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Biomedical subjects

D R Kauder

Publications and source records attributed to D R Kauder.

31 records · Page 2Linked to original sources
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↗
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

Prevalence of MR evidence of diffuse axonal injury in patients with mild head injury and normal head CT findings.

PURPOSE: To assess the prevalence of MR evidence for diffuse axonal injury at 1.5 T in patients with normal head CT findings after mild head injury. METHODS: Twenty consecutive patients with mild head injury (Glasgow Coma Scale, 13 to 15; no subsequent deterioration, loss of consciousness < 20 minutes) and normal head CT findings were examined with MR at 1.5 T. Pulse sequences included a conventional T2-weighted spin-echo sequence (2500-3000/30,80/1[repetition time/echo time/excitations]) and a T2*-weighted gradient-echo sequence (750/40/2, 10 degrees flip angle). Each sequence was read independently by two blinded readers. RESULTS: The readers agreed that abnormalities compatible with diffuse axonal injury were present in the white matter of 6 (30%) of 20 patients (95% confidence interval, 12% to 54%). Both readers agreed that foci of high signal intensity were present on the T2-weighted spin-echo sequence in 3 (15%) of the 20 cases (95% confidence interval, 3% to 38%) and that foci of hypointensity compatible with hemorrhagic shear injury were present on the T2*-weighted sequence in 4 (20%) of the 20 patients (95% confidence interval, 6% to 44%). Both types of abnormality were noted by the readers in one patient. CONCLUSIONS: MR shows evidence of diffuse axonal injury in some patients with normal head CT findings after mild head injury. These lesions may represent the pathologic substrate underlying the postconcussion syndrome that occurs in many patients with moderate to severe head injury.

Adolescent↗
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↗
PubMed1993

Urgent paralysis and intubation of trauma patients: is it safe?

Physicians, fearful of an increase in the incidence of intubation mishaps (IMs) and pulmonary complications (PUCs), have been reluctant to use paralysis and intubation (PI) outside the OR. This study examines the correlations between PI, IM, and PUC. Since 1987, we have used PI when complex injury or combative behavior warranted. From January through December 1989, 851 patients meeting major trauma triage guidelines were evaluated. The medical records of 231 patients (27%) who underwent PI within 8 hours of admission were reviewed; 27 patients were eliminated because of incomplete records. The indications for PI were emergency surgery (131), airway control (30), combativeness (24), and hyperventilation (19). The location was the OR (121), ED (82), other (1). Presence or absence of IM was documented in 198 of 204 charts: Twenty-four IMs (12%) occurred--14 multiple attempts, seven aspirations, three esophageal intubations. Frequency of IM was not statistically related to PI location (Fisher's exact test), AIS, or ISS. In 194 of 204 patients who survived at least 24 hours, there were 15 PUCs (8%): eight pneumonia, five persistent infiltrates, two severe atelectases. No deaths were related to IM or PUC. There was no statistical relationship between IM and PUC (Fisher's exact test). However, patients with PUCs had a significantly higher AIS-chest score (2.9 +/- 1.7 vs. 0.9 +/- 1.5) (p < 0.0005, Student's t test) and ISS (27.3 +/- 9.6 vs. 14.5 +/- 10.8) (p < 0.0005, Student's t test). In our hands, PI is associated with low morbidity, no mortality, and can be safely used to facilitate injury management or to control combative behavior.

Dangerous Behavior↗
PubMed1993

A new approach to probability of survival scoring for trauma quality assurance.

