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Biomedical subjects

D M Heimbach

Publications and source records attributed to D M Heimbach.

At least 73 records · Page 4Linked to original sources
PubMed1982

Steroid therapy following isolated smoke inhalation injury.

Steroids have no positive influence upon pulmonary related morbidity and mortality following combined smoke inhalation and thermal cutaneous injury (3, 4). Steroid administration following isolated smoke inhalation without concomitant thermal cutaneous injury has, however, been shown to have beneficial effects in previous animal studies (1). This potential therapeutic approach to treatment has not been examined in the clinical setting. Recent hotel fires in Las Vegas, Nevada, resulted in a large cohort of individuals with similar smoke exposures without associated injuries. Two of four hospitals in the triage system administered steroids following injury. Patients were divided into two groups, a steroid-treated, and a non-treated group. These groups were compared using multivariate and frequency analyses. There were no detectable differences in sex, signs, symptoms, and previous medical history. There were likewise no differences between groups with respect to oxyhemoglobin saturation, arterial oxygen tension, arterial pH, and pulmonary-related morbidity and mortality. These data suggest that steroid coverage has little beneficial effect upon pulmonary-related morbidity and mortality following isolated smoke inhalation injury.

Adrenal Cortex Hormones↗
PubMed1982

Ventilation and perfusion alterations following homologous blood transfusion.

A previous study in this laboratory examined the effect of micropore ultrafiltration of blood products on pulmonary gas exchange and subsequent pulmonary dysfunction--related morbidity and death. Morbidity and death from pulmonary failure was not affected; however, gas exchange was improved following ultrafiltration with 40 micrometers filters, as reflected by lower Bohr dead-space fractions. This difference might be explained by reduction of the microaggregate load seen in the pulmonary microvasculature. The purpose of this study was to examine in more detail these gas exchange alterations, paying particular attention to the correlation of changing Bohr dead-space ventilation detected with multiple inert gas analysis with direct determinations of microaggregate size and number. Fourteen patients with isolated cutaneous thermal injury scheduled for major early burn would excision were selected for study. Following transfusion with homologous blood products, the ventilation/perfusion ratio (Va/Q) distributions determined by inert gas analysis remained essentially unchanged except for subtle changes in both high VA/Q and dead-space compartments, resulting in significantly increased Bohr dead-space fractions (P less than 0.05). This combination of gas exchange alteration is consistent with vasoactive and occlusive changes in the pulmonary microvasculature following microaggregate infusion. The correlation of changing dead-space ventilation with the total microaggregate load was poor (r = 0.15) but was significant when compared with counts of microaggregates greater than 90 micrometers in diameter (r - 0.85). These findings suggest that gas exchange alterations following blood transfusion are primarily reflected by increased dead-space ventilation secondary to vasoconstriction and occlusion of the pulmonary microvasculature with microaggregates greater than 90 micrometers in diameter.

Adolescent↗
PubMed1981

Role of emergency thoracotomy in the resuscitation of moribund trauma victims: 100 consecutive cases.

(1) Emergency thoracotomy can be a lifesaving procedure in critically injured patients who present with no detectable pulse or blood pressure. (2) Emergency thoracotomy is nonproductive if cardiac electrical activity is absent. (3) Best results are achieved in patients with chest injuries and the worst results in those with isolated blunt abdominal injury. (4) Survival was better if patient was taken directly to the operating room with ongoing cardiopulmonary resuscitation. (5) Prehospital airway control, volume resuscitation and cardiopulmonary resuscitation play a significant role in improving the outcome in traumatized patients who undergo emergency thoracotomy.

Emergency Medical Services↗
PubMed1981

Minor burns: guidelines for successful outpatient management.

