Biomedical subjects
Publications and source records attributed to David V Shatz.
Unlike most natural and man-made disasters, preparation and planning for hurricanes is possible and effective. Medical needs can be disparate, given the large geographic area involved and the often-prolonged recovery phase. All aspects of medical response, from first responders to hospitals, can directly and negatively be affected by the storm. Planning and practice, however, can drastically improve the outcome.
This article outlines the position of The Eastern Association of the Surgery of Trauma (EAST) in defining the role of surgeons, and specifically trauma/critical care surgeons, in the development of public health initiatives that are designed to react to and deal effectively with acts of terrorism. All aspects of the surgeon's role in response to mass casualty incidents are considered, from prehospital response teams to the postevent debriefing. The role of the surgeon in response to mass casualty incidents (MCIs) is substantial in response to threats and injury from natural, unintentional, and intentional disasters. The surgeon must take an active role in pre-event community preparation in training, planning, and executing the response to MCI. The marriage of initiatives among Departments of Public Health, the Department of Homeland Security, and existing trauma systems will provide a template for successful responses to terrorist acts.
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Overwhelming postsplenectomy sepsis is a rare but devastating and often lethal disease. Although vaccines are available, their proper use may be questioned. Standardization of protocols for the immunization of asplenic patients should be universal, thus, likely improving on their use. This article reviews the vaccines to be administered to the asplenic patient.
BACKGROUND: Resuscitative thoracotomy (TCY) after trauma has an overall dismal survival rate, yet patients with isolated penetrating chest wounds have the best chance of meaningful recovery. Although the major factor in outcome is presenting physiology, the site of the TCY may influence survival, with the operating room offering a superior environment to the emergency room. PURPOSE: The purpose of this study was to evaluate the impact of location of TCY on outcome after penetrating chest injury. METHODS: This was a multicenter study of patients admitted with either stab (SW) or gunshot wound (GSW) to the chest, with systolic blood pressure < or = 90 mm Hg, and who underwent TCY within 60 minutes of arrival. Time to TCY, Injury Severity Score, location of TCY (emergency room, operating room, or resuscitation room), and detectable systolic pressure at admission were among the factors studied. RESULTS: Over a 4-year period, 78 SW and 140 GSW victims underwent TCY. GSW victims had greater Injury Severity Scores (39.4 +/- 23.1 for GSW vs. 27.2 +/- 15.7 for SW, p < 0.001) and mortality (69% for GSW vs. 37% for SW, p < 0.001). No parameter studied was found to be significantly associated with survival after SW. After GSW, survival was 13.5 times more likely if TCY was performed in the resuscitation room (confidence interval, 3.3-54.6) and 22 times more likely if it was performed in the operating room (confidence interval, 6.7-73.7). CONCLUSION: Although patient selection is the primary factor determining outcome, there may be an independent benefit for performing TCY after GSW in a specialized resuscitation room or the operating room.
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BACKGROUND: The purpose of this study was to examine trama surgeons' practice patterns regarding immunization of splenic injury patients. METHODS: Data were analyzed from surgeons responding to a survey sent to 557 adult trauma surgeons in the United States and Canada. The survey queried the timing and use of vaccinations in splenic injury patients. RESULTS: Three hundred four (54.6%) surgeons responded to the survey, with 43 no longer active. Of the 261 active surgeons, 99.2% immunize their splenectomized patients, whereas 15.7% immunize those who undergo splenorrhaphy and 8.4% immunize those managed nonoperatively. Vaccines are administered anywhere from the immediate postoperative period to as long as 6 weeks later. All but two responding surgeons provide the pneumococcal vaccine, 62.8% also advocate meningococcal vaccination, 72.4% add the Haemophilus influenzae vaccine, and 56.7% give all three. Thirteen of the responding surgeons reimplant splenic tissue, most frequently in the omentum, and in quantities varying from two slices to the entire spleen. Revaccination practices are extremely varied-ranging from nothing at all to annually-and seldom follow Centers for Disease Control and Prevention guidelines. CONCLUSION: With the exception of immunizing splenectomized patients against pneumococcal infection, little consensus exists among surgeons regarding the immunization of patients sustaining splenic injury.
BACKGROUND: We have previously demonstrated, using functional antibody assays, that patients undergoing splenectomy for trauma exhibit a better response to pneumococcal immunization when vaccinated at 14 days postoperatively versus 1 or 7 days. However, patients immunized at 14 days failed to reach the response of normal controls. This study was conducted to determine whether even later immunization would improve the antibody response. METHODS: Forty surviving patients undergoing emergent splenectomy were randomized to receive Pneumovax at 14 or 28 days after splenectomy. Blood samples were drawn at the time of vaccination (prevaccination) and 4 weeks later (postvaccination). A control group of 24 healthy adults was used for comparison. Antibody titers to four of the most common serotypes were determined by enzyme-linked immunosorbent assay and opsonophagocytic assay (OPA). RESULTS: Samples from 38 patient were analyzed. Each serotype and each group tested demonstrated a statistically significant increase in geometric mean enzyme-linked immunosorbent assay immunoglobulin G antibody concentration (microg/mL) and OPA titer (1/dilution) after vaccination. There were no statistically significant differences (p >or= 0.07) in the immunoglobulin G antibody concentrations and OPA titers between the 14-day or the 28-day study groups when compared with normal healthy adults regardless of the serotype tested. In addition, there were no differences in the antibody responses between the 14-day and the 28-day study groups. CONCLUSION: Despite our previous study suggesting that delay in vaccination after emergent splenectomy resulted in improved antibody response, antibody response was not improved any further by delaying vaccination to 28 days.
Injury to the spleen during routine colonoscopy is an extremely rare injury. Diagnosis and management of the injury has evolved with technological advances and experience gained in the management of splenic injuries sustained in trauma. Of the 37 reported cases of colonoscopic splenic injury, 12 had a history of prior surgery or a disease process suggesting the presence of adhesions. Only 6 had noted difficulty during the procedure, and 31 patients experienced pain, shock, or hemoglobin drop as the indication of splenic injury. Since 1989, 21/24 (87.5%) patients have been diagnosed initially using computed tomography or ultrasonography. Overall, only 27.8% have retained their spleens. None have experienced as long a delay as our patient, nor have any had an attempt at percutaneous control of the injury. This report presents an unusual case of a rare complication of colonoscopy and the unsuccessful use of one nonoperative technique, and reviews the experience reported in the world literature, including current day management options.