Biomedical subjects

J M Burch

Publications and source records attributed to J M Burch.

At least 73 records · Page 4Linked to original sources

PubMed1989

Hypertonic saline-dextran solutions for the prehospital management of traumatic hypotension.

We report the results of the first clinical study on the use of a hypertonic saline-dextran solution for the prehospital management of hypotensive victims of penetrating trauma. During a 4-month period, 48 trauma patients with penetrating injuries and a prehospital systolic blood pressure of 90 mm Hg or less were infused in-field with 250 ml of either a hypertonic saline-dextran solution or the crystalloid plasmalyte A. There were no complications associated with the infusion of the hypertonic saline-dextran solution, and execution of the protocol by paramedic personnel was both safe and uniformly successful. The potential impact of this solution on medical care and the results of this feasibility study justify the initiation of a larger prospective, randomized clinical trial on the efficacy of this solution in the prehospital setting.

Adolescent↗

PubMed1989

Colostomy and drainage for civilian rectal injuries: is that all?

One hundred consecutive patients with injuries to the extraperitoneal rectum were treated over a ten-year period at an urban trauma center. The mechanisms of injury included firearms in 82 patients, stab wounds in 3 patients, a variety of other penetrating injuries in 10 patients, and in 5 patients the injuries resulted from blunt trauma. Treatment of the rectal injury was determined by the bias of the operating surgeon, the condition of the patient, and the magnitude of the rectal injury. Proximal loop colostomies were performed in 44 patients, diverting colostomies in 51 patients, Hartmann's procedure in 4 patients, and an abdominoperineal resection in 1 patient. Extraperitoneal rectal perforations were closed in 21 patients and the rectum was irrigated free of feces in 46 patients. Transperineal, presacral drainage was used in 93 patients. Infectious complications potentially related to the management of the rectal wound occurred in 11 patients (11%) and included abdominal or pelvic abscesses (4 patients), wound infections (6 patients), rectocutaneous fistulas (3 patients), and missile tract infections (2 patients). Four patients (4%) died as a result of their injuries. Of the therapeutic options available, statistical analysis revealed that only the failure to drain the presacral space increased the likelihood of infectious complications (p = 0.03); however, as it could not be determined with certainty that the use of, or failure to use, any particular therapeutic option had an effect on the risk of death. It is concluded that colostomy and drainage are the foundations of the successful treatment of civilian injuries to the extraperitoneal rectum. The use of adjuncts such as diverting colostomies, repair of the rectal wound, and irrigation of the rectum has little effect on mortality and morbidity.

Adolescent↗

PubMed1988

Comparison of multiple-parameter prognostic systems in acute pancreatitis.

A database of laboratory and clinical values was collected from 200 patients with acute pancreatitis. This database was analyzed using several multiple-parameter indicator systems. All systems tested demonstrated a similar ability to predict accurately both mortality and severity in these patients. The predictive power was maintained whether the scores were grouped or presented individually. The superiority of one system over another could not be demonstrated. It is probable that systems could be devised that would be just as effective as those analyzed; on the other hand, a trend toward unification is very desirable.

Acute Disease↗

PubMed1988

Fasciotomy after trauma to the extremities.

Over a 9-year period, fasciotomy for presumed compartmental syndromes after trauma was performed in 25 upper extremities and 100 lower extremities in 122 patients. This procedure was most commonly indicated after vascular injuries in the lower extremities. Twenty percent of patients underwent fasciotomy before vascular repair. Nineteen percent of patients with vascular injuries in the lower extremities had fasciotomies performed at reoperation. Seventy-five percent of amputations in the lower extremities were related to a delay in performing fasciotomy or an incomplete fasciotomy. Upper-extremity fasciotomies most commonly did not decompress the deep component of the volar compartment, whereas lower extremity fasciotomies without fibulectomy most commonly decompressed all four below-knee compartments. Fasciotomy sites were closed by direct suture in more than half of the patients.

