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Biomedical subjects

R L Fulton

Publications and source records attributed to R L Fulton.

At least 19 recordsLinked to original sources
PubMed1998

Impact of trauma attending surgeon case volume on outcome: is more better?

OBJECTIVE: To examine the relationship between annual trauma volume per surgeon and years of attending experience with outcome in a Level I trauma center with a large panel of trauma attending surgeons. METHODS: The outcomes of trauma patients were examined in 1995 and 1996 in relationship to surgeon annual trauma volume and years of experience. Outcome variables studied included overall mortality, mortality stratified by Trauma and Injury Severity Score, mortality in patients with an Injury Severity Score greater than 15, and preventable or possibly preventable deaths. Morbidity outcomes examined were overall complication rate and length of stay per attending surgeon. Additionally, five difficult problems were evaluated for critical management decisions by the attending surgeons, and these outcomes were correlated to annual volume and experience. RESULTS: There was no difference in outcome in either morbidity or mortality that correlated with annual volume of patients treated or years of experience. Critical management errors occurred sporadically and were not related to volume or experience. CONCLUSIONS: Outcome after trauma seemed to be related to severity of injury rather than annual volume of cases per surgeon. Although our results may not be applicable to other institutions, they should urge caution in adopting and promulgating volume requirements for individual attending surgeons in trauma centers.

Emergencies↗
PubMed1997

The role of thoracoscopy in the management of retained thoracic collections after trauma.

BACKGROUND: Retained hemothorax and infected thoracic collections after trauma can be seen in up to 20% of patients initially treated with tube thoracostomy and have traditionally been treated nonoperatively, often with prolonged hospital stays. METHODS: Twenty-five patients with retained thoracic collections were reviewed. They underwent 26 thoracoscopies to evacuate undrained blood with or without infection. RESULTS: In 19 patients (76%), the collections were evacuated thoracoscopically. In 4 patients the procedure was converted to an open thoracotomy, and 2 patients required additional procedures to drain these collections. Failure of thoracoscopy correlated with the time between injury and operation and the type of collection, but not with the mechanism of injury. When thoracoscopy was performed in less than 7 days after admission, no cases of empyema were noted at operation. CONCLUSIONS: Videothoracoscopy is an accurate, safe, and reliable operative therapy to evacuate retained thoracic collections. In 90% of the patients in whom the procedure was completed, good results were obtained, reducing hospital stay and possible complications. Videothoracoscopy should be the initial treatment in trauma patients with retained thoracic collections and should be used earlier and more frequently in these patients.

Adult↗
PubMed1997

Intraoperative duplex scanning reduces both residual stenosis and postoperative morbidity of carotid endarterectomy.

To evaluate the effect of intraoperative duplex scanning (IDS) on the incidence of perioperative and postoperative strokes as well as residual and recurrent stenosis, we reviewed 141 patients who underwent 152 consecutive carotid endarterectomies (CEAs) between July, 1990 and June, 1995. Follow-up of 129 cases, with a mean follow-up of two years, revealed no perioperative deaths and three strokes for a combined perioperative stroke-death rate of 2.3 per cent. In 50% (64 of 129) of the CEAs, intraoperative duplex scans were obtained based on the attending surgeon's preference. We noted that the incidence of residual stenosis (>50% stenosis on the first duplex after CEA) was significantly lower in those undergoing IDS (3/64) versus those without IDS (13/65) (P < 0.05; risk ratio 0.31; 95% confidence interval 0.11, 0.91). IDS resulted in a modification of the internal carotid reconstruction in 9 per cent (6 of 64) of the cases with no resulting postoperative strokes or residual/recurrent stenosis. There was no significant difference in the frequency of recurrent stenosis (>50% stenosis after a normal duplex) in the two groups (3 of 64 with vs 2 of 65 without). Of patients not undergoing intraoperative scanning, four underwent redo CEA for symptomatic residual stenosis due to a retained intimal flap in the internal carotid artery. There were three strokes observed within 30 days of the initial CEA, all of which occurred in patients who did not undergo IDS at their initial operation. We conclude that IDS can identify technical defects following internal carotid reconstruction, thereby reducing the incidence of both residual stenosis and postoperative morbidity in patients undergoing CEA.

Carotid Stenosis↗
PubMed1996

Intraoperative duplex scanning reduces the incidence of residual stenosis after carotid endarterectomy.

