Showing papers by "Lincoln Hospital published in 1995"

Gastric mucosal pH and oxygen delivery and oxygen consumption indices in the assessment of adequacy of resuscitation after trauma: a prospective, randomized study.

Abstract: Objective : To compare gastric mucosal pH (pHi) and global oxygen variables [Oxygen Delivery Index (DO 2 I) and Oxygen Consumption Index (VO 2 I)] as indicators of adequacy of resuscitation after major trauma. Methods : Twenty-seven patients were prospectively randomized into two groups : group 1 (n = 11), normalization and maintenance of pHi at or above 7.30 ; and group 2 (n = 16), maintaining a DO 2 I of 600 and a VO 2 I of >150. The groups had statistically similar injury severity scores, lactate, and base deficit. Results : The goals of therapy were achieved within 24 hours of admission in 10 of the 11 patients in group 1 and in 15 of the 16 patients in group 2. One patient (9.1%) in group 1 died. This patient had transient stabilization of pHi to 7.3 and subsequently had persistent mucosal acidosis. Of the 10 patients with pHi > 7.3 at 24 hours, 9 survived. In group 2, 5 (31.3%) died. Four of the 5 nonsurvivors had achieved DO 2 I and VO 2 I goals, but had pHi < 7.3 at 24 hours. A comparison of time taken for optimization of DO 2 I, VO 2 I, lactate, base excess, and pHi showed pHi and lactate as the variables different in survivors and nonsurvivors. Six of the 8 patients who developed multiple organ dysfunction syndrome had pHi < 7.3 at 24 hours. Persistently low pHi was the first sign of bacteremia (3 patients), small bowel gangrene or pregangrene (2 patients), intestinal anastomotic leak (2 patients), intra-abdominal hypertension (4 patients), and intra-abdominal abscess (5 patients). It was the first finding in all the nonsurvivors at least 72 hours before death. Conclusions : pHi may be an important marker to assess the adequacy of resuscitation. pHi monitoring may provide early warning for systemic complications in the postresuscitation period.

Management of penetrating laryngotracheal injuries

Abstract: Background. Penetrating Iaryngotracheal injuries are uncommon; however, these injuries are associated with significant morbidity and mortality. In an attempt to define the management of penetrating laryngotracheal injuries, we reviewed our experience with these injuries. Methods. We retrospectively analyzed the records of all patients admitted to a Level I trauma center who required operative management for penetrating laryngotracheal injuries. During the period of this study all patients with penetrating neck injuries were managed according to a protocol of selective exploration. Results. Of fifty-seven patients with penetrating laryngotracheal injury 32 patients sustained gunshot wounds and 25 had stab wounds. The injuries were to the larynx in 24 (42%) and trachea in 33 (58%). Forty-six (81%) had isolated airway injuries and 11 (19%) had combined airway and digestive-tract injuries. Emergent airway management in 32 (56%) patients included: tracheostomy (15), endotracheal intubation (14), and cricothyroidotomy (3). Respiratory distress and subcutaneous crepitus were the commonest clinical findings. Diagnostic evaluation included: Iaryngoscopy/tracheoscopy (17), esophagoscopy (12), contrast esophagography (9), angiography (8), and bronchoscopy (3). Repair of laryngotracheal and esophageal injury was performed in the majority of patients. Selected patients with milder Iaryngotracheal injury did not have tracheostomy performed, with no increase in morbidity or mortality. There were 2 (3.5%) early deaths from associated major vascular injury. Conclusion. Mortality can be minimized by aggressive airway control. Endotracheal intubation can be accomplished safely in selected patients with penetrating laryngotracheal injuries. Digestive-tract injuries can often clinically occult and contribute significantly to morbidity and mortality; therefore, early evaluation of the esophagus is vital. Simple repair of Iaryngotracheal and digestive-tract injuries can be performed safely with good results. In patients with minor injuries, tracheostomy does not appear to be mandatory. © 1995 Jons Wiley & Sons, Inc.

Management of penetrating laryngotracheal injuries

Abstract: Background. Penetrating laryngotracheal injuries are uncommon; however, these injuries are associated with significant morbidity and mortality. In an attempt to define the management of penetrating laryngotracheal injuries, we reviewed our experience with these injuries. Methods. We retrospectively analyzed the records of all patients admitted to a Level I trauma center who required operative management for penetrating laryngotracheal injuries. During the period of this study all patients with penetrating neck injuries were managed according to a protocol of selective exploration. Results. Of fifty-seven patients with penetrating laryngotracheal injury 32 patients sustained gunshot wounds and 25 had stab wounds. The injuries were to the larynx in 24 (42%) and trachea in 33 (58%). Forty-six (81%) had isolated airway injuries and 11 (19%) had combined airway and digestive-tract injuries. Emergent airway management in 32 (56%) patients included : tracheostomy (15), endotracheal intubation (14), and cricothyroidotomy (3). Respiratory distress and subcutaneous crepitus were the commonest clinical findings. Diagnostic evaluation included : laryngoscopy/tracheoscopy (17), esophagoscopy (12), contrast esophagography (9), angiography (8), and bronchoscopy (3). Repair of laryngotracheal and esophageal injury was performed in the majority of patients. Selected patients with milder laryngotracheal injury did not have tracheostomy performed, with no increase in morbidity or mortality. There were 2 (3.5%) early deaths from associated major vascular injury. Conclusion. Mortality can be minimized by aggressive airway control. Endotracheal intubation can be accomplished safely in selected patients with penetrating laryngotracheal injuries. Digestive-tract injuries can often clinically occult and contribute significantly to morbidity and mortality ; therefore, early evaluation of the esophagus is vital. Simple repair of laryngotracheal and digestive-tract injuries can be performed safely with good results. In patients with minor injuries, tracheostomy does not appear to be mandatory.

