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Biomedical subjects

F A Moore

Publications and source records attributed to F A Moore.

At least 163 records · Page 9Linked to original sources
PubMed1990

The abdominal trauma index--a critical reassessment and validation.

The Abdominal Trauma Index (ATI) was devised to quantify the risk of complications following abdominal trauma. With scores greater than 25, the risk of postoperative complications became exponential. The purpose of the present study was to determine if: 1) the organ risk factors previously assigned were more statistically valid; and 2) the addition of physiologic variables would enhance the prediction of postinjury intra-abdominal sepsis. Fifteen abdominal organ systems and 17 physiologic variables in 300 consecutive patients were analyzed to determine ability to predict intraabdominal sepsis. There were no significant differences in predictive ability between the old and new organ risk factors. The addition of physiologic factors did not enhance the prediction of intra-abdominal sepsis. This clinical study demonstrates that: 1) the risk of intra-abdominal sepsis increases with increasing ATI score; 2) the previous (1979-initial) organ risk grading concept is statistically valid; 3) six of the 15 organ systems warrant a change in their relative rank order (1989-revision); 4) the addition of demographic, physiologic, and immunologic variables did not significantly improve the prediction of intra-abdominal sepsis.

Abbreviated Injury Scale↗
PubMed1990

Conservative management of duodenal trauma: a multicenter perspective.

The experience of eight trauma centers with duodenal injuries was analyzed to identify trends in operative management, sources of duodenal-related morbidity, and causes of mortality. During the 5-year period ending December 1988, 164 duodenal injuries were identified. Patient ages ranged from 5 to 78 years. There were 38 Class I, 70 Class II, 48 Class III, four Class IV, and four Class V injuries. Injury mechanism was penetrating in 102 (62%) patients and blunt in 62. Primary repair of the duodenal injury was performed in 117 (71%) patients, including 27 patients also managed with pyloric exclusion and 12 with tube duodenostomy. Duodenal resection with primary anastomosis was used in six (4%) patients and pancreatoduodenectomy was necessary in five (3%). There were 30 (18%) deaths. The cause of death was uncontrolled hemorrhage from severe hepatic or vascular injuries in 22 (73%) patients. In only two (1%) patients could death be attributed to the duodenal injury; each as the result of duodenal repair dehiscence and subsequent sepsis. Duodenal-related morbidity was documented in 29 (18%) patients, including 22 patients with intra-abdominal abscess, six with duodenal fistula, and five with frank duodenal dehiscence. In summary, this analysis demonstrated: 1) the great majority of duodenal injuries can be managed by simple repair; 2) tube duodenostomy is not a mandatory component of operative treatment; 3) pyloric exclusion is a useful adjunct for more complex injuries; 4) pancreatoduodenectomy is rarely necessary for civilian duodenal trauma; 5) morbidity following duodenal trauma is more dependent on associated intra-abdominal injuries than the extent of duodenal trauma; and 6) mortality following duodenal injuries is primarily related to associated vascular and hepatic trauma.

Abdominal Injuries↗
PubMed1990

Intra-aortic balloon pump for combined myocardial contusion and thoracic aortic rupture.

The coexistence of myocardial contusion and thoracic aortic injury is probably more common than recognized following rapid deceleration multisystem trauma. This report describes the successful application of intra-aortic balloon counterpulsation in a critically injured patient requiring emergent repair of a thoracic aortic tear complicated by ventricular failure due to cardiac contusion.

Aorta, Thoracic↗
PubMed1990

Inadequate granulopoiesis after major torso trauma: a hematopoietic regulatory paradox.

Late postinjury sepsis is largely the result of defective host defense including failure to maintain an adequate number of functioning phagocytic cells. In this study we used stem cell culture techniques to measure colony-stimulating activity and have quantitated the number of circulating myeloid stem cells to see if defects in granulopoiesis occur after major torso trauma. Forty-two acutely injured patients (13 blunt and 29 penetrating injuries; mean age, 29.7 years) undergoing laparotomy with an abdominal trauma index of 15 to 40 were studied prospectively. Blood samples were obtained on days 1, 5, and 10. Patients were segregated by injury severity: abdominal trauma index less than 25 (n = 25) versus abdominal trauma index greater than or equal to 25 (n = 17). The more severely injured (abdominal trauma index greater than or equal to 25) patients had fewer circulating granulocytes and monocytes. Colony-stimulating activity was below normal control levels in all patients and was decreased further with increased injury severity. The more severely injured patients had a blunted bone marrow response (significantly fewer circulating myeloid stem cells) and suffered more major septic complications (24% vs 8%). In conclusion, major trauma to the torso causes a paradoxic depression in granulopoiesis that worsens with increased injury severity and may contribute to late septic morbidity. This colony-stimulating activity deficiency state is similar to that seen after major burns and may be amenable to future modulation.

