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D V Feliciano

Publications and source records attributed to D V Feliciano.

At least 19 recordsLinked to original sources
PubMed1999

Advances in the diagnosis and treatment of thoracic trauma.

With the exception of the use of ECG to screen patients for blunt cardiac injury, recent advances in the diagnosis of thoracic trauma involve new technology. Use of surgeon-performed pericardial and pleural ultrasound for the detection of tamponade or hemothorax, TEE or spiral CT to diagnose rupture of the thoracic aorta, and thoracoscopy to evaluate a hemothorax or the integrity of the left hemidiaphragm are all standard techniques in modern trauma centers. In terms of treatment, emergency center thoracotomy is performed more selectively and with the adjunct of staple closure for cardiac wounds. Pulmonotomy is used selectively to control deep lobar hemorrhage and to avoid the need for an emergent lobectomy. Finally, nonoperative management of an intimal tear of the thoracic aorta or delayed operative management of a full-thickness tear in the patient with multiple injuries, using beta-blocker-induced relative hypotension, is rapidly becoming the standard of care throughout the United States.

Aortic Dissection↗
PubMed1999

An algorithm to reduce the incidence of false-negative FAST examinations in patients at high risk for occult injury. Focused Assessment for the Sonographic Examination of the Trauma patient.

BACKGROUND: The Focused Assessment for the Sonographic Examination of the Trauma patient (FAST) sequentially surveys for the presence or absence of blood in dependent abdominal regions including the right upper quadrant, left upper quadrant, and the pelvis. But it does not readily identify intraparenchymal or retroperitoneal injuries, and a CT scan of the abdomen may be needed to reduce the incidence of missed injuries. We hypothesized that select patients who are considered high risk for occult injuries should undergo a CT scan of the abdomen when the FAST is negative so that occult injuries can be detected. STUDY DESIGN: An algorithm was prospectively tested for the evaluation of select injured patients over a 3 1/2-year period. Entrance criteria included adult patients with a blunt mechanism of trauma, a negative FAST examination, and a spine fracture (with or without cord injury), or a pelvic fracture. Trauma team members performed the FAST on patients during the Advanced Trauma Life Support secondary survey. Data recorded included the patient's mechanism and type of injury, the results of the FAST and CT scan examinations, operative or postmortem findings or both, and patient outcomes. Patients with spine injuries were grouped according to spine level and the presence or absence of neurologic deficit. The patients with pelvic fractures were grouped according to the Young and Resnick classification. RESULTS: One hundred two of 1,490 patients (6.8%) who had FAST examinations were entered into this study. Thirty-two patients (30.5%) had spine injuries, with only one false-negative ultrasound result. Seventy patients (68.6%) had pelvic fractures with 13 false-negative ultrasound results: 11 ring (9 from motor vehicle crashes, 2 from pedestrians struck), 1 acetabular, and 1 isolated pelvic fracture. Nine patients underwent nonoperative management for solid organ injuries, and 4 patients needed surgery. CONCLUSIONS: Based on these preliminary data, we conclude that patients with pelvic ring-type fractures should have CT scans of the abdomen because of the higher yield for occult injuries.

Abdominal Injuries↗
PubMed1999

The epidemic of cocaine-related juxtapyloric perforations: with a comment on the importance of testing for Helicobacter pylori.

