Search PubMed⌕ Search

Biomedical subjects

R P Fischer

Publications and source records attributed to R P Fischer.

At least 37 records · Page 2Linked to original sources
PubMed1990

Hypothermia and blood coagulation: dissociation between enzyme activity and clotting factor levels.

Previous studies of hypothermia and blood coagulation have focused on alterations in the levels of blood clotting elements using coagulation tests performed under normothermic conditions. However, because of the enzymatic nature of activated clotting factors, hypothermia should also be expected to affect clotting factor activities. Multiple determinations of activated partial thromboplastin times (APTT), prothrombin times (PT), and thrombin times (TT) were performed on commercially available normal human plasma at assay temperatures similar to those encountered clinically (25-37 degrees C). Both the APTT and the PT were significantly prolonged at temperatures below 35 degrees C (P less than 0.05). Clotting time correlated significantly with assay temperature in a negative exponential fashion for all three tests (r = -0.97 for APTT, -0.93 for PT, -0.71 for TT, P less than 0.001 for all regressions). Clotting time prolongation appears proportional to the number of enzymatic steps involved. These data indicate that the coagulopathy observed during hypothermia is, in part, independent of clotting factor levels.

Blood Coagulation↗
PubMed1989

Early fasciotomy for acute clinically evident posttraumatic compartment syndrome.

Our understanding of the effectiveness of early decompressive fasciotomy for acute posttraumatic compartment syndrome is incomplete. Thirty-two patients who developed acute clinically evident compartment syndrome (23 in the leg, 9 in the forearm) were treated with decompressive fasciotomy an average of 16 hours after injury. Thirty patients (94 percent) underwent fasciotomy in conjunction with other urgent operative procedures mandated by concomitant injuries. Three patients required early amputation for a failed arterial repair. Only 2 of 29 patients with limb salvage (7 percent) had postoperative myoneural deficits after decompressive fasciotomy. Both of these patients had preoperative myoneural deficits. Decompressive fasciotomy before the development of ischemic myoneural deficits prevents the ischemic sequelae of acute clinically evident compartment syndrome.

Acute Disease↗
PubMed1989

Pharmacokinetic monitoring of nephrotoxic antibiotics in surgical intensive care patients.

An assessment of the dosage regimens prescribed for potentially nephrotoxic antibiotics (amikacin, gentamicin, tobramycin, and vancomycin) was undertaken on surgical intensive care unit patients. In 166 patients, 224 series of blood antibiotic level determinations were obtained. Using individualized pharmacokinetic determinations, the regimens were revised as necessary to provide optimal blood levels. Because of variable volumes of distribution and elimination rates, dosing according to standard clinical guidelines produced significantly lower peaks than did pharmacokinetically determined regimens for gentamicin (p less than 0.005), tobramycin (p less than 0.0001), and vancomycin (p less than 0.05). Importantly, fewer patients achieved therapeutic levels with the original regimens than with the revised regimens for gentamicin (9% vs. 91%, p less than 0.0005), tobramycin (27% vs. 92%, p less than 0.0001), and vancomycin (30% vs. 69%, p less than 0.0001). Individualized pharmacokinetic analysis of potentially nephrotoxic antibiotics in critically ill patients is essential if therapeutic, non-toxic levels are to be maintained.

Amikacin↗
PubMed1989

Prophylactic antibiotics in trauma: the hazards of underdosing.

Prophylactic antibiotic regimens in trauma patients may be significantly altered by large fluid shifts and hyperdynamic physiologic responses. We prospectively studied prophylactic amikacin and clindamycin in 150 abdominal trauma patients requiring laparotomy, analyzing the effects of duration of coverage, dosing interval, and dose. No difference in infection rates was noted when 72-hour coverage was compared with 24-hour coverage (19% vs. 21%). Clindamycin dosed at 1,200 mg every 12 hours achieved acceptable serum concentrations; infection rates were not significantly higher than seen with 600 mg every 6 hours (21% vs. 12%, p greater than 0.05). High-dose (11 mg/kg) amikacin reduced infection rates in patients with high blood loss (p less than 0.025), high Injury Severity Scores (p less than 0.025), and no colon penetration (p less than 0.005). These data suggest that high doses are more effective than long courses of antibiotics in reducing infections in trauma patients undergoing laparotomy.

