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Biomedical subjects

C W Schwab

Publications and source records attributed to C W Schwab.

At least 19 recordsLinked to original sources
PubMed1996

Comorbidity and the elderly trauma patient.

The elderly are forming an increasingly larger proportion of the population in developed countries with increasingly active life styles. The injured elderly patient has a combination of decreased physiologic reserve and a high incidence of preexisting medical conditions that cause comparably worse outcome, complications, longer hospital stay, and high costs. Although the management of specific injuries is similar in the elderly, many benefit from an overall more aggressive approach to early resuscitation and optimization of cardiopulmonary dynamics. An awareness of the importance of preexisting medical conditions and a coordinated, directed approach to the management of the injuries and the concomitant diseases leads to the most effective care. Upon recovery from injury there is often a change of functional level that precipitates a change in social circumstance. Ethical dilemmas, both at individual and community levels, may arise more frequently in the older trauma patient population. Increased triage to a trauma center, particularly when concomitant disease is present, is justified on the basis of improving outcomes.

Age Factors↗
PubMed1996

Thoracic gunshot wounds in children under 17 years of age.

Over the past decade there has been a significant increase in the incidence of gunshot wounds (GSW) among Americans under 19 years of age. Despite the increase, pediatric GSW have received little attention in the literature, and no study has focused on pediatric victims of thoracic GSW. In the present study, the authors performed a retrospective review of the records of 51 patients under 17 years of age who were treated for thoracic GSW at adjoining level I pediatric and adult trauma centers between July 1987 and June 1995. The primary catchment area for these institutions is a lower socioeconomic, urban tenancy. The study population was 80.4% male and 86.3% black; the mean age was 12.4 years. The mean injury severity score and trauma score were 13.6 and 13.4, respectively. Although statistically significant differences could not be demonstrated with this population size, trends were evident when the group was subdivided by age group (< or = 12 years and > 12 years of age). The younger group was more likely to require a thoracic operation after injury (35.3% v 23.5%), to have unstable vital signs (41.2% v 26.5%), to have a higher total abbreviated injury score (AIS) for the chest (4.8 v 4.0); however, their total extrathoracic AIS was lower (2.1 v 3.1). The younger group spend more time in the hospital and in the intensive care unit (7.6 v 4.6 days and 2.0 v 0.9 days, respectively). The younger children were more likely to have sustained injury by unintentional crossfire (35.3% v 14.7%) and were never injured by intentional assault (0% v 47.2%). Overall, 50% of the patients required surgery, including 93.8% of the patients who had unstable vital signs at the time of arrival. All six deaths (11.8%) owing to the thoracic injury occurred in patients who had mediastinal injury that required an emergency-department thoracotomy (EDT). The authors conclude that among this predominantly black male population, there are different trends with respect to treatment, circumstances, and pattern of injury between the younger and older subpopulations.

Abbreviated Injury Scale↗
PubMed1996

Arterial bleeding diagnosed by CT in hemodynamically stable victims of blunt trauma.

Although the presence of intra-abdominal blood is a common finding on abdominal computed tomography (CT) scans performed for trauma, acute intra-abdominal bleeding is rarely diagnosed by CT. A focal area of high-density contrast, as compared to the surrounding fluid and tissues, is the characteristic CT finding associated with acute intra-abdominal bleeding and should prompt immediate intervention.

Abdominal Injuries↗
PubMed1996

Aortic balloon control of a traumatic aortoenteric fistula after damage control laparotomy: a case report.

Aortoenteric fistula is a rare complication of abdominal trauma. We present a case of a patient with multiple gunshot wounds to the abdomen and thorax in whom control of injury required staged operations. An aortoenteric fistula developed, presenting a diagnostic and therapeutic challenge. The operative control of aortic bleeding was by a retroperitoneal approach to the aorta and facilitated by the use of percutaneous aortic balloon catheters. The patient survived to leave hospital. This case highlights a rare trauma complication, the use of "damage control" for the severely injured abdomen and the technique of intra-arterial balloon control of bleeding from inaccessible locations.

Abdominal Injuries↗
PubMed1996

Out-of-hospital rapid-sequence induction for intubation of the pediatric patient.

