Intrahepatic vascular clamping in complex hepatic vein injuries.
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Adult↗
Biomedical subjects
E H Carrillo
Publications and source records attributed to E H Carrillo.
Abdominal vascular injuries.
Trauma surgeons are occasionally faced with patients with abdominal vascular injuries. Important surgical issues in the successful management of these injuries require a thorough knowledge of the abdominal vascular anatomy and techniques of vascular repair, that surgical exploration be performed without delay, that the vascular injury be exposed rapidly with control of hemorrhage upon entering the abdomen, that efforts be made to reestablish perfusion initially to the structures at the highest risk of anoxic injury, and an understanding that it is occasionally necessary to perform temporary procedures while the general condition of a patient is being stabilized, with subsequent definitive care. The primary goal in the management of these patients should be hemorrhage control rather than maintenance of blood flow. The principles of abbreviated laparotomy with planned reoperation should be used in some patients with major abdominal vascular injuries. The decision to reestablish vascular continuity at a later time should balance anticipated functional outcome against potential complications.
Abdomen↗
Risk-taking behaviors among adolescent trauma patients.
BACKGROUND: Alcohol is a major contributing factor in adult trauma and may adversely affect decision-making in other safety areas such as use of seatbelts and motorcycle helmets. The magnitude of risk-taking behavior and poor decision-making among adolescent trauma patients is not fully appreciated. Our objective was to determine the prevalence and pattern of risk-taking behavior among adolescents (age < or = 20 years) admitted to an adult Level I trauma center. METHODS: The trauma registry was used to identify patients. Data collected included age, mechanism of injury, blood alcohol and urine toxicology results, seatbelt and helmet use, Glasgow Coma Score, Injury Severity Score, and outcome. RESULTS: Fifteen percent of all admissions to an adult trauma center were adolescents (648 of 4,291). Twenty-one percent of adolescents (138 of 648) and 30% of adults (1,067 of 3,643) tested positive for blood alcohol on admission. Seatbelts were worn by only 19% of adolescent motor vehicle crash admissions versus 30% of adults. Only 7% of adolescents (6 of 83) with detectable alcohol used restraints, compared with 22% (67 of 310) without documented alcohol ingestion (p < 0.05). Adults were somewhat better at restraint use (16% of alcohol-positive patients and 36% without alcohol). Eight of 23 minors (35%) in motorcycle/bicycle crashes were wearing a helmet, compared with 95 of 168 adults (57%). Overall, 6.7% of adolescents and 8.6% of adults had positive toxicology screens. Adolescents with known alcohol consumption were twice as likely to have a positive toxicology screen for illegal drugs (15 vs. 7%; p < 0.05). Alcohol was also frequently detected among adolescents with mechanisms of injury other than motor vehicle and motorcycle crashes, such as violence (25%) and falls (44%). CONCLUSION: Alcohol is frequently involved in all types of trauma, for adolescents as well as adults. This is often compounded by poor decision-making and multiple risk-taking behaviors.
Adolescent↗
Endoscopic treatment of posttraumatic "bilhemia": case report.
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Adult↗
Spontaneous rupture of abdominal aortic aneurysms in patients with non-related blunt traumatic injuries.
As the population ages, abdominal aneurysms are expected to increase in frequency, as well as in the number of elderly patients involved in automobile trauma. Therefore, the number of incidental abdominal aortic aneurysms found in elderly trauma patients should be expected to rise. The purpose of this paper is to report two cases of ruptured abdominal aortic aneurysms found after nonassociated blunt trauma. We review the literature and discuss possible etiologic factors and management associated with this problem.
Accidents, Traffic↗
Video-assisted thoracic surgery in trauma patients.
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Diaphragm↗
Pyloric exclusion in the management of duodenal trauma: is concomitant gastrojejunostomy necessary?
