Let's rock and roll.
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Accidents, Traffic↗
Biomedical subjects
F W Clevenger
Publications and source records attributed to F W Clevenger.
Falls and ejections from pickup trucks.
The medical records of 50 patients who sustained injuries during falls or ejections from pickup truck beds and were admitted to the University of New Mexico Level I Trauma Center between January 1985 and December 1989 were retrospectively examined. Falls and ejections commonly involve young adults, and usually occur in the summer months during the afternoon or evening. Twenty-three individuals were thrown from the pickup truck bed during a motor vehicle collision and 27 simply fell out, and this distinction was not related to age or ethanol use. Although those thrown from the pickup truck bed during a crash were less severely injured (average ISS 15.4) than those who simply fell from the bed (average ISS 17.4), this difference was not statistically significant. Mortality was equal in these two groups, with three deaths occurring in each group. Overall, injuries incurred during falls and ejections were more serious than those incurred in MVCs (average ISS 16.5 vs. 14.5, p = 0.06). The head was the most frequently injured body region following falls or ejections (68%), followed by the extremities (46%), the face (28%), the thorax (22%), and the abdomen (10%). Every death in this series was attributed to a head injury. The overall mortality for the series was 12%. Sixteen additional fatalities from falls and ejections during the study period were discovered in a review of the records of the State Medical Examiner. The average age of this cohort was 24 years. Fifteen of these deaths were the result of falls rather than ejections (94%), and 13 were attributed to head injuries (81%).(ABSTRACT TRUNCATED AT 250 WORDS)
Accidental Falls↗
Reoperation for intra-abdominal abscess.
Reoperative procedures for patients with abscess and other septic complications remain among the most difficult management problems in general surgery. The diagnosis of intra-abdominal septic complications has been greatly enhanced within the last 10 years but remains imperfect and requires clinical judgment that transcends objective methods. Surgical drainage remains the mainstay of care for patients with postoperative intraabdominal abscess.
Abdomen↗
Tear of the cervical esophagus following hyperextension from manual traction: case report.
Cervical esophageal disruption is a known complication of hyperextension injuries of the cervical spine. A patient was seen at our institution after nonprofessional manipulation of the cervical spine. There was no apparent cervical spine injury. Following diagnosis, the neck was explored and the esophageal tear repaired and drained. The patient recovered uneventfully.
Adult↗
Barotrauma associated with high-frequency jet ventilation for hypoxic salvage.
Most reports describe reduction in proximal airway pressures with high-frequency jet ventilation. This led us to speculate that high-frequency jet ventilation might reduce barotrauma by providing alveolar ventilation at lower airway pressures. We describe a group of patients in whom a high incidence of barotrauma was observed after institution of high-frequency jet ventilation despite reduction in measured airway pressures. Fifteen hypoxic patients who could not be treated with conventional ventilation and who had no roentgenographic evidence of barotrauma were entered into the study. Airway pressures were measured during conventional ventilation and at 2 and 24 hours after high-frequency jet ventilation. Despite significant reduction in peak inspiratory and mean airway pressures, pneumothorax developed in seven of the 15 patients, an average of 21 hours after initiation of high-frequency jet ventilation. Five patients had bilateral pneumothorax and three developed tension pneumothorax. Despite reductions in proximal airway pressures, barotrauma is a significant potential complication of high-frequency jet ventilation in patients with noncompliant lungs. We currently place bilateral prophylactic thoracostomy tubes in patients with adult respiratory distress syndrome prior to initiation of high-frequency jet ventilation.
Adult↗
Relief of tracheal compression by aortopexy.
We have performed aortopexy in 12 children with tracheal compression. Six infants had compression secondary to a vascular anomaly (group 1), and the other 6 had previous repair of esophageal atresia (group 2). Eleven of the 12 children are alive after a mean follow-up of 36 months. In group 1, 1 patient died and 3 patients (50%) experienced recurrent respiratory distress. Five infants sustained a major postoperative complication, and the average postoperative hospital stay was 25 days. In group 2, however, aortopexy was uniformly successful. There were no deaths, no postoperative complications, and no cases of postoperative respiratory distress, and the mean postoperative hospital stay was only 10 days. For children with reflex apnea after repair of esophageal atresia, aortopexy is lifesaving and can be performed with minimal morbidity and mortality. Great caution is indicated in children with tracheal compression from other causes.
Aorta, Thoracic↗
A computerized approach to injury description.
