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Biomedical subjects

E F Hirsch

Publications and source records attributed to E F Hirsch.

At least 19 recordsLinked to original sources
PubMed2001

Emergency room thoracotomy for penetrating chest injury: effect of an institutional protocol.

BACKGROUND: Emergency room thoracotomy (ERT) can be life saving in patients with penetrating chest injury. A protocol was established at our institution stating that ERT be performed for cases of cardiac tamponade secondary to penetrating chest trauma on patients with vital signs/mentation in the field or on arrival to the emergency room. To validate our protocol, we reevaluated patients undergoing ERT at our institution. METHODS: In our retrospective review, there were 49 patients undergoing ERT over a 6-year period. RESULTS: Survival in patients with vital signs was approximately 50%. Survival in those without was 0%. Compared with the preprotocol data, the number of ERTs declined from 32.2 cases per year to 8.1 cases per year. Overall survival increased from 4% to 20%. Neurologic outcome remained unchanged. CONCLUSION: We believe that the data validate our protocol, and the establishment of a guideline has enabled us to maximize patient survival and minimize exposure risks to our staff.

Boston↗
PubMed1996

Leiomyoma of the breast.

Leiomyoma is the most uncommon benign neoplasm of the breast. We report a case of a middle-aged woman with a palpable breast mass who underwent excisional biopsy. Pathologic examination revealed a leiomyoma. The clinical characteristics, pathologic findings, and proper management of this lesion are discussed. The tumor is thought to arise from the smooth muscle of the endothelium and can be managed similarly to leiomyomas occurring elsewhere. The possible effects of tamoxifen on uterine leiomyomas may be of theoretical concern with breast leiomyomas. The recognition of this entity and an understanding of the management of this rare lesion are necessary by all surgeons who perform breast surgery.

Breast Neoplasms↗
PubMed1996

Trauma system development in Armenia.

UNLABELLED: A medical partnership program between Boston University School of Medicine and the the Emergency Hospital, of Yerevan, Armenia, has been developed to improve the care of the injured in that city. The Emergency Hospital, a trauma center, was site-visited by experts from a Level I trauma center who evaluated prehospital and hospital-based emergency and trauma services and made system-wide recommendations. Recognizing local limitations, the hospital was found to have the leadership commitment, staff complement, and basic infrastructure to meet the American College of Surgeons' criteria for Level II trauma centers. The goal of integration of the academic, clinical, and research roles of a medical center consistent with Level I-type trauma centers was formulated. After 36 months, several issues raised in the assessment are being addressed notwithstanding political and economic turbulence. The Emergency Hospital has established an accredited residency program in emergency medicine; implemented programs for postgraduate medical education of its staff; begun to develop medical information systems; expanded the scope of its activities to other institutions; and restructured the emergency admissions area. Management systems remain largely undeveloped as the discipline lacks recognition as an analytic tool for institutional improvement. CONCLUSIONS: The use of existing published resources for assessment and improvement of health services in dissimilar health-care systems has been validated as a systematic approach. For system advances to be well-founded, a combination of education, management, and clinical approaches needs to be addressed. Of these, our experience is that management issues are the most resistant to change.

Armenia↗
PubMed1996

Penetrating thoracic trauma in a pediatric population.

INTRODUCTION: Penetrating thoracic trauma in the pediatric population is increasing at an alarming rate. We sought to describe this population and to define prognostic factors that might be of benefit in the management of these patients. METHODS: We retrospectively reviewed the charts and trauma registry records of 65 patients 18 years of age and younger admitted to an urban level I trauma center with the diagnosis of penetrating thoracic trauma. RESULTS: The majority of the patients were adolescent boys. Injury severity score greater than 25 and a corrected admission pH less than 7.3 were associated with higher mortality and increased need for surgical intervention. Isolated thoracic injury was found to be associated with a high mortality rate. Autotransfused blood was used in 9 of the 65 patients. CONCLUSIONS: Injury severity score and corrected admission pH are independent predictors of mortality and need for operation in the pediatric population with penetrating chest injuries. Penetrating thoracic wounds demand special attention by the trauma team. The use of autotransfusion may be beneficial in pediatric trauma victims.

Adolescent↗
PubMed1995

Predictive accuracy of the TRISS survival statistic is improved by a modification that includes admission pH.