Pyloric exclusion with gastrojejunostomy (PE-GJ) has been recommended in patients with severe injuries to the pancreatoduodenal complex. Recently, the management philosophy for pancreatoduodenal injuries has been that less treatment is probably the best treatment. But whether gastrojejunostomy (GJ) should be used routinely with pyloric exclusion (PE) remains controversial. A retrospective review was conducted of patients who underwent PE at a Level I trauma center during a 36-month period. Forty-five patients had duodenal injuries and 12 of these (27%) underwent PE for management of complex duodenal injuries. Gunshot wounds were the cause of the injuries in 10 of the 12 patients (83%). Eight patients (67%) underwent PE-GJ and had a mean hospital stay of 25 days. Four patients (33%) underwent PE alone and had a mean hospital stay of 29 days. All 12 patients had spontaneous opening of the PE, regardless of the technique used. One patient (12.5%) in the PE-GJ group developed marginal ulceration and significant hemorrhage, and one patient died in the PE-GJ group. The reported incidence of marginal ulceration in the PE-GJ group, the spontaneous opening of the pylorus, and the need to limit the extent of surgical repair to focus on all other associated lesions present in these patients, suggest that GJ should not be used routinely in patients undergoing PE for the management of severe pancreatoduodenal injuries.
Adult↗
Operative strategies for management of abdominal aortic gunshot wounds.
BACKGROUND: Although management of penetrating abdominal trauma has greatly improved, abdominal aortic gunshot wounds (AAGSWs) remain a highly lethal injury. Our experience with AAGSWs was reviewed to define operative strategies that may improve survival. METHODS: Forty-one patients with AAGSWs were treated between 1976 and 1996. Preliminary thoractomy was performed in seven patients. Thirty-nine patients had at least one major associated injury (average, 3.2). RESULTS: Twenty-one patients died. Six of seven patients who underwent preliminary thoracotomy died; all developed coagulopathy, which appeared to contribute to death. Four patients had missed vascular lesions, two of which contributed to their death. Associated injuries are currently managed by "damage control" strategy, in which some injuries are left untreated to focus on hemorrhage control. CONCLUSIONS: We have identified seven operative principles and procedures that we believe may improve survival: (1) thorough knowledge of supraceliac exposure; (2) rapid aortic control at the hiatus rather than by a preliminary thoracotomy; (3) use damage control or abbreviated laparotomy; (4) use packing and mesh closure when coagulopathy and hypothermia are present; (5) primary concern should be cessation of hemorrhage rather than the maintenance of flow; (6) delayed reconstruction using extraanatomic bypass can restore flow; and (7) use angiography to detect missed vascular lesions or problems with vascular repair.
Adult↗
Complex thoracic injuries.
Complex thoracic injuries are a leading cause of death in trauma patients. Four difficult problems of diagnosis and treatment are discussed, including (1) air leak not associated with pneumothorax, (2) management of major thoracic esophageal injuries, (3) penetrating trauma, and (4) retained hemothorax and empyema.
Bronchi↗
Evolution in the management of duodenal injuries.
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Duodenum↗
Exercise-induced compartment syndrome: case report.
Exercise-induced rhabdomyolysis is a frequent event occurring after severe forms of exercise. This is usually a short-lived, uncomplicated phenomenon that is seldom of any clinical significance. The rare progression of this muscle injury to compartment syndrome is, however, a limb- and life-threatening condition that typically presents in the anterior compartment of the lower leg. A case is reported of a young man who participated in physical activity well beyond his normal level of exertion and subsequently developed bilateral lower extremity compartment syndrome requiring surgical decompression. To our knowledge, this is the only description of this complication occurring in a multicompartment, bilateral distribution. The combination of the rarity and morbidity of this condition, as well as the multitude of very common benign injuries that present in the same manner as the problem discussed, make this insult especially dangerous.
Adult↗
Blunt traumatic injuries to the colon and rectum.
