Biomedical subjects
R E Falcone
Publications and source records attributed to R E Falcone.
Management of penetrating neck injuries. The controversy surrounding zone II injuries.
Penetrating neck injuries present a difficult challenge in management, given the unique anatomy of the neck. Controversy surrounds the approach to zone II injuries; mandatory versus selective exploration. On the basis of an extensive literature review, the authors conclude that neither approach is obviously superior. A selective approach is safe in the asymptomatic and hemodynamically stable patient, provided that accurate invasive diagnostic means are immediately available. The mandatory approach is safe, reliable, and time tested. The greatest problem appears to be the accuracy of detection of cervical esophageal injuries: Radiologic evaluation may be inaccurate, rigid esophagoscopy carries a risk of perforation, and the injury may easily be overlooked during surgical exploration.
Blunt diaphragmatic rupture diagnosed by laparoscopy: report of a case.
Diagnostic laparoscopy provided a minimally invasive and definitive means of diagnosing right-sided diaphragmatic rupture in this patient. The authors recommend laparoscopy as a diagnostic consideration for the patient with suspected traumatic diaphragmatic rupture who presents a difficult diagnostic challenge.
Breast reconstruction: systemic factors influencing local complications.
One hundred seven consecutive breast reconstructions in 83 women were retrospectively reviewed. The reconstructions were with subpectoral prostheses, 54 with permanent tissue expanders, 14 with temporary tissue expanders, and 39 with permanent implants. Immediate breast reconstruction was performed in 69 (64%) breasts and delayed breast reconstruction in 38 (36%) breasts. Risk factors for local complication were diabetes, smoking, age older than 60 years, obesity, and hypertension. Technical factors reviewed included timing of reconstruction, type of prosthesis used, and the presence or absence of drains. Women with immediate breast reconstruction sustained a significantly higher complication rate than women with delayed breast reconstruction; however, the majority of these were due to the antecedent mastectomy. Complications due to the reconstruction were not significantly different for women with immediate versus delayed breast reconstruction. Implant loss occurred in 5 women, 4 with immediate and 1 with delayed breast reconstruction (5.8% vs. 2.6%, p approximately 0.47). Diabetes was significant, and smoking and age greater than 60 years approached significance as risk factors for implant loss in women with immediate breast reconstruction (p approximately 0.01, 0.05, and 0.08, respectively). These risk factors also correlated directly with an increasing severity of complication in women with immediate breast reconstruction (r = 0.414, p = 0.06). Technical factors showed no significant effect on implant loss in women with immediate breast reconstruction.
Prehospital cricothyrotomy in air medical transport: outcome.
In an attempt to determine outcome, this study reviewed the records of air medical patients undergoing prehospital cricothyrotomy (CRIC) from 1987 through 1989. The study included initial airway management, Trauma Score (TS) before and after CRIC and on arrival to the hospital, outcome, and initiator of airway--either emergency medical services (EMS) or LifeFlight air medical crew (LF). There were 68 CRIC in 3285 completed missions (2%). Patients averaged 31.4 years old with 46 males and 22 females. In rural environments, 60/68 patients were injured, with 65/68 injuries by blunt mechanisms. CRIC was performed by EMS in 24/68 patients and by LF in 44/68 patients. TS before CRIC, after CRIC, and on arrival to the hospital was not significantly different, averaging 5.8, 5.8, and 5.2. There were three complications of CRIC: two bleeds and one failure to insert. Five CRIC were changed to another airway at the receiving facility. Twenty-one out of 68 patients survived to discharge. There were no statistically significant differences in complications or overall mortality between LF and EMS CRIC. Prehospital CRIC appeared safe and complications were infrequent. The CRIC, once placed, remained the airway of choice in most patients. The eventual outcome in this population suggested serious injury with the majority of patients (69%) dying.
The risk of AIDS-virus exposure during aeromedical transport of trauma patients.
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Rapid volume replacement with warmed blood and fluids.
A prospective clinical study was undertaken in 50 consecutive patients suffering from severe traumatic shock to evaluate the clinical efficacy of a set for rapid administration of solutions (RSAS), which allows for rapid infusion and simultaneous warming of blood and fluids. The mechanism of injury was blunt in 37 patients and penetrating in 13. Admission trauma score averaged 7.5, and the injury severity score averaged 46. Average preresuscitation systolic blood pressure was 71 mmHg, pulse was 105 beats/minute, and temperature was 34.3 degrees C. Initial resuscitation was with the RSAS, and total fluid infused in the first twenty-four hours averaged 4,632 mL of blood, 1,914 mL of blood products, and 11,248 mL of crystalloid. The average postresuscitation systolic blood pressure was 120 mmHg, pulse was 96 beats/minute, and temperature averaged 34.9 degrees C. Survival at twenty-four hours was 29/50 (58%). There were no local complications of RSAS use and no evidence of infusion-related coagulopathy. The RSAS provided an effective and safe way to infuse large volumes of blood and fluid at body temperature.
Colorectal trauma.