OBJECTIVE: To determine if pH measured at the time of hospital admission and corrected for PCO2 was an independent predictor of trauma survival. DESIGN: Phase 1 was a retrospective case-control analysis of 1708 patients, followed by multivariate multiple logistic regression analysis of a subset of 919 patients for whom the Revised Trauma Score (RTS), Injury Severity Score (ISS), and pH were available. Phase 2 was a prospective comparison of a mathematical model of survival derived in phase 1 (pH-TRISS) with the TRISS method in 508 of 1325 subsequently admitted trauma patients. SETTING: Urban level 1 trauma center. PATIENTS: All patients admitted with blunt or penetrating trauma during the study period. MAIN OUTCOME MEASURES: Survival vs mortality. RESULTS: In phase 1, factors significantly associated with mortality by t test and chi 2 analysis included the RTS, ISS< Glasgow Coma Scale, corrected pH (CpH), and sum of the head, chest, and abdominal components of the Abbreviated Injury Scale-85 (AIS85) (HCAISS) (for all, P < .0001). The TRISS statistic was also a significant predictor of survival (P < .004). Age, sex, and the extremity and soft tissue components of the AIS85 were not associated with mortality. In a multivariate analysis of the RTS, HCAISS, and CpH, all were significant predictors of mortality. Even when controlling for RTS and HCAISS, CpH remained a significant predictor of mortality (P < .008). In phase 2, when pH-TRISS was tested prospectively against TRISS in a new group of patients, the new statistic appeared to provide a more accurate prediction of survival. CONCLUSIONS: The arterial pH measurement obtained on hospital arrival and corrected for PCO2 is a significant independent predictor of survival and adds to the predictive accuracy of the TRISS survival statistic. Age, sex, and the extremity and soft tissue components of the AIS85 did not contribute to the accuracy of the TRISS statistic in this patient population.

Abbreviated Injury Scale↗
PubMed1995

Changes in intracranial pressure associated with apneumic retractors.

OBJECTIVE: To investigate the effect of apneumic retraction on intracranial pressure (ICP) using a live porcine model. DESIGN: Five 25- to 30-kg pigs had a fiber-optic ICP bolt inserted under general endotracheal anesthesia and were monitored for ICP, mean arterial pressure, arterial blood gas measurements, and intra-abdominal pressure before, during, and after pneumoperitoneum, with each period 30 minutes long. These series of measurements were repeated after artificially raising ICP with an epidural balloon to create a head-injured model. The mean (+/- SE) ICP in the noninjured model at baseline was 13.46 +/- 1.01 mm Hg; during pneumoperitoneum, 18.72 +/- 1.50 mm Hg (P = .0001). Similarly, in the head-injured model, ICP was raised artificially to a new baseline of 22 +/- 1.75 mm Hg with an epidural balloon, and pneumoperitoneum increased ICP to 27.40 +/- 0.93 mm Hg (P = .0001). Pneumoperitoneum was then released, and an apneumic retractor was inserted while maintaining the inflated epidural balloon. MAIN OUTCOME MEASURE: Changes in ICP. RESULTS: Applying anterior wall retraction equivalent to 20 mm Hg was not associated with changes in ICP. These observations were independent of any changes in arterial PCO2 or arterial pH. Following the release of pneumoperitoneum, abdominal wall retraction, and epidural balloon, all measurements reverted to baseline. CONCLUSION: Pneumoperitoneum adversely affects ICP, while apneumic retraction may not affect animals with raised ICP. These findings suggest that pneumoperitoneum should be used with caution in patients with raised ICP, and apneumic retraction may be a safer alternative for laparoscopic evaluation in this population.

Abdominal Muscles↗
PubMed1995

Comparison of skeletal muscle laser Doppler flowmetry to changes in central hemodynamics in detecting the physiological response to moderate hemorrhage.