BACKGROUND: Experience in the treatment of patients with blunt colonic injuries is based on isolated case reports, and it is unclear whether the principles that guide the management of penetrating colonic injuries should be applied to these patients. Reviews of patients with these injuries suggest that such injuries present unique problems for diagnosis and treatment and are accompanied by excessive morbidity and mortality. STUDY DESIGN: A 42-month retrospective case series was analyzed. RESULTS: Data from 27 patients were analyzed, accounting for 8.5 percent of all colon and rectal injuries and for 0.5 percent of total blunt trauma admissions. Automobile crashes were the cause of injuries in 20 patients (74 percent). The mean Injury Severity Score was 28. All but 2 patients were operated on within 3 hours after admission. No significant difference was found in the morbidity and mortality rates based on the operation performed to manage the colonic injury. Indications for early exploration included a positive diagnostic peritoneal lavage in 23 patients, abnormal radiologic findings in 2, and positive clinical abdominal findings in the remaining 2 patients. CONCLUSIONS: Blunt colonic and rectal injuries are uncommon and pose problems for diagnosis and treatment. Associated injuries are common, and steering wheel compression of the upper abdomen as well as lap belts seem to predispose to colonic injuries. Initial diagnosis is made at the time of operation, and a thorough exploration of the abdominal cavity is important to diagnose associated injuries. Treatment must be individualized; however, based on our observations, the creation of ostomies is not mandatory for the treatment of these injuries.
Accidents, Traffic↗
Penetrating trauma and emergency surgery in patients with AIDS.
BACKGROUND: Several recent publications have suggested that emergency surgery in patients with acquired immunodeficiency syndrome (AIDS) is associated with extremely high morbidity and mortality. PATIENTS AND METHODS: We reviewed the records of 21 patients with AIDS at the University of Miami/Jackson Memorial Medical Center in Miami, Florida, who underwent 24 emergency operations after sustaining penetrating trauma RESULTS: Nineteen patients (90%) presented with gunshot wounds and 2 (10%) presented with stab wounds. Two patients underwent multiple surgical procedures to control hemorrhage from a complex liver injury and to drain a retained hemothorax, respectively. After surgery, patients were managed according to standard protocols, the same as those for non-AIDS patients. Wound infection was present in 4 patients (19%), and occurred only in patients with < 100 CD4+ cells/microL. Fifty-seven percent of patients had no prior knowledge of having AIDS or being seropositive for the human immunodeficiency virus. One patient died after surgery and 18 patients (86%) were still alive 6 months after discharge. CONCLUSIONS: As the AIDS epidemic grows, general surgeons will be treating an increasing number of these patients. A low morbidity and mortality can be obtained with standard surgical care and techniques. Complications are not uncommon and should be treated as in any other surgical patient, unless it is a terminal condition or that posture runs against the patient's stated views or advance directives.
Acquired Immunodeficiency Syndrome↗
Urgent lobectomy and pneumonectomy.
A small number of trauma patients with penetrating thoracic trauma will require formal pulmonary resections to repair severe injuries or control massive haemorrhage. Although previous reports on this subject have addressed the management of these injuries in battle conditions, civilian experience with this type of chest injury is limited. In a 3-year period, 259 patients underwent urgent thoracotomies for penetrating thoracic trauma. We retrospectively reviewed 43 patients who underwent lobectomies or pneumonectomies to control bleeding (93%) or bronchial injuries (7%). Handguns were the aetiologic agent in 41 patients (95%). The most common complication, pneumonia, was seen in 21 patients (87%). Fifteen patients (62%) developed respiratory failure. The complications of wound infection, post-operative haemorrhage and empyema were seen in equal frequency in four patients (16%). Two patients (8%) developed bronchopleural fistulas. Nine pneumonectomies and 34 lobectomies were performed with mortality rates of 66% and 38%, respectively (overall mortality, 44%). Ten (53%) deaths occurred in the operating room, late deaths (2-15 days) were secondary to sepsis and multiple organ dysfunction syndrome (MODS). Currently, the management of patients with devastating thoracic injuries to the thoracic cavity is divided into two stages. First, initial resuscitation with rapid surgery to control major bleeding, cardiac tamponade, tracheal disruptions and potentially lethal air embolism is indicated. Once the life-threatening conditions have been resolved, definitive surgical procedures are performed to repair injuries to any of the thoracic structures.
