Showing papers by "Robert F. Lavery published in 1995"

Incidence and risk factors for early small bowel obstruction after celiotomy for penetrating abdominal trauma

Abstract: The reported overall incidence of postoperative Small Bowel Obstruction (SBO) is 0.69 per cent. This study examined the incidence and risk factors for early postoperative SBO for penetrating abdominal trauma (PAT), with early SBO defined as SBO within 6 months of operation. This was a prospective cohort study of patients admitted to a Level 1 Trauma Center from 5/91 to 12/93 who required celiotomy for PAT. Patients were followed at least 6 months for readmission for SBO to be considered evaluable. Of 341 patients undergoing celiotomy for PAT and surviving to discharge, 298 (87.4%) were evaluable. The overall incidence of early SBO was 7.4 per cent and varied between 2.3 per cent (nontherapeutic celiotomy) and 10.8 per cent (small/large bowel injury). All patients with celiotomy for PAT are at increased risk for early SBO compared with elective surgery patients. Those with small/large bowel penetration or gunshot wounds are at the highest risk. Previous abdominal surgery is not a risk factor for early SBO in PAT patients. Surgeons and Managed Care case managers should devote special attention to close follow-up in PAT patients, particularly those with the risk factors identified in this study.

Utility of Routine Admission Serum Chemistry Panels in Adult Trauma Patients

Abstract: Objectives: To determine the frequency of abnormal serum chemistries and whether they provide clinically useful information regarding trauma patients. To identify clinical criteria associated with critical serum chemistry values (CSCVs). Methods: The records of all trauma patients admitted to one urban, Level I Trauma Center were retrospectively reviewed for the period (July 1-December 31, 1989). All trauma patients who had had serum chemistry determinations at hospital admission and at least once more prior to discharge were studied. The CSCVs were determined by a panel of experts prior to record review. Serum chemistry values, patient demographics, mechanisms of injury, and outcomes were statistically analyzed. Results: Most (814/913; 89%) trauma patients had abnormal serum chemistry values. However, only 54/913 (6%) had CSCVs and only six of these CSCVs had prompted a change in resuscitation or treatment (therapeutic K+ infusions). Age > 50 years, a history of hypertension therapy, and a Glasgow Coma Scale score ± 10 were associated with CSCVs; and CSCVs were correlated with increased mortality and critical care unit admission. Conclusion: Routine-admission serum chemistry values, while frequently abnormal for major trauma patients, generally do not provide clinically useful information in the resuscitation and treatment of trauma patients. Hypoglycemia and metabolic acidosis were more rapidly determined using bedside glucose determination and arterial blood gas evaluation. The routine-admission serum chemistry panel described in the study lacked utility for most trauma patients. Selective chemistry panel ordering should be used at the time of hospital admission for major trauma patients.

Physician medical direction and advanced life support in the United States.

Abstract: Objective: To determine the specialty training and responsibilities of urban U.S. emergency medical service (EMS) medical directors and how these factors relate to the type of service involved (fire, hospital, private, municipal). Methods: A single mailed survey of training officers—field supervisors of 211 urban advanced life support (ALS) services in the United States. The survey also requested information about medications carried, approved procedures, and who set these standards. Respondents also rated the EMS medical director's involvement in various activities (quality assurance, administrative, executive, run reviews, and in-service/education). Results: Eighty-five percent (n = 179) of the forms were returned, with 165 (78%) usable. The physician EMS medical directors were primarily trained in emergency medicine (77%) and were paid (75%) for EMS responsibilities. The number of medications carried and the number of approved procedures were not related to either the number of hours the physicians commit weekly to the EMS service or their degree of involvement in ALS activities. The physician EMS medical directors were most often involved in quality assurance and education and were less likely to devote time to executive or other administrative functions of ALS units, with the exception of fire-based EMS physician medical directors, who contributed significantly to executive and administrative functions (p < 0.05). Overall practice standards were established by the medical director (46%), the state department of health (24%), and local/regional health authorities (23%). Conclusions: EMS training officers believe that urban ALS medical directors in the United States primarily provide quality assurance and educational support. With the exception of fire-based EMS systems, physicians appear to have limited involvement in other EMS administrative and executive functions.