Previous studies have demonstrated that laser Doppler (LD) flowmetry is a useful technique for following changes in blood flow in a tissue bed, but the potential role of LD flowmetry in management of the critically ill patient is unclear. This study sought to establish the sensitivity of LD flowmetry compared to changes in centrally measured hemodynamic parameters in response to a mild hemorrhagic episode. In order to establish the correlation between LD flow and actual blood flow, livers from Sprague-Dawley rats were isolated and perfused via the portal vein with citrate anti-coagulated rat blood. Changes in LD flow were recorded while changing blood flow via the perfusion pump. There was a strong correlation between pump flow and LD flow (for N = 5 livers, r > 0.9; P < 0.05). This relationship was stable at hematocrits > 20. The second part of this study tested the sensitivity of LD flowmetry in anesthesized baboons. An LD probe was placed on the surface of the gracilis muscle of the adult male baboons. LD flow and hemodynamic parameters were measured following two episodes of bleeding and reinfusing 250 cc of blood. During the first bleed there were significant changes in heart rate (97 + 8 to 159 + 12), mean arterial pressure (125 + 6 to 105 + 9), and LD flow (20.6 + 4.6 to 11.9 + 3.6); these parameters returned to normal after reinfusion of blood. During the second bleed, the only parameters that showed significant changes were heart rate (118 + 5 to 135 + 12) and LD flow (17.5 + 8 to 10.7 + 3.4).(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗
PubMed1994

Diagnostic laparoscopy increases intracranial pressure.

There are numerous reports in the literature concerning the use of laparoscopy for evaluation of abdominal trauma victims. The safety of laparoscopic evaluation in trauma patients with potentially severe intracranial injuries has not yet been analyzed. This study investigates the effect of pneumoperitoneum on intracranial pressure (ICP) and cerebral perfusion pressure. Five 30-kg pigs were monitored for ICP, mean arterial pressure (MAP), arterial blood gases (ABGs), and intra-abdominal pressure (IAP) for 30 minutes before, during, and after pneumoperitoneum. These series of measurements were repeated after artificially elevating the ICP with an epidural balloon. The mean ICP at baseline was 13.46 +/- 1.01 mm Hg. The mean ICP during pneumoperitoneum was 18.72 +/- 1.50 mm Hg (p = 0.0001). The ICP increased to 27.40 +/- 0.93 mm Hg (p = 0.0001) after the ICP was raised artificially to a new baseline of 22 +/- 1.75 mm Hg with the epidural balloon. These increases were independent of changes in arterial PCO2 or arterial pH. Pneumoperitoneum during laparoscopy may increase ICP and must be used cautiously in evaluating patients with severe head injuries.

Animals↗
PubMed1993

Temporary thoracotomy wound closure following penetrating thoracic aorta injury.

On rare occasions, thoracic injuries require resuscitative efforts including emergent thoracotomy that result in edematous changes to the lungs and heart. Hemodynamic compromise occurs when these organs are placed in their anatomic position and closure of the thoracotomy is attempted. Adaptation of a temporary abdominal closure to a thoracic injury is described.

Aorta, Thoracic↗
PubMed1992

Nutritional outcome and pneumonia in critical care patients randomized to gastric versus jejunal tube feedings. The Critical Care Research Team.

OBJECTIVE: To compare nutritional status, gastric colonization, and rates of nosocomial pneumonia in ICU patients randomized to gastric tube feeding vs. patients fed by an endoscopically placed jejunal tube. DESIGN: Randomized, prospective study. SETTING: Medical and surgical ICUs at Boston City Hospital; surgical ICU at University Hospital. PATIENTS: Of the 38 study patients, 19 were randomized to gastric tube feeding and 19 were randomized to an endoscopically placed jejunal tube. The two groups were similar in age, sex, race, underlying disease, and type of surgery. RESULTS: The two patient groups were similar in number of days fed, duration of ICU stay, duration of mechanical ventilation, days of antibiotic therapy, and days with fever. Compared with the gastric group, the jejunal group had more patients with circulatory shock on admission (79% vs. 68.4%), higher admission Acute Physiology Score (24.0 vs. 21.7), and fewer patients with pneumonia at randomization (26.3% vs. 31.6%). The jejunal group received a significantly higher percentage of their daily goal caloric intake (p = .05), and had greater increases in serum prealbumin concentrations (p < .05) than the patients with gastric tube feeding. Although the jejunal tube group had more days of diarrhea (3.3 +/- 6.6 vs. 1.8 +/- 2.9), this difference was not statistically significant. Nosocomial pneumonia was diagnosed clinically in two (10.5%) patients in the gastric tube group and in no patients in the jejunal tube group. CONCLUSIONS: Patients fed by jejunal tube received a significantly higher proportion of their daily goal caloric intake, had a significantly greater increase in serum prealbumin concentrations, and had a lower rate of pneumonia than patients fed by continuous gastric tube feeding.