Minor burns are not necessarily trivial. They often involve dynamic or cosmetically important body areas, and outpatient treatment is not always indicated. Hospitalization is usually necessary for the very young or the elderly; those with deep partial-thickness or full-thickness burns; those with burns of the hand, face, foot, or perineum; those who are alcoholics, demented, or economically deprived; and those who have another illness or injury. Hospitalization is mandatory in cases of suspected child abuse or neglect. Superficial partial-thickness burns can be managed in a variety of ways, including application of biologic dressings and synthetic skin coverings. Most deep partial-thickness burns and all full-thickness ones should be considered for early excision and grafting. All but the most superficial burns require maintenance of joint function and long-term follow-up.

Adult↗
PubMed1981

Vasomotor control in healed grafted skin in humans.

Do the vasomotor functions unique to skin recover in a skin graft? To determine whether locally mediated vasodilation and active reflex vasodilation recovery, we applied direct heating and whole-body heating, respectively. Also, presence of sympathetic cutaneous vasoconstriction was tested with application of lower body negative pressure (LBNP) during local heating. Subjects were six men who had been severely burned. Forearm blood flow (FBF) was recorded (venous occlusion plethysmography) in regions with healed split-thickness circumferential grafts. All subjects responded normally to local heating of the forearm (irrigation with 42 degrees C water). All but one showed cutaneous vasoconstriction in response to LBNP. Three subjects responded normally to whole-body heating with water-perfused suits (oral temperature elevation approximately 1.5 degrees C); two subjects had attenuated responses. No active vasodilation was normal cutaneous vasomotor functions return in (or under) split-thickness skin grafts, recovery and associated thermoregulatory function may be attenuated or absent, perhaps in relation to the survival of dermis.

Adolescent↗
PubMed1981

Ventilation and perfusion alterations after smoke inhalation injury.

Previous studies of human victims of smoke inhalation injury have demonstrated retention of intravenously infused 133xenon2, 6 suggesting either: (1) true intrapulmonary shunting (Qs) secondary to alveolar collapse, flooding, or obliteration, or (2) perfusion of low ventilation/perfusion compartments (low VA/Q) secondary to bronchospasm, bronchial constriction, or partial bronchial occlusion by cellular debris. To differentiate between and quantitate the relative contribution of intrapulmonary shunt versus low VA/Q compartments, multiple inert gas analysis, as described by Wagner et al.,12 was applied to human victims of smoke inhalation. Studies of an animal model of injury were subsequently performed to confirm these observations. These experiments suggest that early alterations of ventilation and perfusion resulted from increased high VA/Q and dead-space ventilation. Late alterations included significantly increased perfusion of low VA/Q compartments and return of high VA/Q ventilation to baseline levels. True intrapulmonary shunting was notably absent. This physiologic sequence may represent early regional pulmonary vasospasm followed by regional bronchial obstruction and gradual alveolar secondary to bronchospasm, bronchial edema, or partial occlusion by cellular debris.

Airway Obstruction↗
PubMed1980

Safety and efficacy of a new synthetic burn dressing: a multicenter study.

A three-tiered, multicenter study evaluated the safety and efficacy of a new synthetic dressing for burn injuries. The first tier compared use of the test dressing with use of a conventional topical chemotherapeutic agent; the test dressing afforded greater patient comfort, equivalent control of bacterial growth, less frequent dressing change, and possibly faster reepithelialization. Drawbacks included difficulty of application, poor adherence during the first 24 hours after injury, frequent necessity to repair cracks and fissures, and inability to easily monitor burn wounds for bacterial growth. Subsequent tiers were noncomparative but included patients with more severe injuries. The test dressing may be useful in treating superficial and moderate second-degree burns of less than 20% of the total body surface area and possibly in treating iatrogenic "burn" wounds such as donor sites. Its use on third-degree burns is not recommended.

Acrylates↗
PubMed1980

Laser scalpel for solid organ surgery.

Hemostasis remains a major technical problem in surgery of the liver and spleen. A high power neodymium-doped yttrium aluminum garnet (Nd:YAG) laser has been coupled with a fiberoptic delivery system and quartz blade designed to yield maximal hemostasis and minimal tissue injury. In a series of experiments we were unable to demonstrate a significant advantage of its use in partial hepatic lobectomy.