Abdominal Injuries↗
PubMed1989

Conservative management of combined pancreatoduodenal injuries.

We have reviewed our recent 12-year experience in treating 62 patients with combined injuries to the pancreas and duodenum; 60 percent were the consequence of penetrating wounds and 40 percent due to blunt trauma. For analysis, grades I through V were assigned to reflect severity of injury. Grade I (16 percent) and II injuries (23 percent) were treated with simple repair and drainage. Grades III (19 percent) and IV (32 percent) were managed primarily by pyloric exclusion, whereas grade V injuries (10 percent) underwent pancreatoduodenectomy. Pancreatic and duodenal complications developed in 35 percent and 2 percent, respectively. The overall mortality was 19 percent; 83 percent died within the first 24 hours from exsanguination or severe head injury. Although no single procedure uniformly applies to the combined pancreatoduodenal trauma, active sump drainage of the pancreas, pyloric exclusion of the duodenum, and early nutritional support through needle catheter jejunostomy are the mainstay treatment principles.

Adult↗
PubMed1989

A plea for sensible management of myocardial contusion.

The purpose of this study was to define the relative risk of life-threatening sequelae in patients at risk for myocardial contusion. During a 3-year period, 280 patients sustaining blunt chest trauma were admitted to the surgical intensive care unit to exclude myocardial contusion. Patients were evaluated by electrocardiogram and creatine phosphokinase (CPK) MB enzyme levels every 8 hours for a minimum of 48 hours. Myocardial contusion was identified in 35 patients (13 percent); the diagnosis was established by transient electrocardiographic changes (30), CPK-MB more than 3 percent (9) or both criteria (4). Two patients (1 percent) died from cardiac decompensation 4 and 12 hours postinjury, and seven (3 percent) required early (12 hours postinjury) intensive care unit treatment of arrhythmias or myocardial failure. None of the remaining 271 patients developed cardiac symptoms. This clinical experience underscores the low incidence of cardiac sequelae among patients at risk for myocardial contusion. Complications were always manifest within 12 hours of injury. The clinical diagnosis of myocardial contusion can be excluded pragmatically in the asymptomatic patient with a normal electrocardiogram and CPK-MB levels during the initial 24-hour postinjury period.

Adolescent↗
PubMed1989

Insertion of a retrohepatic vena cava balloon shunt through the saphenofemoral junction.

Vascular control of the injured retrohepatic vena cava is invariably a surgical challenge. Herein, we describe the technical aspects of inserting a vena cava balloon shunt through the saphenofemoral junction. The advantages of this approach include relative simplicity, maintenance of perihepatic tamponade, and avoiding emergent thoracotomy in the critically injured patient.

Balloon Occlusion↗
PubMed1989

Gastrointestinal symptoms attributed to jejunostomy feeding after major abdominal trauma--a critical analysis.

Meeting the increased metabolic demands in the critically injured is a continuing challenge. Benefits of early enteral feeding after abdominal trauma have been previously reported, but the frequency of patient intolerance due to GI complaints remains unclear. One hundred twenty-three patients undergoing emergent laparotomy for major abdominal trauma with an abdominal trauma index greater than or equal to 15 were prospectively randomized to either a control group (n = 52, no enteral nutrition during the first 5 days) or an enteral-fed group (n = 71). The enteral group had a needle catheter jejunostomy (NCJ) placed at laparotomy and an elemental diet begun 12 h postoperatively, advanced in volume and concentration at 8-h intervals to 100-125 ml/h of full-strength diet. Symptoms of GI complaints (nausea, vomiting, cramping, distention, and diarrhea) were monitored daily and graded as minimal, moderate, or significant. Fifty percent of the control group had one or more GI complaints during the study period; six (12%) developed moderate discomfort. In the enteral group, 59 (83%) patients reported some GI discomfort; 11 had significant complaints (two nausea, seven cramping, six distention, two diarrhea). Nine (13%) of the enteral-fed patients ultimately required total parenteral nutrition supplementation due to GI complaints. The remaining 62 (87%) enteral patients were maintained on the elemental diet for a mean of 7 days (range 5 to 20). By postoperative day 5, patients received an average of 35 kcal/kg and 14.5 g N/day; 66% (41/62) were in positive N balance.(ABSTRACT TRUNCATED AT 250 WORDS)

Abdominal Injuries↗
PubMed1989

TEN versus TPN following major abdominal trauma--reduced septic morbidity.

