Biomedical subjects

Areti Tillou

Publications and source records attributed to Areti Tillou.

11 recordsLinked to original sources

PubMed2006

Pelvic fractures in children.

Although rare, pelvic fractures in children have significant morbidity and mortality. No specific guidelines have been developed for the management of these injuries. We reviewed all trauma patients of age 16 years or younger with pelvic fractures treated at our Level I trauma center over the past 12 years. Of 1008 patients with pelvic fractures, 74 were children. Early hemodynamic instability was seen in 14 per cent of cases. Blood transfusions were required in 26 per cent of cases, angiography in 3 per cent of cases, operations for associated injuries in 46 per cent of cases, operative pelvic fracture fixation in 18 per cent of cases, and intensive care unit care in 58 per cent of cases. Mortality was 5 per cent, mostly from hemorrhage and multiple complex injuries. We conclude that pelvic fractures in children are associated with a high frequency of pelvic bleeding and associated injuries that often require operative interventions and intensive care unit care.

Adolescent↗

PubMed2005

Abdominal computed tomographic scan for patients with gunshot wounds to the abdomen selected for nonoperative management.

BACKGROUND: Computed tomographic (CT) scanning is increasingly used in patients with abdominal gunshot wounds (AGSWs) selected for nonoperative management (NOM). Triple-contrast CT scanning (i.e., intravenous, oral, and rectal) has produced encouraging initial results. The exact role and usefulness of CT scanning with intravenous contrast only is unknown. METHODS: Hemodynamically stable AGSW patients without generalized abdominal tenderness were offered a trial of NOM, underwent single-contrast (intravenous) CT scanning, and were prospectively followed from July 1, 2002, to May 31, 2004. The sensitivity and specificity of CT scanning to detect organ injuries requiring repair were calculated against the clinical results of NOM. The effect of CT scanning in management was recorded. RESULTS: One hundred patients with nontangential AGSWs were included. Twenty-six required laparotomy, which was nontherapeutic in five (19%). These five patients underwent operation on the basis of misleading CT findings (n = 3) or development of clinical symptoms (n = 2). Two CT scans were false-negative, and these patients were operated on at 121 and 307 minutes after arrival for hollow visceral injuries and recovered without postoperative complications. Three CT scans were false-positive and resulted in nontherapeutic laparotomies without postoperative complications. The sensitivity and specificity of CT scanning was 90.5% and 96%, respectively. CT findings resulted in a change of management in 40 patients. In nine, the decision to operate was changed to a decision to manage nonoperatively; whereas in eight, the opposite occurred. In addition, in 17, the decision to observe was changed to a decision to discharge; whereas in 1, the opposite occurred. Finally, five patients had additional tests after the findings of CT scanning. CONCLUSION: Abdominal CT scanning is a safe and useful method of selecting AGSW patients for NOM. Further exploration is needed to define the precise benefits of routine CT scanning over clinical examination with selective CT scanning.

Abdominal Injuries↗

PubMed2004

Thoracic packing for uncontrolled bleeding in penetrating thoracic injuries.

We present a series of three patients who suffered penetrating thoracic injury, and in whom thoracic packing was used as a life-saving procedure. Survival among these patients paralleled the severity and extent of the original injuries. Restriction of cardiac filling and lung expansion are potential deterrents from using this technique; however, its use seems to be a valid adjunct, especially in the setting of chest wall bleeding coming from the intercostal arteries. Damage control surgery in pentrating thoracic trauma, including thoracic packing, is a sound alternative when uncontrollable bleeding, hypothermia and coagulopathy compromises the survival of a patient.

Adolescent↗

PubMed2004

Can we rely on computed tomographic scanning to diagnose pulmonary embolism in critically ill surgical patients?

BACKGROUND: Spiral computed tomographic pulmonary angiography (CTPA) is gaining an increasing role in pulmonary embolism (PE) diagnosis because it is more convenient and less invasive than conventional pulmonary angiography (PA). Encouraging reports on the reliability of CTPA for medical patients have prompted widespread use despite the fact that its value in critically ill surgical patients has been inadequately explored. Hemodynamic and respiratory issues of critical illness may interfere with CTPA's diagnostic accuracy. The objective of this study was to compare CTPA with PA for the diagnosis of PE in critically ill surgical patients. METHODS: Over 30 months (August 1999-February 2002), 37 critically ill surgical patients (28 trauma and 9 non-trauma patients) wiith clinical suspicion of PE were enrolled prospectively. CTPA and PA were independently interpreted by four radiologists (two for each test) blinded to each other's interpretation. Clinical suspicion for PE was classified as high, intermediate,or low on the basis of predetermined criteria. PA was considered as the standard of reference for the diagnosis of PE. RESULTS: PE was found in 15 (40%) patients by: central PE in 8 and peripheral PE in 7. CTPA and PA findings were different in 11 patients (30%): CTPA was false-negative in 9 patients and false-positive in 2. Its sensitivity and specificity were PE 50% and 100%, respectively, for central PE; 28% and 93% for peripheral PE; and 40% and 91% for all PE. There were no differences in risk factors or clinical characteristics between patients with and without PE. The level of clinical suspicion was identical in the two groups. The independent reviewers disagreed on CTPA or PA interpretations in 11% and 16% of the readings, respectively. CONCLUSION: PA remains the "gold standard" for diagnosis of PE in critically ill surgical patients. CTPA should be explored further before being universally accepted. Clinical criteria are unreliable for detecting PE in this population and therefore a high index of suspicion should be maintained.