Adult↗

PubMed1988

Injuries of the inferior vena cava.

Beginning in 1946, 577 patients with inferior vena cava injuries were managed at a single institution. After decreasing from 37 to 30 percent, the mortality rate showed a distinct increase in the last 7 years studied. This increase was related to an increasing percentage of patients who arrived in the emergency center in severe shock and required resuscitative thoracotomy. In-hospital care advances have not kept pace with improvements in prehospital care. Although venous complications have not been infrequent, morbidity has not been a significant long-term problem. Fatal pulmonary embolism occurred and was a special problem for patients over the age of 50. More basic research is needed to expedite diagnosis and vascular control in addition to understanding and treating the severe metabolic problems of patients dying from shock and hemorrhage.

Adolescent↗

PubMed1988

The atriocaval shunt. Facts and fiction.

During the past 11 years, 31 patients with major juxtahepatic venous injuries were treated with the atriocaval shunt. Penetrating injuries occurred in 27 patients (87%), and injuries from blunt trauma occurred in four patients. Shock was present on admission in 28 patients (90%). Resuscitative thoracotomy for cardiovascular collapse was required in 13 patients (42%). Juxtahepatic venous injuries included the vena cava in 23 patients (74%) and the hepatic veins alone in five patients (16%). One patient had an isolated portal venous injury, and two patients died before their vascular injuries could be delineated. Technical problems related to the shunt occurred in seven patients. Most were related to delays in placement or problems encountered in obtaining vascular control of the suprarenal vena cava. Major hepatic resection was performed in 11 patients (35%). Twenty-five patients died of their injuries. No patient survived who required resuscitative thoracotomy, hepatic resection, or when technical problems with the shunt occurred. Six patients (19%) survived and were discharged from the hospital. All sustained gunshot wounds to the retro-hepatic vena cava. Four of the six survivors had serious postoperative complications, but none were related to the shunt. Major juxtahepatic venous injuries are highly lethal. The atriocaval shunt will permit the salvage of some patients where other methods are not possible. Avoidance of delay and alternative shunting techniques that eliminate difficult maneuvers may improve survival in the future.

Adolescent↗

PubMed1988

Abdominal gunshot wounds. An urban trauma center's experience with 300 consecutive patients.

From July 1983 through December 1987, 300 consecutive patients with penetrating gunshot wounds of the abdomen causing visceral or vascular injuries were treated. Resuscitative thoracotomy was required in 20 patients (6.6%), and only two survived. The most commonly injured organs were the small bowel (60%), colon (41.6%), liver (29.3%), vascular structures (24.6%), stomach (17.3%), and kidney (17.0%). The overall survival rate for the series was 88.3%; however, if only the 226 patients without vascular injuries are considered, the survival rate was 97.3%. In the 35 patients who died, the blood pressure on admission was 51 mmHg, 18 required a resuscitative thoracotomy, four visceral or vascular injuries were present, and the median blood replacement was 18 units. The cause of death was perioperative shock in 30 patients (85.7%), whereas five patients (14.3%) died of sepsis and multiple organ failure. The most common postoperative complication in survivors and patients who died later in the study was an intra-abdominal abscess (3.0%). Rapid conservative operative techniques for civilian gunshot wounds leads to few postoperative complications and an excellent survival rate, especially if vascular injuries are not present.

Abdominal Injuries↗

PubMed1988

The treatment of crotalid envenomation without antivenin.