Adult↗
PubMed1992

Pathologic consequences of bilateral pulmonary lower lobectomies: case report.

Most injuries to the lung can be managed nonoperatively and rarely require resection. A case of bilateral hilar injuries requiring bilateral pulmonary lower lobectomies is presented. The resulting pulmonary hypertension, right ventricular failure, and cardiogenic shock explain the high mortality following extensive pulmonary resection in thoracic trauma and support the concept of a conservative approach.

Adult↗
PubMed1991

Liver viability after ischemia-reperfusion.

Lack of a reproducible model to quantitatively assess hepatocellular injury following ischemia has made it difficult to assess new strategies for minimizing hepatic injury. We studied the progression of hepatocellular injury after ischemia and ischemia with reperfusion in rats. Irreversible injury was quantitated using a triphenyltetrazolium chloride assay that was shown to correlate with ultrastructural changes. Adenosine triphosphate decreased to 36% of basal values after 30 minutes, but returned to normal with reperfusion with no decrease in viability. In contrast, viability fell by 30% after 60 minutes of ischemia, and by 64% when 60 minutes of ischemia was followed by reperfusion. We conclude that reperfusion of ischemic liver increases the degree of irreversible damage. The model employed here seems to be useful for studying ischemic and reperfusion injury in the liver.

Adenine Nucleotides↗
PubMed1991

Carinal injury: diagnosis and treatment--case report.

Injury to the thoracic trachea is a potentially lethal condition in a patient with multiple injuries. Several clinical signs are commonly associated with this process: subcutaneous emphysema, aphonia, stridor, pneumothorax refractory to thoracostomy tube drainage, pneumomediastinum, and hemoptysis. The clinical appearance of tracheobronchial rupture may be delayed for hours or even weeks following injury. Standard treatment for disruption of the thoracic trachea is primary repair via a right thoracotomy. We describe a patient with a complex carinal injury following blunt thoracoabdominal trauma who was successfully managed with prompt surgical intervention.

Accidents, Traffic↗
PubMed1989

Glucan enhances survival in an intraabdominal infection model.

The immunomodulator glucan exists in two forms, particulate (glucan-P) and soluble (glucan-F). Both preparations of glucan, either alone or in combination with antibiotic therapy, were evaluated for their ability to augment survival in rats following cecal ligation and puncture (CL/P). Adult male rats were infused once daily for 5 consecutive days with either glucan-P (10 mg/kg), glucan-F (10 mg/kg), or 5% (w/v) dextrose in water. Three days later all rats underwent CL/P. Postoperatively, the rats received (a) no therapy, (b) saline (1 ml subcutaneously every 12 hr) or (c) ampicillin (33 mg/kg subcutaneously every 12 hr) for 7 days. Without any associated pre-or postoperative treatment, CL/P was associated with an 85% 7-day mortality. Neither glucan preparation alone significantly altered this mortality. Administering ampicillin postoperatively decreased the mortality to 53% (P less than 0.001 vs untreated controls). When postoperative ampicillin therapy was combined with preoperative glucan treatment, the mortality was reduced even further (26% for glucan-P, 21% for glucan-F; P less than 0.02 vs ampicillin-treated controls). We conclude from these results that (i) neither glucan preparation alone effectively enhances survival following CL/P when using the doses and administration schedule employed herein, (ii) both glucan-P and glucan-F do act synergistically with antibiotics to enhance survival in this rat model of polymicrobial sepsis, and (iii) in this particular model, nontoxic glucan-F is as efficacious as glucan-P.

Abdomen↗
PubMed1988

Intraabdominal sepsis after hepatic trauma.

In a review of 58 patients who survived liver trauma seen at Boston City Hospital, 10 patients had 13 intraabdominal abscesses and 1 died from overwhelming sepsis. Multivariate analysis of risk factors revealed that the number of units of perioperative, postoperative, and total blood transfused were each highly significant (p less than 0.0001). Mode of injury, hepatic resection, gastrointestinal tract perforation, and the number of associated injuries were not significant risk factors when transfusion requirements were accounted for. Fever and leukocytosis were unreliable predictors of abscess formation. The available literature suggests a strong relationship between intraperitoneal bleeding and septic complications.

Abdomen↗