Adolescent↗

PubMed2004

Necrotizing soft tissue infections: improved outcomes with modern care.

The outcome of necrotizing soft tissue infections (NSTI) remains unchanged despite advances in care. Reasons cited are changing patterns of causative factors, delays in diagnosis, and inadequate antibiotic coverage and surgical treatment. To document outcomes of NSTI after aggressive management and to identify risk factors of mortality and prolonged hospital stay, we reviewed all our patients with NSTI admitted from January 2000 to January 2002. Causative factors, comorbid conditions, site of NSTI, physiologic parameters, symptoms, diagnostic tests, therapeutic interventions, and outcomes were analyzed. Patients were treated aggressively with antibiotics, admission to ICU, and frequent surgical debridements. Of 46 patients identified, 28 (61%) were admitted in ICU, and eight (17%) died. The patients who died had higher admission white blood cell counts (46 +/- 22 vs 22 +/- 10 x 10(3)/mm3, P = 0.01), higher admission pain score (8 +/- 1 vs 5 +/- 3, P = 0.02), longer intervals from admission to antibiotic administration (16 +/- 20 vs 6 +/- 12 hours, P = 0.02), and fewer surgical debridements (2.6 +/- 1.1 vs 3.6 +/- 1.7, P = 0.04). No independent risk factors of mortality or ICU admission were identified. We concluded that severe local pain and a significantly elevated white blood cell count on admission should alert the physician to the presence of severe infection and prompt the initiation of expeditious aggressive treatment.

Adult↗

PubMed2003

High success with nonoperative management of blunt hepatic trauma: the liver is a sturdy organ.

HYPOTHESIS: Nonoperative management of liver injuries (NOMLI) is highly successful and rarely leads to adverse events. DESIGN: Prospective observational study. SETTING: High-volume academic level I trauma center. PATIENTS: For 26 months, 78 consecutive unselected patients with liver injuries were followed up prospectively. In the absence of hemodynamic instability or signs of hollow visceral trauma, NOMLI was offered irrespective of the magnitude of the liver injury. Main Outcome Measure Failure of NOMLI, defined as a laparotomy after an initial decision to treat the patient nonoperatively. RESULTS: Of the 78 patients, 23 (29%) were operated on immediately, but only 12 (15%) for bleeding from the liver. All 12 patients required packing in addition to other maneuvers (hepatorrhaphy [n = 8], resection [n = 4], and liver isolation [n = 1]). Of the remaining 55 patients selected for NOMLI, the method failed in 8 for reasons unrelated to the liver injury: 2 underwent a splenectomy, 1 underwent a nephrectomy, 1 had a small-bowel repair, 1 underwent abdominal decompression for abdominal compartment syndrome, and 3 underwent a nontherapeutic laparotomy. The success rate of NOMLI was 85% (47 of 55 patients), but the liver-specific success rate was 100%. Compared with those in whom NOMLI was successful, patients in whom it failed had a higher Injury Severity Score and underwent more blood transfusions, but they had similar liver injury grades. In total, 66 (85%) of liver injuries did not bleed significantly. No adverse events were attributed to NOMLI. CONCLUSIONS: Nonoperative management of liver injuries is safe and effective regardless of the grade of liver injury. Failure of NOMLI is caused by associated abdominal injuries and not the liver. Fluid and blood requirements, the degree of injury severity, and the presence of other abdominal organ injuries may help predict failure.

Abdominal Injuries↗

PubMed2003

Necrotizing soft-tissue infections.

It has been more than 130 years since NSTIs were first described. Despite the development of various classification systems and progress in surgical management, these infections continue to have high mortality and pose enormous diagnostic and therapeutic challenges. For optimal outcome, treatment involves rapid institution of appropriate antibiotic coverage and early wide surgical debridement. Recovery requires aggressive resuscitation, postoperative nutritional support and wound care that is similar to the care of burn patients in many respects. The entire therapeutic process requires a well-prepared and coordinated team of health care professionals including EPs, general, orthopedic, and other specialist surgeons, infectious disease consultants, specially trained nursing staff, and physical therapists.

Humans↗

PubMed2003

Operative management and outcomes in 103 AAST-OIS grades IV and V complex hepatic injuries: trauma surgeons still need to operate, but angioembolization helps.