Abdominal Injuries↗
PubMed1988

Major injury as a unique opportunity to initiate treatment in the alcoholic.

A prospective study was performed on the use of a standard outpatient intervention technique to induce inpatient alcoholic trauma patients into accepting alcoholism treatment. Interventions were performed on 17 trauma patients. All patients who underwent intervention accepted treatment and were immediately transferred to a 28-day inpatient treatment facility. Alcoholic trauma patients are highly susceptible to intervention for their disease. We found that intervention performed upon discharge from the trauma service successfully initiates alcoholism treatment.

Alcoholism↗
PubMed1988

Urgent thoracotomy for pulmonary or tracheobronchial injury.

Three hundred eighty-eight of 7,283 (5.3%) admitted trauma patients underwent urgent thoracotomy. In 61 patients (15.7%), pulmonary or tracheobronchial injury prompted thoracotomy (11, blunt; 50, penetrating). Pulmonary hemorrhage necessitated thoracotomy in 54 patients (88.5%); tracheobronchial injury in five patients (8.2%). The mortality was 27.9%. Nine patients (14.8%) underwent pneumonectomy: eight died of intractable hemorrhagic shock during thoracotomy despite rapid control of pulmonary hemorrhage: one died of sepsis. Eleven patients (18.0%) underwent lobectomy: six (54.5%) died of concomitant injuries. Thirty-six patients (59.0%) underwent pneumonorrhaphy: one died of concomitant injuries. Five (8.2%) patients underwent tracheobronchial repair: one died of concomitant injuries. Pneumonectomy was uniformly fatal and should be a procedure of last resort in the treatment of pulmonary injury, as lobectomy and pneumonorraphy are better tolerated by these critically ill patients.

Bronchi↗
PubMed1988

Gastrointestinal disruption: the hazard of nonoperative management in adults with blunt abdominal injury.

The danger inherent to nonoperative management of patients with blunt abdominal injury is that gastrointestinal disruptions will escape timely diagnosis and repair. However, children with blunt abdominal injury have been successfully treated nonoperatively for more than a decade. It has been recently proposed, based upon small series, that adults can be managed nonoperatively in a manner similar to that for children. To assess the likely safety for nonoperative management of adults with blunt abdominal injury, we determined the frequency of blunt gastrointestinal disruption in adults, and reviewed the sensitivity of the diagnosis of gastrointestinal disruption by computed tomography. The salient statistically significant findings, based upon an analysis of 6,301 adults and 1,275 children admitted following blunt trauma, were that blunt abdominal injury, blunt gastrointestinal injury, and blunt gastrointestinal disruption are much more frequent in adults. Based upon these findings and the low sensitivity reported for the diagnosis of gastrointestinal disruption by computed tomography, we conclude that the nonoperative management of adults with blunt abdominal injury is as a matter of routine not justified.

Abdominal Injuries↗
PubMed1987

Modified Paul-Mikulicz ileocolostomy.

Primary anastomosis can often be safely performed between the distal ileum and colon after emergent right colectomy. However, when this is not possible, we believe that this ileocolostomy procedure can be performed safely and offers an attractive alternative to ileostomy. It differs from the classic Paul-Mikulicz procedure in that a common channel is created at the initial operation using a stapling device. This obviates the inherent risks of blindly placing bulky spur clamps between the colon and ileum in the postoperative period. Using this technique, we have encountered no staple line leaks, fluid or electrolyte imbalance, or skin excoriation in the postoperative or follow-up period of 26 patients. All ileocolostomies were closed through the ileocolostomy site without formal laparotomy and without complications.

Abscess↗
PubMed1987

Selective management of pediatric pelvic fractures: a conservative approach.