Animals↗
PubMed1980

The role of peritoneal lavage in the management of stab wounds to the abdomen.

In a 2 year period, 237 patients presented with stab wounds to the lower chest and anterior abdomen. Ninety-six patients were discharged from the emergency room after negative findings on wound exploration. There were no apparent missed injuries but two wound infections in this group for an overall morbidity of 2.1 percent. One hundred forty-one patients underwent exploratory laparotomy. Seventy-seven required emergency laparatomy because of hemodynamic signs of blood loss or peritonitis. Sixty-four patients whose only indication for laparotomy was penetration of the anterior abdominal wall fascia by local wound exploration underwent peritoneal lavage before laparotomy. If 50,000 red blood cells/mm3 in the lavage fluid had been used to select patients for observation, the incidence of negative laparotomy would have been reduced from 58 to 3.2 percent, and only one significant visceral injury would have been missed.

Abdominal Injuries↗
PubMed1980

The use of the argon laser-assisted quartz scalpel for burn wound excision to fascia.

We have developed a new method for coupling the hemostatic capabilities of argon laser light with the mechanical advantages of a sharpened quartz blade using fiberoptics. Using the new laser-assisted scalpel, a series of symmetrical skin excisions was done in 20- to 30-kg pigs on one side and with electrosurgery on the other. The laser scalpel was superior in its hemostatic properties (p less than 0.01) with no statistically significant difference in surgical speed. Take of split-thickness skin grafts was 90% in beds excised with either the laser or the electrosurgical device. Histologic sections showed less tissue damage with the laser-assisted scalpel than with electrocautery.

Animals↗
PubMed1980

The burned hemophiliac.

Major surgical procedures are now performed with acceptable risk on patients with hemophilia A with pre- and postoperative anti-hemopilic Factor (AHF) infusions. However, there is almost no literature on care of the burned hemophiliac. We recently treated a patient with Factor VIII levels of less than 2% of normal and 45% TBSA burns. A forearm escharotomy was done with hemostatic protection by AHF infusion, but burn therapy, which included operative debridement and successful split-thickness skin grafting, was accomplished without the use of AHF. It is concluded that after early loading with cryoprecipitate, burned hemophiliacs do not require continued AHF, because repair and restoration of vascular integrity in small vessels may occur due to platelet plugging and vessel retraction. Tissue thromboplastin may also contribute to clotting in burned hemophiliacs.

Adult↗
PubMed1980

Phenytoin pharmacokinetics in burned rats and plasma protein binding of phenytoin in burned patients.

Unexpectedly low serum phenytoin levels occurred in burned epileptic patients, suggesting the possibility of altered phenytoin disposition. Subsequently, phenytoin log-linear elimination kinetics after a 10 mg/kg i.v. single dose was examined in a burned rat model. Clearance increased from 1.08 +/- 0.28 liters/hr/kg in control rats to 1.50 +/- 0.38 liters/hr/kg in burned rats (P less than .05). The volume of distribution increased from 0.82 +/- 0.058 liters/kg in control rats to 1.01 +/- 0.11 liters/kg in burned rats (P less than .0005). The first order elimination rate constant (KE) did not change significantly (1.31 +/- 0.37) hr-1 in control rats vs. 1.52 +/- 0.48 hr-1 in burned rats; P greater than .05). The increase in clearance and in volume of distribution could be explained on the basis of a decrease in plasma protein binding. The free fraction in plasma increased from 27.1% +/- 1.2 in controls to 33.4% +/- 1.6 in burned rats (P less than .0005). The change in binding was consistent with a decrease in serum albumin from 2.64 +/- 0.33 g/dl in controls to 1.98 +/- 0.16 g/dl in burned rats (P less than .0005). Plasma samples of four burned human subjects revealed low serum albumin and markedly decreased plasma protein binding of phenytoin (2- to 3-fold increase in free fraction in plasma).