OBJECTIVE: This is a report of 50 consecutive patients with juxtapyloric perforations after smoking "crack" cocaine (cocaine base) at one urban public hospital. SUMMARY BACKGROUND DATA: Although the exact causal relation between smoking crack cocaine and a subsequent juxtapyloric perforation has not been defined, surgical services in urban public hospitals now treat significant numbers of male addicts with such perforations. This report describes the patient set, presentation, and surgical management and suggests a possible role for Helicobacter pylori in contributing to these perforations. METHODS: A retrospective chart review was performed, supplemented by data from the patient log in the department of surgery. RESULTS: From 1994 to 1998, 50 consecutive patients (48 men, 2 women) with a mean age of 37 had epigastric pain and signs of peritonitis a median of 2 to 4 hours (but up to 48 hours) after smoking crack cocaine. A history of chronic smoking of crack as well as chronic alcohol abuse was noted in all patients; four had a prior history of presumed ulcer disease in the upper gastrointestinal tract. Free air was present on an upright abdominal x-ray in 84% of patients, and all underwent operative management. A 3- to 5-mm juxtapyloric perforation, usually in the prepyloric area, was found in all patients. Omental patch closure was used in 49 patients and falciform ligament closure in 1. Two patients underwent parietal cell vagotomy as well. In the later period of the review, antral mucosal biopsies were performed through the juxtapyloric perforation in five patients. Urease testing was positive for infection with H. pyonri in four, and these patients were prescribed appropriate antimicrobial drugs. CONCLUSIONS: Juxtapyloric perforations after the smoking of crack cocaine occur in a largely male population of drug addicts who are 8 to 10 years younger than the patient group that historically has perforations in the pyloroduodenal area. These perforations are usually 3 to 5 mm in diameter, and an antral mucosal biopsy for subsequent urease testing should be performed if the location and size of the ulcer allow this to be done safely. Omental patch closure is appropriate therapy for patients without a history of prior ulcer disease; antimicrobial therapy and omeprazole are prescribed when H. pylori is present.

Adult↗
PubMed1999

The role of ultrasound in patients with possible penetrating cardiac wounds: a prospective multicenter study.

BACKGROUND: Ultrasound is quickly becoming part of the trauma surgeon's practice, but its role in the patient with a penetrating truncal injury is not well defined. The purpose of this study was to evaluate the accuracy of emergency ultrasound as it was introduced into five Level I trauma centers for the diagnosis of acute hemopericardium. METHODS: Surgeons or cardiologists (four centers) and technicians (one center) performed pericardial ultrasound examinations on patients with penetrating truncal wounds. By protocol, patients with positive examinations underwent immediate operation. Vital signs, base deficit, time from examination to operation, operative findings, treatment, and outcome were recorded. RESULTS: Pericardial ultrasound examinations were performed in 261 patients. There were 225 (86.2%) true-negative, 29 (11.1%) true-positive, 0 false-negative, and 7 (2.7%) false-positive examinations, resulting in sensitivity of 100%, specificity of 96.9%, and accuracy of 97.3%. The mean time from ultrasound to operation was 12.1+/-5 minutes. CONCLUSION: Ultrasound should be the initial modality for the evaluation of patients with penetrating precordial wounds because it is accurate and rapid.

Acute Disease↗
PubMed1999

Penetrating cardiac trauma at an urban trauma center: a 22-year perspective.

This is a report of a 22-year experience with penetrating cardiac trauma at a single urban Level I trauma center. We conducted a retrospective chart review supplemented by computerized patient log. Comparisons of mortality between Period 1 (1975-1985; 113 patients) and Period 2 (1986-1996; 79 patients) were by chi2 or Fisher's exact tests. Statistical significance was defined as P < or = 0.05. From 1975 to 1996, 192 patients (mean age, 32 years; 88% male) with penetrating cardiac stab wounds (68%) or gunshot wounds (32%) were treated. The most common initial clinical presentation was cardiac tamponade, and most patients (54%) were hypotensive (systolic blood pressure 30-90 mm Hg). The most common initial intervention in the emergency center was tube thoracostomy. The use of pericardiocentesis as a diagnostic and therapeutic modality in the emergency center virtually disappeared in Period 2, as compared with Period 1. Since 1994, surgeon-performed cardiac ultrasound has been performed and has correctly diagnosed hemopericardium in 12 patients (100% survival). The overall mortality for all patients during the 22-year study interval was 25 per cent and was not significantly different between Period 1 (27%) and Period 2 (22%). The mortality associated with gunshot wounds was increased compared with that of stab wounds. Similarly, mortality for patients who arrested in the emergency center was increased compared with those patients who did not arrest. We conclude: 1) cardiac tamponade is the most common presentation in patients with cardiac wounds; 2) pericardiocentesis in the emergency center has essentially disappeared; 3) surgeon-performed ultrasound of the pericardium should improve survival of future patients who are normotensive or mildly hypotensive; 4) over the last 11 years, there has been a substantial decrease in mortality in patients with stab wounds and a statistically significant decrease in arrested patients; and 5) overall mortality for penetrating cardiac trauma has not changed during the 22-year interval.