Eighty-one patients were treated for crotalid envenomation over the past 12 years at the Ben Taub General Hospital, Houston. Bites were inflicted by copperheads (56%), water moccasins (15%), and rattlesnakes (12%). In 17% of patients the species of snake was not identified. Using a grading scale of one to four from minimal to severe envenomation, 54% were grade I, 29% grade II, 7% grade III, 6% grade IV, and 4% were not graded because the patients were seen more than 12 hours after envenomation and not evaluated by other physicians. Five patients received one dose (10 cc) of crotalid antivenin each before transfer to our Emergency Center. All patients were treated with intravenous fluids, antibiotics, tetanus prophylaxis, immobilization of the injured part, and elevation of the extremity to the level of the heart. No patients received antivenin or excisional therapy at this institution and one minor digital fasciotomy was performed. There were no deaths or amputations in this series. Eight patients developed superficial necrosis of the skin but only one required a skin graft. Three patients developed hematologic abnormalities and were treated with either platelet transfusions or fresh-frozen plasma. One patient required dopamine for hypotension refractory to fluid resuscitation. This experience supports a conservative approach to venomous snakebites and raises the question about the need to utilize traditional therapy for snakebites caused by species seen in our locality.

Adolescent↗

PubMed1988

Management of vascular injuries in the lower extremities.

From 1981 through 1985, 220 consecutive patients with presumed vascular injuries in the lower extremities underwent operation at the Ben Taub General Hospital. More than 81% of injuries were due to penetrating wounds, and blunt and iatrogenic injuries accounted for the remainder. A preoperative emergency center arteriogram was performed in 63.2% of patients, and physical examination alone prompted operation in 36.8%. Eight patients underwent immediate amputation; the remaining 212 patients were found to have 225 arterial (63.9%) and 127 venous (36.1%) injuries. More than 50% of patients were noted to have both arterial and venous injuries. Arterial repair was most commonly accomplished by segmental resection with an end-to-end anastomosis (28.4%) or insertion of a graft (38.8%). Venous repair was most commonly accomplished by lateral venorrhaphy (48.8%), ligation (19.7%), or insertion of a conduit (18.1%). Postoperative infection in closed wounds, in wounds left open because of the magnitude of injury, and in adjacent fractured bone occurred in 13% of patients. Late amputations were necessary in only four patients, three of whom had infection as the cause.

Adult↗

PubMed1988

Delayed diagnosis of injuries to the diaphragm after penetrating wounds.

During a 9-year period, 16 patients with a delay in diagnosis of an injury to the diaphragm after a penetrating wound were treated. The left hemidiaphragm was involved in 15 of 16 patients, and the delay in diagnosis from the time of arrival in the emergency center immediately after injury ranged from 16 hours to 14 years. In the patients in the Acute Group (delay of hours to days), three patients had diaphragmatic defects missed at the time of laparotomy, three patients had chest X-rays not immediately suggestive of diaphragmatic defects, two patients had false-negative lavages, and one patient treated elsewhere did not have a chest X-ray in the emergency room. In the patients in the Chronic Group (hernias presenting months to years after injury), four of seven patients had misreading of a recent chest X-ray or failure to have a chest X-ray performed during numerous return visits to the emergency center. Despite a variety of diagnostic maneuvers, these defects and hernias continue to be diagnosed after a delay. Careful review of early and late followup chest X-rays appears to be the easiest mechanism to avoid significant delays in diagnosis.

Adult↗

PubMed1987

Delayed diagnosis of arterial injuries.

During an 8 1/2 year period, 28 patients with a delayed diagnosis of an arterial injury in an extremity or the neck were treated. The median delay between injury and diagnosis was 10 days. The tibio-peroneal arteries were the most commonly injured vessels. After extensive analysis of the records and arteriograms of the involved patients, the following conclusions were drawn: Arteriograms are mandatory for penetrating wounds proximal to major arteries of the extremities because of the 5 to 15 percent incidence of occult injuries; the timing of arteriography in the distal leg is critical if subtle injuries to the tibial and peroneal vessels are to be detected; when experienced radiologists are not available, interpretation of exclusion arteriograms is best performed by experienced trauma surgeons; false aneurysms, arteriovenous fistulas, or a combination of both continue to be the most common manifestations of missed arterial injuries; failure to find an injury previously diagnosed by a preoperative arteriogram mandates an intraoperative arteriogram and, on occasion, an arteriotomy; and, late arterial repairs usually require segmental resection with an end-to-end anastomosis or insertion of a graft.