Adult↗
PubMed1980

Burn injury in infants and young children.

Scalding, most often self-precipitated, is the most common cause of burn injuries in children. Flame burns are much less common but are more severe and have a higher mortality than do scalds. Most burns in this age group are small, but affect areas functionally and cosmetically sensitive to burn injury. Abused infants and toddlers have a much higher mortality than do unabused children. Younger children have a higher mortality after serious burns than do older children. Common infections include otitis media, viral gastroenteritis and viral infections of the upper part of the respiratory tract, many of which are established prior to injury. Hyperthermia and leukocytosis are common and may be misleading as indicators of infection. Fluid needs are greater than predicted by the Parkland formula. Hypertension is uncommon and resolves spontaneously.

Adolescent↗
PubMed1979

Pyogenic osteomyelitis of axial bones following civilian gunshot wounds.

A series of forty-five patients with low velocity gunshot wounds to the spine and pelvis were followed up for at least eight weeks to determine the incidence of pyogenic osteomyelitis and the role of debridement and fragment removal in its prevention. Four cases of osteomyelitis were found, and although debridement was not frequently done, the incidence of osteomyelitis was higher following debridement than it was without debridement. The most important cause appeared to be spread of contiguous intraabdominal abscesses into the injured paravertebral muscles and spine. If an intraabdominal abscess did not develop, the presence of gastrointestinal injury did not predispose the patient to osteomyelitis. Based on this study, we can conclude that debridement and fragment removal of the spine and pelvic bones are unnecessary for low velocity missile wounds.

Abscess↗
PubMed1979

Effect of micropore filtration on pulmonary function after massive transfusion.

1. This study demonstrates a positive correlation between the number and size of infused microaggregates and the subsequent abnormality in pulmonary function as measured by oxygenation and dead space. 2. No such correlation between the severity of injury and the altered pulmonary function or transfusion volume was demonstrated. 3. We were unable to demonstrate an advantage to the use of a 40 mu micropore filter in preventing the adult respiratory distress syndrome (ARDS) or in improving pulmonary function in our patients. 4. One explanation for the failure to demonstrate such an advantage is the low efficiency of the filter used.

Adolescent↗
PubMed1979

Hemostasis in massively transfused trauma patients.

Twenty-seven patients requiring massive transfusions were studied prospectively to determine whether administration of stored, modified whole blood induced a primary disorder of hemostasis evidenced by generalized microvascular oozing. Platelet counts fell in proportion to the number of units of blood transfused. In contrast, the levels of factors V and VIII correlated poorly with the units of blood transfused, 85% of the total variation in the levels being due to influences other than transfused blood. Levels of all other clotting factors were unrelated to the number of units of blood given. Eight patients developed abnormal bleeding. The cause appeared to be dilutional thrombocytopenia in five patients, and DIC in three. In six of the eight, bleeding was controlled with platelet concentrates alone. Two patients were given cryoprecipitate also. The most useful laboratory test for predicting abnormal bleeding was the platelet count. Fibrinogen levels should be followed as an aid in the diagnosis of DIC. The BT, PT, and PTT were not helpful in assessing the cause of bleeding, unless they were greater than 1.5 times the control value. We recommend that any patient receiving massive transfusions who develops diffuse microvascular bleeding be given platelet concentrates. Platelet counts as high as 100,000 may be required to control bleeding from surgical wounds. It is not necessary to supplement transfusions of stored, modified whole blood with fresh blood or fresh frozen plasma.

Adolescent↗
PubMed1979

Immediate and long term effects of instrumental dilation of the sphincter of Oddi.

Large dilators passed through the sphincter of Oddi do not prevent retained or recurrent common bile duct stones. Large dilators are more likely to cause postoperative pancreatitis than are small ones. Pancreatitis resulting from maximal dilation is more likely to be severe, and the patients are more likely to die from it.

Ampulla of Vater↗