We studied the effect of intraoperative duplex scanning on the incidence of residual and recurrent stenosis and stroke after carotid endarterectomy (CEA). We retrospectively analyzed 98 veteran patients undergoing 106 consecutive CEAs between July 1990 and June 1994. Follow-up duplex scans were available for 86 cases (81%, mean follow-up 20 months). There were no perioperative deaths. Intraoperative duplex scans were obtained in 39 (45%) of 86 CEAs. The incidence of residual stenosis was lower in the patients scanned at the time of surgery (O of 39) than in those who underwent CEA without intraoperative scan (7 of 47, P < 0.04). One patient who did not receive intraoperative duplex scanning underwent redo CEA for symptomatic residual stenosis due to an intimal flap of the carotid artery. Operative management was changed in 9 of 39 cases because of abnormal intraoperative duplex scans, with no postoperative strokes or residual/recurrent stenosis. The incidence of recurrent stenosis was not different in the two groups (2 of 39 vs 2 of 47, ns). There was no difference in stroke rate. There were three strokes, one perioperative and two postoperative (mean 3.5 months, range 0.5 to 9). Two of the three patients did not undergo an intraoperative duplex scan, but none had developed restenosis >50% over a mean of 21 months of follow-up. Intraoperative duplex scanning significantly reduced the incidence of residual stenosis, but did not affect the incidence of recurrent stenosis or stroke following CEA.

Aged↗
PubMed1996

Operative strategies for management of abdominal aortic gunshot wounds.

BACKGROUND: Although management of penetrating abdominal trauma has greatly improved, abdominal aortic gunshot wounds (AAGSWs) remain a highly lethal injury. Our experience with AAGSWs was reviewed to define operative strategies that may improve survival. METHODS: Forty-one patients with AAGSWs were treated between 1976 and 1996. Preliminary thoractomy was performed in seven patients. Thirty-nine patients had at least one major associated injury (average, 3.2). RESULTS: Twenty-one patients died. Six of seven patients who underwent preliminary thoracotomy died; all developed coagulopathy, which appeared to contribute to death. Four patients had missed vascular lesions, two of which contributed to their death. Associated injuries are currently managed by "damage control" strategy, in which some injuries are left untreated to focus on hemorrhage control. CONCLUSIONS: We have identified seven operative principles and procedures that we believe may improve survival: (1) thorough knowledge of supraceliac exposure; (2) rapid aortic control at the hiatus rather than by a preliminary thoracotomy; (3) use damage control or abbreviated laparotomy; (4) use packing and mesh closure when coagulopathy and hypothermia are present; (5) primary concern should be cessation of hemorrhage rather than the maintenance of flow; (6) delayed reconstruction using extraanatomic bypass can restore flow; and (7) use angiography to detect missed vascular lesions or problems with vascular repair.

Adult↗
PubMed1996

Predicting the need to pack early for severe intra-abdominal hemorrhage.

OBJECTIVE: To determine if the decision to pack for hemorrhage could be refined. MATERIALS AND METHODS: Seventy consecutive trauma patients for whom packing was used to control hemorrhage were studied. The patients had liver injuries, abdominal vascular injuries, and bleeding retroperitoneal hematomas. Preoperative variables were analyzed and survivors compared with nonsurvivors. RESULTS: Packing controlled hemorrhage in 37 (53%) patients. Significant differences (p < 0.05) between survivors and nonsurvivors were Injury Severity Score (29 vs. 38), initial pH (7.3 vs. 7.1), platelet count (229,000 vs. 179,000/mm3), prothrombin time (14 vs. 22 seconds), partial thromboplastin time (42 vs. 69 seconds), and duration of hypotension (50 vs. 90 minutes). Nonsurvivors received 20 units of packed red blood cells before packing compared to 13 units for survivors. CONCLUSION: Patients who suffer severe injury, hypothermia, refractory hypotension, coagulopathy, and acidosis need early packing if they are to survive. Failure to control hemorrhage is related to severity of injury and delay in the use of pack tamponade. A specific protocol that mandates packing when parameters reach a critical limit should be considered.

Abdominal Injuries↗
PubMed1996

Identification of the motor vehicle accident victim who abuses alcohol: an opportunity to reduce trauma.