OBJECTIVE: To determine the effectiveness and morbidity of out-of-hospital rapid-sequence induction (RSI) for endotracheal intubation (ETI) in the pediatric population. METHODS: The medical records were retrospectively reviewed for a consecutive series of pediatric patients undergoing out-of-hospital RSI by flight paramedics from July 1990 through July 1994. Patient demographics, pharmacologic agents, ED arterial blood gas data, pulmonary complications, and RSI-related complications were abstracted. RESULTS: Forty patients (31 injured, 9 medical) with a mean age of 8.1 years (range 0.5-17 years) underwent out-of-hospital RSI. Indications for intubation included hyperventilation (n = 20), combativeness (n = 16), apnea (n = 5), and unknown (n = 5). Intubation mishaps occurred in 13 patients (33%); these included multiple attempts (n = 9), aspiration (n = 8), and esophageal intubation (n = 1). The success rate of ETI was 97.5% (one failed attempt). Hemodynamic side effects occurred in three patients (8%); all three had bradycardia, with one developing hypotension. Bradycardia was associated with failure to pretreat with atropine (p < 0.05). Sixteen pulmonary complications, seven pneumonia (18%) and nine atelectasis (22.5%), occurred in 13 patients within the first ten hospital days. Intubation mishaps were not associated with pulmonary complications. There were six deaths, none associated with RSI. CONCLUSIONS: 1) Rapid-sequence induction is an effective method for obtaining airway control in the critically ill pediatric patient. 2) Intubation mishaps did not influence the rate of pulmonary complications. 3) Omission of atropine was associated with bradycardia during RSI in pediatric patients.

Adolescent↗
PubMed1995

Characteristics of crashes attributed to the driver having fallen asleep.

While it has been known for some time that crashes can result from the driver falling asleep at the wheel, this issue has received less attention in traffic safety programs than the role of alcohol or speed of the vehicle. The present study was done to investigate the characteristics of crashes attributed to the driver being asleep. The study utilized the database at the Highway Safety Research Center at the University of North Carolina that is based on the uniform crash reporting system in that state. Over the years 1990-1992, inclusive, there were 4333 crashes in which the driver was judged to be asleep but not intoxicated. The crashes were primarily of the drive-off-the-road type (78% of the total) and took place at higher speeds (62% in excess of 50 mph). The fatality rate was of similar magnitude to that in alcohol-related crashes with fatalities in 1.4% of such crashes (alcohol crashes had fatalities in 2.1%). The crashes occurred primarily at two times of day--during the nighttime period of increased sleepiness (midnight to 7.00 a.m.) and during the mid-afternoon "siesta" time of increased sleepiness (3.00 p.m.). These crashes occurred predominately in young people. Fifty-five percent of these were in individuals 25 years of age or younger, with a peak age of occurrence at age 20 years. Sleepiness may play a role in crashes other than those attributed by the police to the driver being asleep. Determining the magnitude of this role is a challenge to the traffic safety community.

Accidents, Traffic↗
PubMed1995

Bronchoscopic guidance makes percutaneous tracheostomy a safe, cost-effective, and easy-to-teach procedure.

BACKGROUND: We wanted to assess the efficiency of instituting a modified technique of percutaneous tracheostomy (PET) with bronchoscopic guidance. METHODS: During a 10-month period 48 consecutive trauma patients requiring tracheostomy were divided between a standard tracheostomy control group (ST) and a PET group. All patients were followed prospectively. The hospital charges were reviewed retrospectively. RESULTS: Age, gender, body habitus, and principal diagnosis were similar in the 21 ST patients and the 27 PET patients. All STs and 15 of the PETs were performed in the operating room (OR), and the 12 remaining PETs were done in the intensive care unit (ICU). Four patients in the ST group and six in the PET group died. One of these deaths occurred in a patient in the PET group with severe adult respiratory distress syndrome. Procedure time was shorter for PET (16 versus 45 minutes, p < 0.0001). Junior residents performed more PETs than STs (33% versus 10%), and PET was considered "easier" to perform than ST (81% versus 47%). Hospital charges for PET in the ICU were $3400 less per patient compared with ST or PET in the OR. CONCLUSIONS: PET was performed easily and safely in the OR and at the ICU bedside. PET required one-third the time of ST. Bronchoscopic supervision of PET may have contributed to the small number of complications and the educational experience of junior residents. PET in the ICU can reduce hospital charges significantly and avoids transport of patients to the OR. PET is as safe as ST and should be considered the procedure of choice for an ICU patient requiring an elective tracheostomy.

Adult↗
PubMed1995

Temporary vascular continuity during damage control: intraluminal shunting for proximal superior mesenteric artery injury.

"Damage control" is an accepted technique for the treatment of the patient with exsanguinating injuries to the abdomen and intraoperative coagulopathy. We describe the use of an intraluminal shunt to maintain temporary vascular continuity of the superior mesenteric artery during rewarming and correction of coagulopathy in the intensive care unit following a gun shot wound to the abdomen. Successful complex reconstruction was achieved at definitive laparotomy using an autogenous vein interposition graft.

Adult↗
PubMed1995

Occult hypercarbia. An unrecognized phenomenon during percutaneous endoscopic tracheostomy.