Recent animal models suggest that enteral feeding (TEN) compared to parenteral nutrition (TPN) improves resistance to infection. This prospective clinical trial examined the impact of early TEN vs. TPN in the critically injured. Seventy-five patients with an abdominal trauma index (ATI) greater than 15 and less than 40 were randomized at initial laparotomy to receive either TEN (Vivonex TEN) or TPN (Freamine HBC 6.9% and Trophamine 6%); both regimens contained 2.5% fat, 33% branched chain amino acids, and had a calorie to nitrogen ratio of 150:1. TEN was delivered via a needle catheter jejunostomy. Nutritional support was initiated within 12 hours postoperatively in both groups, and infused at a rate sufficient to render the patients in positive nitrogen balance. The study groups (TEN = 29 vs TPN = 30) were comparable in age, injury severity and initial metabolic stress. Jejunal feeding was tolerated unconditionally in 25 (86%) of the TEN group. Nitrogen balance remained equivalent throughout the study period, at day 5 TEN = -0.3 +/- 1.0 vs. TPN 0.1 +/- 0.8 gm/day. Traditional nutritional protein markers (albumin, transferrin, and retinol binding protein) were restored better in the TEN group. Infections developed in 5 (17%) of the TEN patients compared to 11 (37%) of the TPN group. The incidence of major septic morbidity was 3% (1 = abdominal abscess) in the TEN group contrasted to 20% (2 = abdominal abscess, 6 = pneumonia) with TPN. This clinical study demonstrates that TEN is well tolerated in the severely injured, and that early feeding via the gut reduces septic complications in the stressed patient.

Abdominal Injuries↗
PubMed1989

Nonoperative management of blunt splenic trauma: a multicenter experience.

The experience of six referral trauma centers with 832 blunt splenic injuries was reviewed to determine the indications, methods, and outcome of nonoperative management. During this 5-year period, 112 splenic injuries were intentionally managed by observation. There were 40 (36%) patients less than 16 years old and 72 adults. The diagnosis was established by computed tomography in 89 (79%) patients, nuclear scan in 23 (21%), ultrasound in four (4%), and arteriography in two (2%). There were 28 Class I, 51 Class II, 31 Class III, two Class IV, and no Class V splenic injuries. Nonoperative management was unsuccessful in one (2%) child and 12 (17%) adults (p less than 0.05). Failure was due to ongoing hemorrhage in 12 patients and delayed recognition of pancreatic injury in one patient. Of the 12 patients ultimately requiring laparotomy for control of hemorrhage, seven (58%) were successfully treated with splenic salvage techniques. Overall mortality was 3%; none of the four deaths was due to splenic or associated abdominal injury. This contemporary multicenter experience suggests that patients with Class I, II, or III splenic injuries after blunt trauma are candidates for nonoperative management if there is: 1) no hemodynamic instability after initial fluid resuscitation; 2) no serious associated abdominal organ injury; and 3) no extra-abdominal condition which precludes assessment of the abdomen. Strict adherence to these principles yielded initial nonoperative success in 98% of children and 83% of adults. Application of standard splenic salvage techniques to treat the patients with persistent hemorrhage resulted in ultimate splenic preservation in 100% of children and 93% of adults.

Adolescent↗
PubMed1989

Emergency Department thoracotomy in children--a critical analysis.

Recent clinical reviews have helped to clarify the role of Emergency Department (E.D.) thoracotomy in critically injured adults. However, guidelines in the pediatric population remain ill defined. The purpose of this report is to examine the yield of E.D. thoracotomy in patients less than or equal to 18 years of age to allow for a more cost-effective application of this heroic measure. From an 11-year experience of 689 consecutive E.D. thoracotomies, 83 patients (12%) were less than or equal to 18 years old. Mechanism of injury was blunt trauma in 57%, gunshot wound in 30%, and stab wound in 13%. Mean age was 15 years and 71% were male. Survival by injury mechanism was 9% (1/11) for stab wound, 4% (1/25) for gunshot wound, and 2% (1/47) for blunt trauma. Sixty-nine patients presented to the E.D. without vital signs and only one, a 16-year-old with stab wounds to the chest and abdomen, survived. In contrast, two (14%) among 14 patients presenting with vital signs were salvaged. As in adults, outcome was largely determined by injury mechanism and physiologic status on E.D. presentation. Blunt trauma, the predominant mechanism of lethal injuries in children, had a dismal outcome, with only 2% salvage and no survivors when vital signs were absent. This study demonstrates a similar outcome for E.D. thoracotomy in children compared to adults, and supports a selective policy of liberal use in penetrating injury irrespective of physiologic status but limited in those arriving lifeless following blunt trauma.