OBJECTIVE: We hypothesized that a poor driving history and alcohol abuse, evident in a large number of people injured in automobile accidents, contribute to repeated injury, and that treatment for alcohol abuse may reduce vehicular trauma. METHOD: Patients (N = 150) admitted to the emergency surgical service because of injury sustained in a motor vehicle accident (MVA) were tested for their blood alcohol concentrations, and they responded to a questionnaire concerning their prior driving and medical histories. RESULTS: Contrary to the assumption that motor vehicle injuries are isolated episodes, 68% of MVA patients had experienced a prior accident, and 43% had been injured in an MVA before the present event. Prior MVAs were associated with having been previously arrested for driving while intoxicated (DWI), with illegal drug use and with prior hospitalization. Of the MVA patients, 37% were intoxicated (blood alcohol concentration [BAC] > or = 100 mg/dl). Elevated BAC was associated with having been stopped for drinking, having a restricted license, having a DWI arrest, using illegal drugs and having a previous admission to a hospital. Prior MVAs, prior DWIs, elevated BAC and male gender formed the Louisville Alcohol Abuse Predictor Checklist and were independent predictors of alcohol abuse diagnosis, based on the patient's self-report of problems with alcohol. Forty-two percent of MVA patients were diagnosed as alcohol abusers. The alcohol abuser had a significantly higher rate of recurrent MVAs, DWIs and injuries than did nonabusers. CONCLUSIONS: Surgical service may present an opportunity for assessment of alcohol abuse among MVA victims, and treatment for alcoholism might reduce vehicular trauma.

Accidents, Traffic↗
PubMed1995

Confusion surrounding the treatment of traumatic cardiac arrest.

BACKGROUND: To delineate the most reasonable approach to patients with traumatic cardiac arrest we studied the experience at our level 1 trauma center. STUDY DESIGN: Patients with life-threatening trauma admitted during a 41-month period were screened to identify 245 patients who suffered cardiac arrest. Mechanisms of injury, location of arrest, length of arrest, transport methods, treatment rendered, neurologic state, outcomes, and cost of treatment were determined. RESULTS: Six (2.4 percent) patients survived. Mechanism of injury, location of arrest, and age did not correlate with survival. Arrest time longer than ten minutes and loss of neurologic function were associated with mortality. Cost of care was not excessive. CONCLUSIONS: Patients with traumatic cardiac arrest with intact neurologic function should receive treatment. Resuscitation should not be attempted in patients who also have severe brain injury or prolonged time of cardiac arrest.

Accounts Payable and Receivable↗
PubMed1993

Ritual head computed tomography may unnecessarily delay lifesaving trauma care.

Examination of 462 consecutive patients with blunt trauma suggested reassessment of the timing of head computed tomographic (CT) scanning in the critical care of the seriously injured. Even though potential brain injury was the most common reason for admission, few (5 percent) of the patients required neurosurgical intervention. It is apparent that the more common non-neurosurgical procedures that were used to squelch hemorrhage and provide hemodynamic stability and airway control should not be delayed to obtain "routine" head CT scans.

Adolescent↗
PubMed1992

Gallbladder and extrahepatic biliary duct injury following abdominal trauma.

Extrahepatic biliary tract and gallbladder injuries are rare, but many occur after both blunt and penetrating abdominal trauma. During a 5-year period, 24 patients requiring laparotomy for abdominal trauma were found to have an extrahepatic biliary tract injury, representing 13 per cent of all patients admitted with hepatic trauma during the same period. The majority of patients had injury to the gallbladder; only one case of common bile duct injury was identified. Of the patients, 50 per cent had an associated hepatic injury; 17 per cent had important pancreatic trauma. Isolated gallbladder injury occurred in only 8 per cent of patients. The overall mortality associated with gallbladder trauma was 16 per cent. This uncommon injury usually results from severe trauma and is associated with a high incidence of other major visceral injuries.

Adolescent↗
PubMed1990

A useful technique for closure of pulmonary lacerations.

Methods of closing lung tissue with stapling devices or simple sutures are usually adequate. In some patients lung tissue is so friable that reinforcement of the sutures with tissue flaps is beneficial. Felt bolsters or pledgets can also be used as we describe.

Humans↗
PubMed1984

The efficacy of routine completion operative angiography in reducing the incidence of perioperative stroke associated with carotid endarterectomy.