This study examined the application of an artificial intelligence technique, the neural network (NET), in predicting probability of survival (Ps) for patients with penetrating trauma. A NET is a computer construct that can detect complex patterns within a data set. A NET must be "trained" by supplying a series of input patterns and the corresponding expected output (e.g., survival). Once trained, the NET can recall the proper outputs for a specific set of inputs. It can also extrapolate correct outputs for patterns never before encountered. A neural network was trained on Revised Trauma Score, Injury Severity Score, age, and survival data contained in 3500 of 8300 state registry records of all patients with penetrating trauma reported in Pennsylvania from 1987 through 1990. The remaining 4800 records were analyzed by TRISS, ASCOT, and the trained NET. Sensitivity (accuracy of predicting death) and specificity (accuracy of predicting survival) were 0.840 and 0.985 for TRISS, 0.842 and 0.985 for ASCOT, and 0.904 and 0.972 for the neural network. This represents a decrease in the number of improperly classified ("unexpected") deaths, from 73 for TRISS and 72 for ASCOT, to 44 for the neural network. The increased sensitivity was statistically significant by Chi-square analysis. The NET for penetrating trauma provided a more sensitive but less specific technique for calculating Ps than did either TRISS or ASCOT. This translated into a 40% reduction in the number of deaths requiring review, and the potential for more efficient use of quality assurance resources.

Artificial Intelligence↗
PubMed1993

On the nature of things still going bang in the night: an analysis of residency training in trauma.

In the 1982 Presidential Address to the Society of University Surgeons, Trunkey reported on the inadequacy of surgical education in trauma care. His conclusions were based on American Board of Surgery operative experience data compiled from residents completing surgical training in 1980. The purpose of this study was to compare current resident operative experience in trauma surgery with the American Board of Surgery data from 1980. Yearly resident operative experience data obtained from the Residency Review Committee from 1987 through 1991 were analyzed. The relationship between the percentile rank and the number of operative cases was defined using linear regression. The percentile rank of residents performing a specified number of operative cases was computed using a linear regression coefficient. The results were then compared with previously published 1980 American Board of Surgery summary data. Resident operative experience in trauma surgery was stable over the 5-year period investigated and no significant trends were identified. Comparison of the data from 1980 to 1991 revealed that the percentage of residents performing less than ten cases decreased markedly, from 18% to 9%. Moreover, the percentage of residents claiming fewer than 50 cases declined from 86% to 29%. Based on this analysis, it appears that resident operative experience dramatically increased from 1980 to 1987 and has since remained stable. The reasons for this are unclear but undoubtedly involve the accuracy of reporting operative experience, Residency Review Committee operative trauma definitions, and the actual number of trauma surgery cases available for trainees.(ABSTRACT TRUNCATED AT 250 WORDS)

General Surgery↗
PubMed1993

'Damage control': an approach for improved survival in exsanguinating penetrating abdominal injury.

Definitive laparotomy (DL) for penetrating abdominal wounding with combined vascular and visceral injury is a difficult surgical challenge. Physiologic derangements such as dilutional coagulopathy, hypothermia, and acidosis often preclude completion of the procedure. "Damage control" (DC), defined as initial control of hemorrhage and contamination followed by intraperitoneal packing and rapid closure, allows for resuscitation to normal physiology in the intensive care unit and subsequent definitive re-exploration. The purpose of the study was to compare the damage control technique with definitive laparotomy. Over a 3 1/2-year period, 46 patients with penetrating abdominal injuries required laparotomy and urgent transfusion of greater than 10 units packed red blood cells for exsanguination. Medical records were retrospectively reviewed for degree and pattern of injury, probability of survival, actual survival, transfusion requirements for the preoperative and postoperative phases, resuscitation and operative times, lowest perioperative temperature, pH, and HCO3. No significant differences were identified between 22 DL and 24 DC patients and actual survival rates were similar (55% DC vs. 58% DL). However, in a subset of 22 patients with major vascular injury and two or more visceral injuries (maximum injury subset), otherwise similar to the overall group, survival was markedly improved in patients treated with damage control (10 of 13, 77%*) vs. DLM (1 of 9, 11%) (Fisher's exact test, * p < 0.02). In preparation for return to the operating room, DC survivors averaged 8.4 units of packed red blood cells transfused and 10.3 units fresh frozen plasma over a mean ICU stay of 31.7 hours. Resolution of coagulopathy (mean prothrombin time/partial thromboplastin time 19.5/70.4 to 13.3/34.9), normalization of acid-base balance (mean pH/HCO3 7.37/20.6 to 7.42/24.2), and core rewarming (mean 33.2 degrees C to 37.7 degrees C) were achieved. All patients had gastrointestinal procedures at reoperation (mean operative time, 4.3 hours). We conclude that damage control is a promising approach for increased survival in exsanguinating patients with major vascular and multiple visceral penetrating abdominal injuries.