Colorectal injury remains a source of significant morbidity and mortality. Gunshot and stab wounds are the most common etiologic agents. Diagnosis is usually established on clinical grounds. For the purposes of management, the large bowel can be considered as colon and rectum. Minor colon injuries can be repaired primarily; management of major colon injuries or injuries associated with multiple organ involvement, significant blood loss, or massive contamination should be individualized. Diversion or exteriorization remains the gold standard of treatment when there is any doubt. Rectal injury should be repaired when feasible and diverted and the presacral space drained. Distal rectal washout is of proven merit. Antibiotics provide an important adjunct to therapy. They should be initiated early (preoperatively), ended quickly (12 to 72 hours postoperatively), and provide a broad spectrum of coverage. The treatment of established infection should be guided by bacterial culture. Postoperatively, aggressive support is important for a good outcome. The significant incidence of complications even in the face of optimal management demands continued vigilance and aggressive intervention by the operating surgeon.
Normothermic rapid volume replacement in vascular catastrophes using the Infuser 37.
Twenty patients (Group 1) with a mean age of 38.5 +/- 16 years and an admission Trauma Score of 7.26 +/- 5.9, suffered 27 vascular injuries and were resuscitated with the Infuser 37 (IN-37) with an integral heat exchanger. Admission systolic BP averaged 46.47 mmHg (seven with absent vital signs). A mean of 7,030 ml of blood, 3,313 ml of colloid and 13,630 ml of crystalloid per patient was given in less than 24 hours, mostly through the IN-37. Twelve thoracotomies, nine laparotomies, and one extremity exploration were performed. Twelve patients, seven with a Trauma Score less than 3, died in less than 24 hours of exsanguination. The survival rate was 40% at 24 hours and 25% at 30 days. Six patients (Group 2) with a mean age of 70.33 +/- 8.3 years underwent operation for ruptured aortic aneurysm (5 pts), and elective aortic aneurysm (1 pt) with a 66% survival at 24 hours. Admission systolic blood pressure averaged 84 mmHg. A mean of 3,895 ml of blood, 1,900 ml of colloid and 7,733 ml of crystalloid per patient was administered in less than 24 hours, mostly through the IN-37. The IN-37 provides a safe and simple means of normothermic, rapid volume replacement in hemorrhagic shock. Its use in critically ill but potentially salvageable patients with vascular injuries and aortic aneurysm may avoid the consequences of prolonged hypoperfusion and hypothermia.
The effect of dacarbazine on wound healing.
The effects of dacarbazine on wound healing were studied in an animal model. Sixty rats were divided into four groups. Each animal received a standard dorsal midline wound on day 0. Group 1 was injected with normal saline and acted as control; group 2 received 4 mg/kg of dacarbazine daily on days -3, -2, -1 (preoperative); group 3 received dacarbazine on days +1, +2, +3 (perioperatively); and group 4 received dacarbazine on days +5, +6, +7 (postoperatively). Wound bursting strength (WBS) was measured on days +7, +14, and +21. There was a significant decrease in WBS in experimental animals in groups 3 and 4 (perioperative and postoperative administration) compared to control animals, but no significant effect of preoperative dacarbazine on WBS in experimental animals (group 2). It is suggested that these effects are mediated through the late inflammatory phase of wound healing.
Pseudopneumothorax: a migratory mirage.
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Normothermic rapid volume replacement in traumatic hypovolemia. A prospective analysis using a new device.
Inadequate infusion flow rates and hypothermia are significant problems encountered in managing traumatic hemorrhagic shock. The Rapid Solution Administration Set (RSAS) allows normothermic volume restoration at flow rates of up to 2200 mL/min via a single peripheral venipuncture. The RSAS was utilized in 33 consecutive multiple-trauma patients with a mean trauma score (TS) of 6.8. Admission systolic blood pressure averaged 66.9 mm Hg. A mean of 5692 mL of packed red blood cells, 5515 mL of blood products, and 12,052 mL of crystalloid solution per patient was infused within 24 hours of admission mostly via the RSAS. Mortality was 45% at 24 hours following arrival and 61% overall. The mortality was 93.8% (15/16) in patients with a TS of 5 or less and 29.4% (5/17) in patients with a TS over 5. The initial postinfusion patient temperatures averaged 35.2 degrees C. All abnormal preinfusion coagulation values normalized within 24 hours in the survivors, and no significant complications occurred with the use of the RSAS. The RSAS seems to provide an uncomplicated means of normothermic volume replacement. The 24-hour survival in potentially salvageable patients may be improved. Its use in patients with lethal injuries (TS less than or equal to 3) requires further evaluation.
The lack of effect of nifedipine on failing skin flaps.
The calcium channel blocker, nifedipine, was administered to 16 pigs in randomized blinded fashion in an unsuccessful attempt to salvage failing random pattern flaps. Despite the moderate dose of drug used, nifedipine caused significant hypotension that may have countered any beneficial effect on small vessel flow. Further studies are needed before nifedipine is abandoned as a potential agent for the pharmacologic manipulation of failing skin flaps.
Chemotherapy and wound healing.
This paper provides a review of common chemotherapeutic agents and the experimental evidence supporting their effects on wound healing. Correlation with clinical studies is used to establish relevance, and therapeutic guidelines are developed.
Meshed skin grafts versus sheet skin grafts on a contaminated bed.
An experimental model was designed to test the premise that meshed skin grafts survive better than sheet grafts on contaminated wounds. In this rat model, meshing of grafts significantly improved graft take, and expansion of the mesh led to an even greater improvement. The results of this study indicate a need for further investigation of this technique in the management of contaminated wounds.