Adolescent↗
PubMed1998

Management of casualties from the bombing at the centennial olympics.

BACKGROUND: The explosion of a bomb 75 to 100 yards away from attendees at a concert who were in the process of being evacuated from Centennial Olympic Park at approximately 1:25 AM on July 27, 1996, resulted in a multiple-casualty event involving primarily four hospitals in proximity to the blast. The purpose of this study was to review triage and care of the victims, emphasizing those with significant injuries. METHODS: Retrospective review of triage and care of injured patients. RESULTS: Ninety-six of the 111 victims of the blast were triaged in the first half hour to four hospitals within 3 miles of the bombing. Only four minor operations were performed in 61 patients evaluated at community hospitals. Ten of 35 patients evaluated at the regional trauma center underwent emergency or urgent operations, and all who were seriously injured did well. CONCLUSIONS: Although overtriage to the regional trauma center occurred, outcome was excellent in all seriously injured victims treated there.

Disaster Planning↗
PubMed1998

Ultrasound as used in thoracoabdominal trauma.

Because it is unique in being portable, rapid, and noninvasive, ultrasound is particularly suited to the trauma setting. When performed by the surgeon, it offers immediate feedback that can be incorporated into the management plan for the patient. Multiple studies in this area have now documented that surgeons can perform and interpret focused ultrasound examinations. Enthusiasm for surgeons as ultrasonographers will likely increase now that the Advanced Trauma Life Support Subcommittee of the American College of Surgeons has published an algorithm that includes ultrasound for the assessment of patients with blunt truncal injuries. As a rapid, sensitive, and specific diagnostic test for the detection of pericardial tamponade, hemothorax, and hemoperitoneum, ultrasound is now an integral part of the practice at many Level I trauma centers.

Abdominal Injuries↗
PubMed1998

Surgeon-performed ultrasound for the assessment of truncal injuries: lessons learned from 1540 patients.

OBJECTIVE: To determine the accuracy of the Focused Assessment for the Sonographic examination of the Trauma patient (FAST) when performed by trauma team members during a 3-year period, and to determine the clinical conditions in which the FAST is most accurate in the assessment of injured patients. SUMMARY BACKGROUND DATA: The FAST is a rapid test that sequentially surveys the pericardial region for hemopericardium and then the right and left upper quadrants and pelvis for hemoperitoneum in patients with potential truncal injuries. The clinical conditions in which the FAST is most accurate in the assessment of injured patients have yet to be determined. METHODS: FAST examinations were performed on patients with precordial or transthoracic wounds or blunt abdominal trauma. Patients with a positive ultrasound (US) examination for hemopericardium underwent immediate surgery, whereas those with a positive US for hemoperitoneum underwent a computed tomography scan (if they were hemodynamically stable) or immediate celiotomy (if they were hemodynamically unstable- blood pressure < or = 90 mmHg). RESULTS: FAST examinations were performed in 1540 patients (1227 with blunt injuries, 313 with penetrating injuries). There were 1440 true-negative results, 80 true-positive results, 16 false-negative results, and 4 false-positive results; the sensitivity was 83.3%, the specificity 99.7%. US was most sensitive and specific for the evaluation of patients with precordial or transthoracic wounds (sensitivity 100%, specificity 99.3%) and hypotensive patients with blunt abdominal trauma (sensitivity 100%, specificity 100%). CONCLUSIONS: US should be the initial diagnostic modality for the evaluation of patients with precordial wounds and blunt truncal injuries because it is rapid and accurate. Because of the high sensitivity and specificity of US in the evaluation of patients with precordial wounds and hypotensive patients with blunt torso trauma, immediate surgical intervention is justified when those patients have a positive US examination.

Abdominal Injuries↗
PubMed1998

Rapid detection of traumatic effusion using surgeon-performed ultrasonography.