Abdominal Injuries↗
PubMed1993

Urban firearm deaths: a five-year perspective.

Firearm violence is an ever-increasing element in the lives of the U.S. urban population. This study examined the trends in firearm violence and victims during a 5-year period in the city of Philadelphia. Medical Examiner records of all deaths in Philadelphia County in 1985 and 1990 were reviewed. Demographic, autopsy, and criminal record information was analyzed. There were 145 firearm homicide victims in 1985 versus 324 in 1990, a 123% increase. This was primarily because of deaths among young (age 15-24 years), black male victims. Handguns were involved in at least 90% of firearm homicides in both study years. The use of semiautomatic handguns increased from 24% to 39% during the study period. In 1985, 42% of revolver homicides died at the scene, versus 18% in 1990. However, 5% of victims of semiautomatic weapons fire died at the scene in 1985 versus 34% in 1990. The decrease in survival of semiautomatic weapon victims occurred despite the implementation of six trauma centers within the county, and probably reflects a shift toward high-velocity, high-caliber ammunition. Antemortem drug use and criminal history was common. A total of 54% of victims were intoxicated in 1985 and 61% were in 1990. Cocaine became the most common intoxicant in 1990, with 39% of victims using it during the antemortem period. The percentage of victims with a criminal record increased from 44% to 67%. Although the duration of criminal history decreased from 14 to 6 years, the number of patients with previous drug offenses increased from 33% to 84%..(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1992

Trauma in the geriatric patient.

Elderly individuals are living longer, healthier, and more active lives, and, in the process, they are continually exposed to the risk of injury. Trauma is now the fifth most common cause of death in people over the age of 65 years, and the elderly suffer disproportionately high injury-related mortality rates compared with younger adults. They consume a vast portion of health care resources and their care precipitates some of the most difficult ethical and sociologic questions in modern medicine. Physiologically, the elderly present a unique and complex picture that requires an understanding of the process of aging and the concomitant effects of acquired diseases. As surgeons involved in the care of the injured, we find ourselves becoming more frequently involved with this national dilemma. This review provides some insights and guidelines for the care of the injured elderly, with the hope of improving our understanding and their outcome.

Aged↗
PubMed1990

Supplemental emergent chest computed tomography in the management of blunt torso trauma.

The efficacy of conventional chest X-ray (CXR) in comparison to chest computed tomography (CCT) in acutely injured blunt trauma patients was examined. Over a 21-month period, 50 patients underwent CXR and CCT according to a standard protocol, and their films and records were reviewed retrospectively. Hemo- and/or pneumothorax (HPTX) was noted in 12 patients (five by CXR, 12 by CCT). Pulmonary contusion (PC) was identified in ten patients (four by CXR, ten by CCT). Three additional false positive PC were diagnosed by CXR. Therapy changes based upon CCT findings occurred in seven of seven HPTX and five of six PC. The two imaging techniques were complementary in detecting fractures. Atelectasis was a common CCT finding (58% incidence). Chest X-ray is less sensitive than chest computed tomography in the detection of HPTX (42% vs. 100%) and PC (40% vs. 100%). Emergent chest computed tomography is recommended in stable patients with: 1) blunt high-energy torso trauma, 2) "cross-body" injury pattern, and/or 3) a mechanism of injury suggestive of chest trauma.

Adult↗