Perimortem Cesarean Section: Case Reports and Recommendations

Abstract: Per mortem cesarean section is rarely required in the ED However, since trauma now represents a leading cause of no obstetric maternal death, emergency physicians (EPs) may more commonly be faced with the difficult decision of performing an emergency cesarean section Two cases are described of severely traumatized pregnant patients for whom per mortem cesarean section in the ED led to birth of viable infants, with one long-term survivor The rationale and guidelines for the procedure are discussed, and it is emphasized that the EP should be thoroughly familiar with the procedure and prepared to perform it when indicated to enhance fetal (and potentially maternal) survival

Evaluation of subxiphoid pericardial window used in the detection of occult cardiac injury

Abstract: We critically evaluated several diagnostic modalities (clinical criteria, subxiphoid pericardial window (SPW) and laparoscopy) used in the detection of occult cardiac injury in haemodynamically stable patients at high risk of cardiac injury. Over 5 years, 122 patients were admitted to a Level I trauma centre with such an injury. They sustained 69 stab wounds, and 53 gunshot wounds. Sites of penetration were: precordial (81), right chest (25), lateral chest (13), thoracoabdominal (40) and abdominal (19). Vital signs in the emergency room were (mean ± SD): systolic BP, 111 ± 23.2 mmHg; HR, 106 ± 18.7; GCS, 13.6 ± 1.3; and CVP, 17 ± 7.8 cmH2O. SPW was performed in all patients and was positive for haemopericardium in 26 patients, 24 (92 per cent) of whom had a cardiac injury at operation. Two patients had pericardial lacerations without cardiac injury. In addition, 14 patients with lower precordial and thoracoabdominal wounds underwent laparoscopy. At laparoscopy, the pericardium was evaluated by transdiaphragmatic inspection in 10 patients. The presence (two) or absence (eight) of blood within the pericardium was accurately predicted and verified by SPW. Univariate and multiple logistic regression analysis of clinical data failed to reveal any significant predictor of cardiac injury. SPW remains the standard means of diagnosing occult cardiac injury in high-risk patients. Since the incidence of occult cardiac injury in haemodynamically stable patients is 20 per cent, SPW should be used liberally. Laparoscopy may have a role in evaluating the pericardium in the subgroup of patients with lower chest wounds, and it facilitates inspection of intra-abdominal viscera and diaphragm at the same time.

A combination of Vicryl and Marlex mesh: a technique for abdominal wall closure in difficult cases.

Abstract: The circumstances in which it is unsafe or impossible to perform primary fascial closure are becoming more frequent. Five cases are reported using a combination of Vicryl and Marlex mesh, such that the Vicryl mesh prevents enterocutaneous fistulae and the Marlex mesh prevents late ventral hernias.

Gardner’s syndrome: a case report

Abstract: Gardner's syndrome (GS) is a dysplasia characterized by neoformations of the intestine, soft tissue, and osseous tissue. Because extra-intestinal manifestations, in particular osteomas, appear promptly even in infants affected with the syndrome and because of the possibility of malignant degeneration, the presence of osteomas necessitates regular surveillance to promptly diagnose the development of an intestinal polyposis typical of GS. This study describes a case of GS diagnosed merely upon suspicion of the existence of the syndrome in a patient who came to our Emergency Department. The study also emphasizes the importance not only of carrying out regular surveillance investigations to ascertain the presence of GS (colonoscopy), but also studying the relatives of any patient with GS, in light of the fact that this particular dysplasia is transmitted genetically.

Unusual presentation of focal nodular hyperplasia.

Abstract: We report an unusual case of focal nodular hyperplasia presenting as a large tumor-like mass extending to the gastric pylorus. This showed increased activity on hepatobiliary imaging. Focal nodular hyperplasia usually develops in women of childbearing age (1). Although It may manifest clinically with vague abdominal pain and fullness, it typically Is identified Incidentally (1). The etiology of FNH remains unknown. However, regression has been documented after the discontinuation of oral contraceptives. Pathologically, the lesion consists of a nodular mass, frequently containing a central stellate scar with radiating fibrous septations (2). Histologic examination reveals an abnormal arrangement of hepatocytes, Kupffer cells, and bile ducts (2). Nuclear imaging reveals uptake of Tc-99m SC in 70% of cases because of the presence of Kupffer cells (3). Although rarely reported, two cases of hepatoblastoma showing uptake of Tc-99m SC have been noted in children (4). However, no known cases of hepatoblastoma have been reported to demonstrate both Tc-99m SC and HIDA uptake. These findings also assist in excluding hepatic adenomas from further clinical consideration (5,6). Sonographic evaluation reveals a nonspecific appearance, ranging from hypoecholc to hyperechloc (7). The size of individual lesions ranges from I cm to 20 cm, with multiple lesions being reported in 13% of cases (7). CT evaluation typically demonstrates a homogeneous mass of slightly decreased density, which becomes iso-to-hyperdense with intravenous contrast administration (7). A central fibrous scar Is infrequently demonstrated on CT or ultrasound (3). This case emphasizes the potential of FNH to appear as a large tumor with extra-hepatic extension. It also supports the role of nuclear imaging when evaluating the etiology of a mass identified on CT or ultrasound.

An adolescent group within a milieu setting

Abstract: A group in a milieu setting is most effective when it uses the shared reality of the milieu in the group. This makes the issues come alive in the group and allows for the learning in the therapy to become applied in the larger environment of the milieu. A clinical example is presented to illustrate the effectiveness of bringing the “world” of the milieu in the group.