Bronchoscopy has been incorporated as a useful adjunct to increase the safety and effectiveness of percutaneous endoscopic tracheostomy (PET). Insertion of the bronchoscope, along with the intraluminal dilators of the PET set, into the airway potentially leads to hypoventilation and hypercarbia during the procedure. Using continuous in-line arterial blood gas monitoring, we documented profound hypercarbia in two patients undergoing PET in the surgical ICU. In a third patient, the rise in PaCO2 was accompanied by a marked rise in intracranial pressure (ICP), and a corresponding fall in cerebral perfusion pressure. While transient hypercarbia seems well tolerated by most patients, this phenomenon and its effect on cerebral blood flow should be strongly considered before performing PET on the critically ill patient with evidence of elevated ICP.

Blood Pressure↗
PubMed1995

Penetrating neck trauma: sensitivity of clinical examination and cost-effectiveness of angiography.

PURPOSE: To evaluate penetrating neck trauma for (a) sensitivity of the clinical examination as an indicator of clinically significant vascular injury, and (b) cost-effectiveness of performing screening diagnostic angiography. METHODS: The medical records of all patients with penetrating neck trauma presenting at our institution over 4 years were retrospectively reviewed. Injuries were classified into one of three anatomic zones and classified into four mutually exclusive groups based on the extent of vascular injury; (a) no vascular injury; (b) minor vascular abnormality; (c) major vascular abnormality without a change in clinical management; or (d) any injury requiring a change in clinical management. Cost data were also obtained for each patient's hospitalization. RESULTS: There were 111 patients with penetrating neck trauma. No statistically significant difference between the sensitivities of the clinical examination or angiography for the detection of vascular injury were detected. Of the 48 patients who had vascular injuries, 45 had an abnormal clinical findings (93.7% sensitivity). None of the remaining 3 patients with vascular injury and normal clinical findings would have had their treatment altered by the results of angiography. The calculated cost of using angiography as a screening tool for vascular injury in patients with normal clinical findings was approximately $3.08 million per central nervous system event prevented. CONCLUSION: Our study suggests that in patients with zone II penetrating neck injuries the clinical examination is sufficient to detect significant vascular lesions and that screening angiography may not be indicated. Because our sample size was relatively small and the mean follow-up only 13.3 days, further investigation is needed to demonstrate definitively the lack of usefulness of screening angiography.

Adolescent↗
PubMed1995

The single-layered, parachuted intussuscepted pancreaticojejunostomy.

The pancreas to jejunal anastamosis after pancreaticoduodenectomy can be a troublesome and difficult procedure. We describe a single-layered intussuscepted end-to-end anastamosis that has been used in both the trauma and elective settings with good results. The technique is easily and quickly performed and allows for uniform placement, tension, and depth of sutures, even in the nonfibrotic pancreas.

Humans↗
PubMed1994

Transcutaneous balloon catheter tamponade for definitive control of subclavian venous injuries: case reports.

Two cases are presented in which transcutaneous balloon catheter tamponade of exsanguinating infraclavicular injuries was performed in the trauma admitting area. Angiography and venography demonstrated isolated injuries of the subclavian vein tamponaded by the balloon catheter. Balloon catheter tamponade provided emergency control of bleeding in the admitting area and ultimately definitive treatment of the venous injury.

Adolescent↗
PubMed1994

Gluteal gunshot wounds: who warrants exploration?

It is difficult to determine which stable patients with gluteal gunshot wounds warrant exploration since 22% to 36% will have injuries requiring operative intervention. The ability of preoperative studies to identify major injuries was evaluated to determine which studies could accurately triage patients into a high-risk group that would warrant laparotomy and a low-risk group that could be managed with observation. The findings of abdominal tenderness or gross blood in the urine or rectum were each highly predictive of major injury. The determination of an extrapelvic versus transpelvic bullet trajectory allowed accurate triage of 94% of patients. Nearly 85% of patients with a transpelvic trajectory had injuries that required operative intervention. No patients with an extrapelvic trajectory required laparotomy. Given the density of vital structures above and below the peritoneum in the pelvis, we conclude that any patient with a transpelvic bullet trajectory warrants exploration.

Adult↗
PubMed1994

Pelvic kidney laceration: an unusual complication of percutaneous diagnostic peritoneal lavage--case report.

Diagnostic peritoneal lavage (DPL) is considered the gold standard in the evaluation of patients with suspected blunt abdominal trauma when the results of the abdominal examination are equivocal or when the patient's mental status is altered. In recent years a percutaneous method using the Seldinger technique has been performed. We present a case report of an unusual complication of DPL using the percutaneous method.

Abdominal Injuries↗
PubMed1994

Massive blood loss in trauma patients. The benefits and dangers of transfusion therapy.

In acutely injured patients, recognition of profound shock may be difficult initially. Ensuring adequate oxygenation, restoring intravascular volume, and controlling ongoing blood loss are key principles of treatment in these patients. Additionally, an appreciation for and recognition of the possible adverse consequences of massive transfusion (ie, hypothermia, coagulopathy, hypocalcemia, hyperkalemia, and hemolysis) enable physicians to prevent them or at least lessen their effects.

Blood Transfusion↗