Injury mechanism was motor vehicular in 214 (40%), falls in 152 (28%), auto-pedestrian in 92 (17%), motorcycle in 46 (9%), crush in 26 (5%), and assault or skiing in eight (1%). Ninety-two (17%) of these patients required greater than 6 units of blood transfusion during the first postinjury day, and are the primary focus of this report. Twenty-five patients (28%) had unilateral anterior (Group I, n = 20) or posterior (Group II, n = 5) fractures. The remaining 67 patients (72%) had anterior and posterior element involvement on the same side (Group II, n = 38), bilaterally (Group IV, n = 14), or open perineal wounds (Group V, n = 15). The PASG was applied in 47 patients (51%), and controlled hemorrhage in 12 (71%) of the 17 in whom it was used alone to tamponade pelvic bleeding. Peritoneal lavage was performed in 73 patients (79%). Initial aspirate yielded gross blood in 32 patients; 27 (84%) of these required urgent laparotomy. External skeletal fixation was applied in 19 patients; bleeding was controlled in 18 (95%). Pelvic angiography identified active hemorrhage in three patients and selective embolization was successful in two. Sixty-eight (74%) of the high-risk patients survived. Thirteen (54%) of the 24 deaths were attributable to the pelvic trauma, ten were due to recalcitrant bleeding, and three to delayed sepsis.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1986

Differentiation of F9 embryonal carcinoma cells. Differences in the effects of retinoic acid, 5-bromodeoxyuridine, and N'-N'-dimethylacetamide.

We found that monolayer cultures of F9 cells induced to differentiate with trans-retinoic acid (RA) contain two major subpopulations of cells. These two cell types can be distinguished by their cellular morphology, their pattern of laminin accumulation, and their ability to undergo further differentiation in response to N6-O2-dibutyryl adenosine 3':5' cyclic monophosphoric acid (dBcAMP). Furthermore, the developmental pathway induced by RA appears to lead to two alternative pathways, and differentiation at the branch point is either directly or indirectly controlled by cAMP. Differentiation along one branch of this pathway can be induced by 5-bromodeoxyuridine, whereas differentiation along an unrelated pathway is induced by N'-N'-dimethylacetamide. In all cases, differentiation is closely paralleled by suppression of the tumorigenic phenotype, indicating that these two processes are tightly linked and probably share a common step.

Acetamides↗
PubMed1985

Penetrating abdominal wounds. Rationale for exploratory laparotomy.

Over the past decade a general consensus has evolved about the indications for celiotomy after civilian penetrating wounds. Stab injuries to the anterior part of the abdomen clearly warrant a selective approach based on physical signs, local wound exploration, and diagnostic peritoneal lavage. Gunshot wounds violating the peritoneum, on the other hand, mandate abdominal exploration. Peritoneal lavage is also valuable for the selective management of lower thoracic penetrating wounds. Back and flank injuries are difficult to assess, and patient care must be individualized with the assistance of retroperitoneal contrast studies. Although the adjunctive role of peritoneal lavage in the evaluation of penetrating wounds has substantially reduced unnecessary celiotomy, the safest policy is to explore the abdomen if any question of visceral injury exists.

Abdominal Injuries↗