An analysis of clinical characteristics and pelvic fracture management in a recent 5-year period is presented. Ninety-eight percent of pelvic fractures were the result of a motor vehicle accident, which included 61% auto-pedestrian accidents. Seventy-nine percent of patients sustained one or more major injuries while 21% sustained an isolated pelvic fracture. Head injury was the most common concomitant injury (23% of patients). Forty-six percent of patients required blood transfusions (mean 15.8 mL/kg). Forty-one (72%) patients were treated with bedrest. The remainder were treated with traction (5), spica cast immobilization (5), open reduction and internal fixation (4), or anterior external fixation (2). Overall mortality was 14%. In comparing nonsurvivors with survivors there were significant differences in Modified Injury Severity Scores and Glasgow Coma Scores. The types of pelvic fractures that occur in children were found to be similar to those of adults. There was no significant difference in mortality among children with different types of pelvic fractures. In contrast to adults, pelvic fracture hemorrhage was not a major contributing cause of death in this series of patients. All eight deaths were secondary to severe closed head injury.

Adolescent↗
PubMed1987

The demographics of trauma in 1995.

By 1995 population aging will decrease the size of the high-injury-risk age cohort (14-34 years) by 7.0 million (-8.2%). The reduction in the high-injury-risk age cohort should reduce the overall volume of penetrating and blunt injury nationally despite a population increase of 21 million. However, the number of, and the proportion of, elderly victims of injury will increase as there will be an additional 5.3 million (+18.5%) people age 65 years or older. Yet payments based on Medicare diagnosis-related groups (DRG's) do not provide adequate reimbursement for any, let alone the elderly, victims of injury. Moreover, Medicare and Medicaid reimbursements for the long-term care so frequently needed by the elderly victims of injury is inadequate. As our population ages, the adverse financial impact of these circumstances resultant from population aging will increasingly strain the financial resources of our trauma centers.

Age Factors↗
PubMed1987

Penetrating abdominal trauma: the use of operative findings to determine length of antibiotic therapy.

Penetrating abdominal trauma is associated with a high incidence of postinjury infection which can be reduced by appropriate surgical management and short-term antibiotic therapy. Patients at high risk for developing infectious complications may be identified on the basis of operative findings and the duration of the postinjury antibiotic regimen determined. Colonic injury is the most important determinant of infectious complications. Number of other organs injured, age, and mode of injury have little or no additional impact on infection rates. Low-risk patients can be successfully managed with three perioperative doses of antibiotics. Nontrauma related nosocomial infections appear to be associated with trauma related infections in high-risk patients. Intravenous clindamycin plus tobramycin and metronidazole plus tobramycin for 72 hours postinjury are equally effective in reducing postinjury infections in "high-risk" patients.

Abdominal Injuries↗
PubMed1986

The natural history of traumatic branch renal artery injury.

Between 1979 and 1984, 24 patients with traumatic branch renal artery injuries documented by selective angiography were managed at our center. A total of 7 patients (29 per cent) died of nonurological organ system injury during the initial hospitalization. Of the remaining patients 10 were followed for 1 to 5 years after injury. None of these patients required immediate or delayed surgical intervention for complications, while 2 had hypertension after injury that resolved spontaneously by 1 year. The eventual renal function attained by these patients remained normal, the mean creatinine was 0.9 plus or minus 0.1 mg. per dl. and there were no other urological complications. Patients who sustain branch renal artery injuries should be managed nonoperatively unless they exhibit cardiovascular instability. Excision of ischemic parenchyma is indicated only when intractable hypertension associated with increased renin secretion can be identified.

Adolescent↗
PubMed1986

Ground versus air transport of trauma victims: medical and logistical considerations.