Adolescent↗
PubMed1989

Post-traumatic pulmonary pseudocyst in the adult: pathophysiology, recognition, and selective management.

Pulmonary contusion is the usual manifestation of lung parenchymal injury following blunt chest trauma. With rapid deceleration, however, parenchymal lacerations can result in cavities best termed post-traumatic pulmonary pseudocyst (PPP). This report discusses eight adult PPP cases encountered at the Denver General Hospital over the past 30 months. Five were males and the mean age was 29 years (range, 18 to 54). Injury mechanism was motor vehicle accident in four, industrial machinery in two, autopedestrian accident in one, and large-animal rodeo rollover in another. Review of daily portable anteroposterior chest roentgenograms revealed parenchymal infiltrates consistent with pulmonary contusion that typically cavitated within the first week. Computed tomography of the chest was pursued in complicated patients and clearly influenced therapy. Three (38%) pseudocysts developed into lung abscesses; two required resection and the other responded to percutaneous drainage. Although previously described as a benign pediatric entity, in our adult experience, PPP may result in a recalcitrant lung abscess requiring aggressive intervention.

Adolescent↗
PubMed1989

Operative splenic salvage in adults: a decade perspective.

The immunologic value of the spleen is now unchallenged; recognition of this fact has changed the management of splenic trauma radically over the past decade. This review describes our clinical experience in adults during this metamorphosis. In the 10-year period ending December 1987, 314 adults had splenic injury identified at emergent laparotomy. Mean patient age was 30.1 years and 81% were men. Injury mechanism was blunt in 227 (72%), stab wound in 49, and gunshot wound in 38. In 1978 splenorrhaphy was accomplished in nine (29%) of 31 patients; during 1982-1987 the rate of operative splenic salvage has been 63% (107/170). Splenorrhaphy was achieved with hemostatic agents in 40%, debridement and suturing in 40%, formal splenic resection in 13%, and mesh bag in 7%. Grade I splenic injuries were amendable to hemostatic agents alone, and suturing or mesh enclosure was necessary in 43% of Grade II and in all Grade III injuries. Grade IV disruption required anatomic splenic resection for hemorrhage control in 88% of the cases. During this period 63 patients underwent splenectomy; 48 (76%) had Grade V injuries that were technically unapproachable. The remaining splenectomies were performed expeditiously in multisystem injured patients harboring other critical injuries. This decade perspective documents the feasibility of operative splenic salvage in nearly two thirds of acutely injured adults. Conversely, more than one third require prompt splenectomy due to massive splenic disruption or the presence of concomitant life-threatening injuries.

Adolescent↗
PubMed1989

Intraoperative cardiac sampling following penetrating wounds: a technique for early detection of traumatic intracardiac shunts--case report.

Intracardiac shunts complicating penetrating heart wounds may be unrecognized during the early postoperative period due to the insensitivity of noninvasive diagnostic tests. This case demonstrates the value of intraoperative cardiac sampling for oxygen saturation to identify an otherwise occult aorta-right ventricular fistula secondary to a precordial stab wound, ultimately progressing to a 1.9:1 shunt requiring operative repair.

Adult↗
PubMed1989

Presumptive antibiotics for penetrating abdominal wounds.

The optimal antimicrobial agent or agents for penetrating abdominal injuries remains undetermined. During the three year period ending August 1987, 317 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 kilograms every eight hours. Antibiotics were begun in the emergency department with duration of coverage based on the pattern of injury: the colon, five days; other hollow visceral injury, two days, and all others, one day. Twenty-three patients were excluded because of breach of protocol and 16 others died within 72 hours of presentation. The two study groups, 136 patients receiving mezlocillin and 142 patients receiving gentamicin and clindamycin, were comparable with respect to age, sex, mechanism of injury, shock, intraoperative replacement of blood, abdominal trauma index and distribution of hollow visceral injuries. The over-all incidence of septic morbidity was similar: infections developed in 21 (15 per cent) of the patients receiving mezlocillin compared with 19 (13 per cent) of patients receiving gentamicin and clindamycin. There was no significant difference in major infections (lobar pneumonia and intra-abdominal abscess), with 13 per cent in each group. The offending pathogens were similar. The most common isolates in intra-abdominal abscess were Escherichia coli, Klebsiella and Enterococcus species and anaerobic Bacteroides species. Mezlocillin, an extended spectrum penicillin, achieved similar results, compared with the expensive and potentially toxic combination regimen in patients with penetrating abdominal injuries.

Abdominal Injuries↗