BACKGROUND: In the injured patient, rapid assessment of the thorax can yield critical information for patient management and triage. OBJECTIVES: The objectives of this prospective study were (1) to determine if experienced surgeon sonographers could successfully use a focused thoracic ultrasonographic examination to detect traumatic effusion, and (2) to compare the accuracy and efficiency of ultrasonography with supine portable chest radiography. METHODS: Surgeon-sonographers performed thoracic ultrasonographic examinations on patients with blunt and penetrating torso injuries during the Advanced Trauma Life Support secondary survey. All patients also underwent portable chest radiography. Performance times for ultrasonography and chest radiography were recorded. Comparisons were made of the performance times and accuracy of both tests in detecting traumatic effusion. RESULTS: In 360 patients, there were 40 effusions, 39 of which were detected by ultrasonography and 37 of which were detected by chest radiography. The 97.5% sensitivity and 99.7% specificity observed for thoracic ultrasonography were similar to the 92.5% sensitivity and 99.7% specificity for portable chest radiography. Performance time for ultrasonography was significantly faster than that for chest radiography (1.30 +/- 0.08 vs. 14.18 +/- 0.91 minutes, p < 0.0001). CONCLUSION: Surgeons can accurately perform and interpret a focused thoracic ultrasonographic examination to detect traumatic effusion. Surgeon-performed thoracic ultrasonography is as accurate but is significantly faster than supine portable chest radiography for the detection of traumatic effusion.

Adolescent↗
PubMed1998

Early detection of hemoperitoneum by ultrasound examination of the right upper quadrant: a multicenter study.

BACKGROUND: The focused assessment for the sonographic examination of the trauma patient (FAST) is a rapid diagnostic test that sequentially surveys for hemopericardium and then the right upper quadrant (RUQ), left upper quadrant (LUQ), and pelvis for hemoperitoneum in patients with potential truncal injuries. The sequence of the abdominal part of the examination, however, has yet to be validated. The objectives of this multicenter study were as follows: (1) to determine where hemoperitoneum is most frequently identified on positive FAST examinations; and (2) to determine if a relationship exists between that areas and the organs injured. METHODS: Ultrasound registries from four Level I trauma centers identified patients who had true-positive FAST examinations. Demographic data, areas positive on the FAST, and organs injured were recorded; injuries were classified as multiple, single solid organ (liver or spleen), isolated hollow viscus, or retroperitoneal. Relationships between positive locations on the FAST examinations and the associations of organs injured to areas positive were assessed using McNamara's chi2 test; a p value < 0.05 was considered statistically significant. RESULTS: The RUQ was the most common site where hemoperitoneum was detected, and this was statistically significant compared with either the LUQ or the pelvis. Also, statistically significant correlations (p < 0.001) were observed between positive RUQ areas on the FAST and multiple injuries, single solid organ (liver or spleen) injury, and retroperitoneal injuries. CONCLUSION: Blood is most often found on the FAST in the RUQ area in patients with multiple intraperitoneal injuries or isolated injury to the liver, spleen, or retroperitoneum, but not when there is injury to a hollow viscus.

Abdominal Injuries↗
PubMed1998

The clinical complexity of splenic vein thrombosis.

Upper gastrointestinal hemorrhage secondary to splenic vein thrombosis is a curable form of localized portal hypertension when treated with splenectomy. A high index of suspicion is necessary in order to promptly diagnose and treat this underrecognized condition that is most commonly caused by inflammation or neoplasm of the pancreas. The triad of isolated gastric varices, splenomegaly, and normal hepatic function is classic; it is not uncommon, however, for patients to have only some or even none of these conditions. Mesenteric angiography with venous phase imaging is the gold standard of diagnosis. Ultrasound and CT may identify splenic vein thrombosis, but are most helpful in delineating concomitant upper abdominal pathology. Early recognition and intervention allow associated underlying conditions to be treated under the same anesthetic with minimal morbidity and mortality.

Adenocarcinoma↗
PubMed1997

Iliac vessel injury: operative physiology related to outcome.