Emergency aeromedical transport for trauma victims varies widely, from 10% or less in some programs to more than 90% in others. There is the potential in all such programs for dramatic, lifesaving efforts as well as for costly and dangerous overuse. We propose the following preliminary guidelines for emergency aeromedical transport of trauma victims. Trauma scene flights should be dispatched only for seriously injured patients who are potentially salvageable. Trauma scene flights are not justified if the flight does not significantly reduce the interval between injury and patient arrival at an appropriate hospital (eg, from motor vehicle accident with entrapment) unless the flight delivers needed medical expertise or equipment to the scene. Critically injured patients should be returned to the closest hospital of appropriate capabilities and demonstrated expertise. Flight services should be a public service fully integrated into the metropolitan emergency medical services system. Scene flights should be dispatched within medical guidelines established by the regional emergency medical services system. Emergency aeromedical evacuation of trauma victims should assist the regionalization of trauma care to centers with special capabilities for the management of seriously injured patients. Promulgation of more detailed guidelines will depend on the accumulation of clinical experience and will be possible only if consistent efforts are made to obtain measures of injury severity, categories of injury, and long-term outcomes of management.

Aircraft↗
PubMed1985

Hospital-based rotorcraft aeromedical emergency care services and trauma mortality: a multicenter study.

A group of 1,273 blunt trauma patients who were treated and transported from the site of injury by seven different hospital-based rotorcraft aeromedical emergency care services were studied using a methodology based on injury severity designed to predict the mortality of such patients. The methodology predicted that 241 patients should have died; 191 patients did die. This 21% reduction in expected mortality was highly significant (P less than .001). Each of the seven rotorcraft services had a reduction in predicted mortality. The reduction was statistically significant (P less than .05) in five of the seven aeromedical services, or 86% of the total patient cohort. Hospital-based rotorcraft aeromedical emergency care services may reduce the expected mortality of blunt trauma patients treated at the site of injury.

Adult↗
PubMed1985

The economics of fatal injury: dollars and sense.

This study reviewed the direct costs (charges for goods and services) for 77 consecutive patients who presented to this trauma service with a Trauma Score (TS) of four or less. Seventy-four patients died (96.1%). The survival rates based upon the Trauma Scores were: TS 1, 0(0/34); TS 2, 0(0/9); TS 3, 7.7% (1/13); TS 4, 9.5% (2/21). Only four nonsurvivors lived more than 24 hours. The remaining 70 patients died within 24 hours without achieving even transient cardiovascular stability. Three of the 77 patients survived (3.9%) but only one achieved a productive recovery. The total direct cost for the 77 patients was +544,477.66. Physician fees, which accounted for 26.7% of the direct costs, averaged +1,887.57 per patient (range, 0-+11,291.00). The average direct cost for the three survivors was +50,138.94. The average direct cost for nonsurvivors was +5,325.18 (+3,383.29 for patients with a TS 1 or 2, +8,018.76 for patients with a TS 3 or 4). The hospital direct costs for nonsurvivors ranged from +40.00 for a patient declared dead on arrival to +57,817.91 for a patient who died 41 days after admission. It is futile to continue resuscitational efforts if a valid Trauma Score of 1 or 2 is confirmed shortly after the initiation of appropriate resuscitative measures. Continued therapy is futile for the remainder of patients admitted with Trauma Scores of 4 or less if they do not achieve cardiovascular stability in response to appropriate resuscitative measures within 1 hour of admission.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1985

The significance of scapular fractures.

Scapular fractures in the multiply injured patient have received little attention. Fifty-six patients with 58 scapular fractures secondary to blunt trauma were reviewed. The patients averaged 3.9 major injuries excluding their scapular fractures. The injury pattern associated with blunt scapular fracture is unique. Patients with scapular fracture have a high incidence of injury to the ipsilateral lung and chest wall and to the ipsilateral shoulder girdle and its contained structures: rib fractures, 53.6%; pulmonary contusions, 53.6%; clavicular fracture, 26.8%; brachial plexus injury, 12.5%; subclavian, brachial, or axillary artery injury, 10.7%. Eight patients died (14.3%). Although no patient died from the scapular fracture, half of the deaths in this series were the result of pulmonary sepsis arising in an associated ipsilateral pulmonary contusion. Scapular fractures provide the trauma surgeon with a reliable clinical clue that the patient is at inordinate risk to have associated injuries of major consequence to the ipsilateral lung and chest wall, the ipsilateral shoulder girdle, and the ipsilateral subclavian, axillary, or brachial artery.

Adolescent↗