Routine operative angiography was performed during a 14 1/2-year period ending June 1982, during which 603 consecutive carotid endarterectomies were performed. For the purpose of standardization, a functional classification of stroke in terms of severity was established: class I--minimal, class II--moderate, class III--marked, class IV--severe, and class V--coma or death. Patients were analyzed to determine the cause of the stroke, the severity of the stroke, and the efficacy of routine operative angiography in reducing the incidence of perioperative stroke caused by technical error. Perioperative stroke occurred in 18 patients (2.9%), with only one having been caused by technical error. Fifteen patients underwent revision of the endarterectomy before wound closure because of unsatisfactory operative angiography results. None of the patients developed permanent neurologic deficits. Permanent perioperative neurologic deficits resulted from embolization (six patients), hypertensive episodes with cerebral hemorrhage (three patients), conversion of ischemic to hemorrhagic infarcts (two patients), spontaneous thrombosis (one patient), clamp ischemia (two patients), and other factors (three patients). Nine patients died, two of myocardial infarction and seven of stroke, for a combined mortality and morbidity rate of 3.3%. There were three class II, five class III, two class IV, and eight class V strokes that were determined to be related to the procedure. In this series stroke may have been prevented in 15 patients who underwent revision of the endarterectomy because of an unacceptable technical error demonstrated on operative angiography.

Arterial Occlusive Diseases↗
PubMed1983

Oblique incision of the groin for vascular reconstruction at the femoral level.

Exposure of the common femoral artery and its branches for vascular reconstruction has most often been accomplished with a vertical or hockey stick incision which crosses the inguinal folds. An oblique skin incision placed parallel to, and slightly above, the inguinal ligament affords adequate exposure, possesses better healing characteristics and, in the obese, avoids a potentially inflamed inguinal skin crease.

Femoral Artery↗
PubMed1980

Multiple system organ failure. The role of uncontrolled infection.

Multiple system organ failure (MSOF) remains a principal cause of death after major operative procedures and/or severe trauma. We studied multiple parameters in 553 consecutive emergency surgical patients to determine the incidence of MSOF, the predisposing factors to MSOF, and the sequelae of MSOF. Thirty-eight patients had MSOF; mortality was 74% for these patients. Evaluation of multiple factors demonstrated that (1) MSOF is primarily due to infection, (2) the temporal sequence of organ failure is lung, liver, gastric mucosa, and kidney, and (3) MSOF is the most common fatal expression of uncontrolled infection.

Acute Kidney Injury↗
PubMed1979

The nonoperative approach to esophageal perforation due to celestin tube placement.

Perforation of the esophagus during placement of esophageal tubes for palliation of obstructing inoperable cancer is a well-known complication that may preclude satisfactory amelioration of symptoms. Experience with two such patients suggests that the complication can best be treated by proper placement of the tube so that it seals the leak and bypasses the obstruction. Judicious use of antibiotics is beneficial. Drainage of the mediastinum may also be necessary. Resectional or extensive operative therapy is probably not wise in these ill and debilitated patients, particularly if the cancer is incurable.

Aged↗
PubMed1979

Principles for the management of penetrating cardiac wounds.

An experience with penetrating cardiac injuries between 1974 and 1977 has permitted designation of particular findings as indications for emergent operations and appropriate therapeutic approaches. Of the 46 patients with cardiac trauma, 28 suffered gunshot wounds. Seventeen patients died, and 14 of the deaths occurred as a result of asystole, ventricular fibrillation or exsanguination during operation. Two patients died of neurologic sequelae following successful cardiac repair, and one died secondary to injury not disclosed by physical examination or roentgenogram. The surviving 29 patients had five major complications. Sepsis, organ system failure and cardiac defects rarely occurred despite rapidly performed thoracotomy and severe shock. Since delayed operation has been uniformly associated with adverse outcome and because postoperative complications of emergent pericardial exploration are mild, the following conclusions have been reached: 1) Mediastinal entrance wounds, severe hypotension and signs of cardiac tamponade are demonstrative of cardiac trauma. Therefore, virtually any combination of these physical signs mandates pericardial exploration. 2) Subxiphoid or transdiaphragmatic exploration (during laparotomy) of the pericardium has been valuable in diagnosis of suspected heart wounds. 3) Emergent cardiorrhaphy is the treatment of choice. Pericardiocentesis is at best only temporarily effective. Thoracotomies performed in the emergency room were uniformly unsuccessful. If possible, cardiorrhaphy should be done in the operating room. 4) Median sternotomy is the approach of choice. 5) The basic principles of management of cardiac injury are rapid diagnosis, relief of tamponade, control of hemorrhage, repair of cardiac defects and restoration of blood volume.

Adolescent↗