BACKGROUND: Fifty-three patients treated at a level I trauma center with iliac vessel injury were studied to determine if body temperature and acid-base status in the operating room predicts outcome. METHODS: Records were reviewed for demographics, mechanism of injury, body temperature, acid-base status, operative management, and outcome. Statistical methods included Student's t test, odds ratio determination, and chi-square analysis to determine statistical significance. RESULTS: Fifty-three patients (47 male, 6 female) sustained 92 iliac vascular injuries (36 arterial, 56 venous). Mortality was 34%, with 72% of deaths due to shock within 24 hours. Physiologic parameters differed significantly between survivors and nonsurvivors. Odds ratio identified six conditions; the number present predicted outcome. CONCLUSIONS: (1) There are significant differences between initial and final operating room temperature and acid-base status in survivors versus nonsurvivors with iliac vessel injury. Conditions for odds ratio can be calculated and correlated with outcome. (2) A patient with two or more conditions should be considered for an abbreviated laparotomy to allow for reversal of "physiologic failure."

Acid-Base Equilibrium↗
PubMed1997

Trauma to the aorta and major vessels.

Techniques for the diagnosis of blunt thoracic vascular injuries continue to evolve, and both helical CT scanning and transesophageal echocardiography are being compared with thoracic aortography. Repair of a tear in the descending thoracic aorta often is performed with the antriofemoral centrifugal pump. Patients with penetrating thoracic vascular injuries have a variety of presentations, with aortography restricted to those with proximity of wound to the superior mediastinum or the presence of a hematoma on admission chest radiograph.

Aorta, Thoracic↗
PubMed1996

Complex hepatic injuries.

The most significant contribution to the management of hepatic injuries over the past 5 years has been the nonoperative management of blunt injuries in the adult patient. Recent data suggest that as many as 80% of all blunt hepatic injuries may be treated in this fashion, with a success rate exceeding 95%. The fear of missing hollow viscus injuries, as well as the risk of sudden hemorrhage in the observational period, leading to an increase in hepatic-related deaths, seems exaggerated. The intraoperative management of complex hepatic injuries revolves around strict adherence to resuscitation prior to addressing the lesion itself. At times, "damage control" with termination of surgery and "packing" the patient with planned re-exploration are critical, as these maneuvers are often lifesaving. The Pringle maneuver and intrahepatic hemostasis for grades III to IV injuries have resulted in a mortality rate under 10%. Juxtahepatic venous injuries continue to carry an inordinately high mortality rate. Intracaval shunts, when used, should be inserted early in the course of the operation before excess transfusions are given and acidosis and hypothermia develop.

Abdominal Injuries↗
PubMed1996

The role of surgeon-performed ultrasound in patients with possible cardiac wounds.

OBJECTIVE: The authors evaluate surgeon-performed ultrasound in determining the need for operation in patients with possible cardiac wounds. BACKGROUND DATA: Ultrasound quickly is becoming part of the surgeon's diagnostic armamentarium; however, its role for the patient with penetrating injury is less well-defined. Although accurate for the detection of hemopericardium, the lack of immediate availability of the cardiologist to perform the test may delay the diagnosis, adversely affecting patient outcome. To be an effective diagnostic test in trauma centers, ultrasound must be immediately available in the resuscitation area and performed and interpreted by surgeons. METHODS: Surgeons performed pericardial ultrasound examinations on patients with penetrating truncal wounds but no immediate indication for operation. The subcostal view detected hemopericardium, and patients with positive examinations underwent immediate operation by the same surgeon. Vital signs, base deficit, time from examination to operation, operative findings, treatment, and outcome were recorded. RESULTS: During 13 months, 247 patients had surgeon-performed ultrasound. There were 236 true-negative and 10 true-positive results, and no false-negative or false-positive results; however, the pericardial region could not be visualized in one patient. Sensitivity, specificity, and accuracy were 100%; mean examination time was 0.8 minute (246 patients). Of the ten true-positive examinations, three were hypotensive. The mean time (8 patients) from ultrasound to operation was 12.1 minutes; all survived. Operative findings (site of cardiac wounds) were: left ventricle (4), right ventricle (3), right atrium (2), right atrium/superior vena cava (1), and right atrium/inferior vena cava (1). CONCLUSIONS: Surgeon-performed ultrasound is a rapid and accurate technique for diagnosing hemopericardium. Delay times from admission to operating room are minimized when the surgeon performs the ultrasound examination.

Adolescent↗