Adult↗

PubMed1987

Management of injuries to the suprarenal aorta.

During a 12 year period, 79 patients with a diagnosis of a penetrating wound to the suprarenal aorta were treated. An analysis of the records of these patients has led to the following conclusions: With a midline penetrating wound and presence of a supramesocolic hematoma or hemorrhage, injury to the suprarenal aorta should be suspected. If a midline supramesocolic hematoma is present or if hemorrhage can be controlled by direct pressure, a lateral approach with medial mobilization of the intraabdominal viscera on the left side allows rapid vascular control. Although lateral aortorrhaphy is preferred, patch grafting, and end-to-end anastomosis, or insertion of a prosthetic graft was required in 46 percent of the patients who underwent repair. As in all previous series, the insertion of synthetic patches or prostheses was not complicated by infection. The average survival rate for injuries to the suprarenal aorta in series reported since 1974 is 33 percent. Finally, the continuing problem of irreversible shock suggests the need for rapid transport from the field to the hospital for victims of penetrating wounds to the abdomen.

Aorta, Abdominal↗

PubMed1987

Management of combined pancreatoduodenal injuries.

From 1969 to 1985, 129 patients with combined pancreatoduodenal injuries were treated at one urban trauma center. A total of 104 patients (80.6%) had penetrating wounds, and multiple visceral and vascular injuries were usually associated with the pancreatoduodenal injury. Primary repair or resection of one or both organs coupled with pyloric exclusion and gastrojejunostomy (68 patients) and drainage was used in 79 patients (61.2%) in the entire study and in 59% (36 of 61) of all patients treated since 1976. Simple primary repair of one or both organs and drainage was performed in 31 patients (24%), whereas the remaining 19 patients (14.8%) had pancreatoduodenectomies (13 patients) or no repair before exsanguination (six patients). Major pancreatoduodenal complications occurring in the 108 patients surviving more than 48 hours included pancreatic fistulas (25.9%), intra-abdominal abscess formation (16.6%), and duodenal fistulas (6.5%). The overall mortality rate for the study was 29.5% (38 of 129). The acute mortality rate with these injuries will remain high secondary to injuries to associated organs and vascular structures. The morbidity and late mortality rates related to the moderate to severe pancreatoduodenal injury itself can be decreased by the addition of pyloric exclusion and gastrojejunostomy to the primary repairs.

Abdomen↗

PubMed1986

Liberal use of emergency center thoracotomy.

Emergency center thoracotomy is a heroic technique of resuscitation and treatment which was revived in the 1960s to improve the survival of patients presenting with cardiac wounds. With excellent survival rates attained in such patients, the technique was extended to victims of trauma with other mechanisms and locations of injury. At present, the technique has a survival rate ranging from 3 to 20 percent; however, most recent series of unselected patients show a survival rate of 8 to 10 percent. In this series, there were no survivors when emergency center thoracotomy was utilized after a period of prehospital cardiopulmonary resuscitation. Patients with isolated stab wounds to the thorax, especially those with cardiac injuries, had the best survival rate of any subgroup in the series. If emergency center thoracotomy was utilized for patients with some vital signs on admission and with neck or truncal gunshot wounds, blunt trauma, or abdominal trauma, the survival rate decreased to 2 to 4 percent; however, the small but constant survival rate in all of these groups justifies its continued use.

Adult↗

PubMed1986

Single agent cephalosporin prophylaxis for penetrating abdominal trauma. Results and comment on the emergence of the enterococcus.