The study of trauma has been handicapped from its inception by the absence of a single coherent method of cataloging injuries. The AIS and ICD-9 systems have failed to fill this void because they lack the precision necessary to describe surgically treated injuries. We conceived a simple system of injury description in which injuries are rapidly encoded using a microcomputer in sufficient detail to distinguish among millions of different injuries. This system is easily searched by a microcomputer and allows for the automatic assignment of AIS, ISS, and CPT codes. In this system a patient is described by a 'paragraph' consisting of any number of identically patterned 'sentences,' each describing one of the patient's injuries. Each 'sentence' is composed of a string of six 'words' from controlled vocabularies and has the following structure: "Body region, Organ, Anatomic region, Injury, Physiology, Treatment." Defining the vocabulary allowed for each 'word' in a 'sentence' is complex because the allowed vocabulary is dependent upon the preceding 'words' in a 'sentence,' but in practice a microcomputer simply provides short lists of acceptable choices at each step of injury description, and records the user's selections. Additionally, the microcomputer assigns AIS, ISS, and CPT codes appropriate to the injury description sentence. The ease of data entry, the fineness of detail captured, the automation of code assignment, and the accuracy of database searching for specific injuries, classes of injuries, or combinations of injuries, we believe will give this approach widespread application in academic trauma centers where an accurate and accessible trauma database is important.
Humans↗
Injuries in the elderly: evaluation and initial response.
The injured elderly patient presents a special challenge to the treating physician; there tends to be less margin for error than in younger patients and a greater chance that mortality will result. Beyond the general need for rapid assessment of an often complicated situation, there are specific evaluative and therapeutic techniques, system-by-system and organ-by-organ, that can help expedite the patient's recovery. Guidelines for ICU admission and possible withholding of care are also suggested.
Abdominal Injuries↗
Resuscitative thoracotomy: the effect of field time on outcome.
In the past 5 years, 72 moribund patients have undergone resuscitative thoracotomy (RT) at the Medical University of South Carolina: 62 patients underwent the procedure before the adoption of a policy of mandatory rapid transport (scoop and run) for penetrating and unstable victims of trauma by our EMS system (Group I). Group II is comprised of ten patients who underwent RT following adoption of this policy. Resuscitation was successful in three patients in Group I (4.8%) and there were only two survivors (3.2%). In contrast, resuscitation was successful in two of ten patients in Group II (20%) and there was one survivor (10%). Nineteen patients in Group I (31%) were in traumatic full arrest on the scene, all of whom died. Twenty-five patients in Group I (40%) had a measureable pulse and/or blood pressure when EMS personnel arrived at the scene and subsequently "died" before their arrival at the trauma center. RT was also uniformly unsuccessful in this subgroup. Eighteen patients in Group I (29%) suffered cardiac arrest following their arrival at the hospital. Three of these patients (16.6%) were successfully resuscitated and two (11%) survived to leave the hospital. There were four traumatic full arrests in Group II (40%) and all four died. Only two patients in Group II (20%) lost their vital signs in transport and both died. Four patients in Group II (40%) suffered cardiac arrest after arrival at the hospital. Two of these patients (50%) were successfully resuscitated and one left the hospital (25%).(ABSTRACT TRUNCATED AT 250 WORDS)
Emergency Medical Services↗
The surgical experience with annuloaortic ectasia at the Medical University of South Carolina.
Hemodynamically significant aortic insufficiency can result from dilatation of the aortic valve annulus in association with an ascending aortic aneurysm (annuloaortic ectasia). Controversy has centered around the optimal surgical management. This study evaluates the results of total replacement of the aortic valve and ascending thoracic aorta with a valved aortic prosthesis and reimplantation of the coronary arteries in a small series. In 7 patients with a mean preoperative New York Heart Association Classification (NYHAC) of III, there have been no operative or long-term mortalities, and the average upgrade in NYHAC is 1.6. There have been no major complications or technical difficulties. The composite approach to the repair of patients with annuloaortic ectasia is described and advocated.
Adult↗
Obligatory negative nitrogen balance following spinal cord injury.
Obligatory nitrogen losses due to paralysis in the spinal cord-injured (SCI) patient prevent positive nitrogen balance (NB) regardless of the calorie and protein intakes. Ten patients with SCI and 20 controls with nonspinal cord injury (NSCI) matched for time, sex, age, and injury severity score (ISS) were admitted to our Level I trauma center. In both groups, total nutritional support was delivered within 72 hours of admission based on predicted energy expenditures (PEE = Harris-Benedict equation x 1.2 x 1.6) and 2 g of protein/kg of ideal body weight (IBW). Subsequent changes in nutrient delivery were based on NB. No SCI patient established positive NB during the 7-week period following injury despite an average delivery of 2.4 g of protein/kg IBW and 120% of the PEE at the time of peak negative NB (-10.5). In six SCI patients, an average increase of 25% in delivered protein and 12% in delivered calories over a 1-week period effected no change in average NB (-7.4 vs -6.8). Indirect calorimetry in five SCI patients showed that calorie intakes were 110% more than average measured energy expenditures. In contrast, 17 of 20 NCSI patients achieved positive NB within 3 weeks of admission. They required an average delivery of 2.3 g of protein/kg IBW and 110% of PEE to reach positive NB. These data demonstrate the phenomenon of obligatory negative NB acutely following SCI. Aggressive attempts to achieve positive NB in these patients will fail and result in overfeeding.
Adult↗
The use of positive end expiratory pressure to alter systemic-pulmonary shunt flow using conventional and high frequency jet ventilators.
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Animals↗