BACKGROUND: American Association for the Surgery of Trauma (AAST) Organ Injury Scale (OIS) grades IV and V complex hepatic injuries are highly lethal. Our objectives were to review experience and identify predictors of outcome and to evaluate the role of angioembolization in decreasing mortality. METHODS: This was a retrospective 8-year study of all patients sustaining AAST-OIS grades IV and V hepatic injuries managed operatively. Statistical analysis was performed using univariate and multivariate logistic regression. The main outcome measure was survival. RESULTS: The study included 103 patients, with a mean Revised Trauma Score of 5.61 +/- 2.55 and a mean Injury Severity Score of 33 +/- 9.5. Mechanism of injury was penetrating in 80 (79%) and blunt in 23 (21%). Emergency department thoracotomy was performed in 21 (25%). AAST grade IV injuries occurred in 51 (47%) and grade V injuries occurred in 52 (53%). Mean estimated blood loss was 9,414 mL. Overall survival was 43%. Adjusted overall survival rate after emergency department thoracotomy patients were excluded was 58%. Results stratified to AAST-OIS injury grade were as follows: grade IV, 32 of 51 (63%); grade V, 12 of 52 (23%); grade IV versus grade V (p < 0.001) odds ratio, 2.06; 95% confidence interval, 2.72 (1.40-3.04). Logistic regression analysis identified as independent predictors of outcome Revised Trauma Score (adjusted p < 0.0002), angioembolization (adjusted p < 0.0177), direct approach to hepatic veins (adjusted p < 0.0096), and packing (adjusted p < 0.0013). CONCLUSION: Improvements in mortality can be achieved with an appropriate operative approach. Angioembolization as an adjunct procedure decreases mortality in AAST-OIS grades IV and V hepatic injuries.

Embolization, Therapeutic↗

PubMed2003

Intubation after cervical spinal cord injury: to be done selectively or routinely?

Patients with cervical spinal cord injuries (CSCIs) often develop acute respiratory failure and require intubation. It is unknown if intubation should be offered preemptively in all CSCI patients or selectively based on signs of acute respiratory failure. The purpose of this study was to evaluate the role of routine early intubation in CSCI patients. The medical records of 68 patients with CSCI were reviewed. Univariate and multivariate analyses were used to identify independent risk factors for the need of intubation. Statistical significance was considered at P < 0.05. Fifty patients (74%) required intubation and 27 (40%) developed pneumonia. Of patients with CSCI above C5, 87.5 per cent required intubation compared with 61 per cent of patients with CSCI at C5-C8 (P = 0.026). Similarly, of patients with complete quadriplegia, 90 per cent required intubation compared to 48.5 per cent of patients with incomplete quadriplegia or paraplegia (P < 0.001). Of 31 patients not presenting with overt signs of acute respiratory failure on admission, 13 (42%) decompensated later and were eventually intubated up to 53 hours after admission. Six of these 13 patients had emergent intubation due to acute desaturation and developed pulmonary complications associated with emergent intubation. There were 3 independent risk factors for the need of intubation: Injury Severity Score > 16, CSCI higher than C5, and complete quadriplegia. The combination of the 2 latter risk factors resulted in intubation in 21 of 22 patients (95%). The majority of patients with CSCI require intubation. In patients with CSCI above C5 and complete quadriplegia, intubation should be offered routinely and early because delays may cause preventable morbidity.

Adult↗

PubMed2003

Fascial dehiscence after trauma laparotomy: a sign of intra-abdominal sepsis.

Fascial dehiscence (FD) after trauma laparotomy is associated with technical failure, wound sepsis, or intra-abdominal infection (IAI). The association of IAI with FD is inadequately evaluated. Knowing about its presence is essential to guide clinical diagnosis and management. Our objective was to identify the incidence and risk factors of IAI in patients with FD. We performed a medical record review of 55 trauma patients with FD. Patients with IAI were compared to patients without IAI and FD patients to all trauma laparotomy patients during the same period. Statistical significance was at P < 0.05. Thirty-nine (71%) FD patients had IAI, significantly higher than all trauma laparotomies (4.6%, P < 0.0001). Only 31 per cent of patients underwent laparotomy and drainage while 69 per cent received CT-guided percutaneous drainage followed by expectant management. Similarly, 33 per cent of the non-IAI group had operative management. No differences were found between the two groups in any of the examined factors. The majority of trauma patients with FD have IAI. No clinical or laboratory factors help identify FD patients likely to have IAI. Therefore, FD should be viewed as a sign of possible underlying IAI. Appropriate radiographic imaging or direct visualization of the entire abdominal cavity should be pursued before managing the dehisced fascia.

Abdomen↗

PubMed2002

Visceral vascular injuries.

This article deals with injuries to the celiac trunk, superior and inferior mesenteric arterial injuires. Surgical approaches and physiological implications of interruption of the mesenteric arterial circulation are addressed in detail. Surgical techniques for the management of these injuries and the need for second look operations are also examined.

Abdominal Injuries↗