Multiple studies have shown that the incidence of infectious complications after penetrating abdominal wounds are decreased by the perioperative administration of antibiotics. In this study of three separate single cephalosporin agents (cefotaxime, cefoxitin, and moxalactam) given for a 48 hour period in patients who sustained perforating gastrointestinal wounds, uncomplicated recoveries occurred in 93 percent of all patients. The rates of uncomplicated recovery were significantly different for the three groups; however, patients with major intraabdominal vascular injuries were more common in the cefoxitin-treated group. One disturbing feature was the presence of enterococci in 57 percent of isolates from wound infections and 60 percent of isolates from intraabdominal abscesses. Enterococci as sole isolates were found in one of two wound infections and three of four intraabdominal abscesses in the moxalactam-treated group.

Abdominal Injuries↗

PubMed1986

The injured colon.

Controversy continues regarding the initial management of civilian colon injuries. The main issues are the safety of colostomy versus the desirability of primary repair and the role of exteriorized repair. From 1979 through 1984, 727 patients with injuries to the colon were treated at a large urban trauma center. Ninety-seven per cent of injuries were caused by penetrating wounds. Ten patients died in the operating room prior to repair of the colon wound. For patients who survived long enough to have their injury treated, 52.4% were treated by primary repair, 32.9% were treated with colostomies, and 14.6% were treated with exteriorized repair. Of the factors that have been stated to influence decision making, the extent of the colon injury was the most important. Location, number, and type of associated injuries, fecal contamination, and shock were less important. However, none of these latter factors mandated performance of a colostomy. The overall mortality rate for the series was 9.9%. Forty-one out of 70 deaths occurred within the first 48 hours and were due to shock and hemorrhage. The mortality rate for primary repair was significantly lower than that for colostomies (p less than 0.01). The presence of shock and age greater than 40 were significant factors influencing mortality (p less than 0.01). Mortality also was directly related to the number and type of associated abdominal injuries. Abdominal abscess also occurred significantly less often in patients treated with primary repair than in those with colostomies (p less than 0.01). The use of exteriorized repair was successful in avoiding colostomy in 59% of patients. Primary repair can be performed with minimal morbidity and mortality and should be the mainstay of treatment for civilian colon injuries.

Adolescent↗

PubMed1986

Management of 1000 consecutive cases of hepatic trauma (1979-1984).

From 1979 to 1984, 1000 patients with hepatic injuries were treated at one urban trauma center. Penetrating wounds were present in 86.4% of patients. Simple hepatorrhaphy, use of topical hemostatic agents, or drainage alone were the only forms of therapy required in 881 patients, and 65 (7.3%) died. Extensive hepatorrhaphy or hepatotomy with selective vascular ligation, resectional debridement or resection, selective hepatic artery ligation, or perihepatic packing were required, often in combination, in 119 patients, and 40 (33.6%) died. Uncomplicated recoveries occurred in 798 of the 918 patients (86.9%) surviving greater than 48 hours. In the remaining 13.1% of patients, intra-abdominal abscess formation was the most common late complication (32/918 = 3.5%). Mortality for the entire series of 1000 patients was 10.5%, with 78.1% (82/105) of all deaths occurring in the perioperative period from shock or transfusion-related coagulopathies.

Constriction↗

PubMed1986

Management of injuries to the superior mesenteric artery.

From 1978 through 1984, 22 patients with 20 penetrating and two blunt injuries to the proximal superior mesenteric artery were treated. Patients presented with exsanguinating hemorrhage (19), midline hematomas (two), or 'black bowel' (one). Two other patients developed 'black bowel' during operation. Direct cutdown through the mesentery was the approach in 11 patients, and three survived; a Mattox maneuver was used in ten patients, and five survived. Complex bypass or grafting procedures were performed in nine patients, and two survived. Ten of 15 deaths were secondary to hemorrhagic shock; two of five late deaths were related to problems with the vascular repair in patients with multiple injuries. Interposition grafting near a major pancreatic injury may lead to catastrophic postoperative problems. Bypass grafts from the distal aorta should have retroperitoneal tissue coverage of the suture line.

Abdominal Injuries↗