Adolescent↗
Incidental finding of occult hydronephrosis after blunt abdominal trauma.
Occult congenital and acquired renal lesions are often discovered during evaluation of patients with haematuria after minor blunt torso trauma. This relatively 'minor trauma', can precipitate severe haematuria and hypovolemic shock. This group of patients frequently presents a difficult diagnostic and therapeutic challenge. We discuss the significance of occult hydronephrosis and minor blunt trauma in one patient.
Abdominal Injuries↗
Long term outcome of blunt trauma care in the elderly.
Ninety-four consecutive elderly patients with blunt trauma injuries were studied to determine what impact advanced age had on patient outcome. The current study included patients ranging from 65 to 100 years of age who were admitted to our service from July 1986 to December 1988. Follow-up evaluation was conducted on all patients one to three years after the patient was discharged from the hospital. Seventy-six of the patients were injured as a result of automobile related accidents and 18 were injured as a result of a fall. Fifty-six of the 94 patients required admission to the intensive care unit. There was an average of 3.4 operations per patient in this group. Twelve of the 94 patients died; six within the first 48 hours of hospitalization. More than 70 percent of the survivors were able to function independently after discharge from the hospital. Twelve of the 22 patients who required institutional care after discharge from the hospital were eventually able to return home. A prolonged stay in intensive care was not associated with an unfavorable long term outlook. This high hospital survival rate (87 percent) and percentage of patients living independently at home after hospitalization (87 percent) suggests that the expenditure of extensive resources for the care of the elderly trauma patient is worthwhile.
Age Factors↗
Impaired antibiotic entry into lung tissue following acid injury.
The purpose of this study was to compare the lung tissue burden of intravenous (i.v.) and intrabronchial (i.b.) cefazolin, using a standardized hydrochloric acid injury to the lungs. Ten mongrel dogs were anesthetized with pentobarbital and artificially ventilated. Following administration of cefazolin i.v. (N = 5) or i.b. (N = 5), lung biopsies were obtained at 6 hourly intervals. Simultaneous serum levels were also determined. The effective time (Teff) was defined as the period during which all serum and lung specimens demonstrated antibiotic activity exceeding 8 mcg/gm. These levels should provide comprehensive coverage of common lung and wound pathogens that are sensitive to cefazolin. Teff for the i.v. group was 1 hour, while aerosolized cefazolin never produced lung levels exceeding 8 mcg/gm. Thus, these findings suggest an explanation for cefazolin failure in gram negative pneumonia.
Aerosols↗
Common and external iliac artery injuries associated with pelvic fractures.
BACKGROUND: Common and external iliac artery injuries associated with pelvic fractures are uncommon. The diagnosis of such injuries is based on clinical findings and confirmed by arteriography. DESIGN: Retrospective chart review. SETTING: University Level I trauma center. PATIENTS: Five men and three women, aged seventeen to seventy-six years, with injuries to the common and external iliac arteries associated with pelvic fractures. RESULTS: All patients sustained complex pelvic fractures associated with multiple blunt injuries. Five injuries occurred on the right side. Two patients had an associated right vertical shear pelvic fracture. In five patients, vascular injury was diagnosed in the first six hours after admission. One patient presented with an aneurysm of the right common iliac artery two months after his initial injury. All patients underwent surgical repair with an interposition graft, which failed in two patients, who underwent vascular reconstruction ten hours after the injury. One patient died of associated injuries. CONCLUSIONS: Arterial hyperextension with intimal damage seems to be the most likely cause of this injury. Ideally, an extraperitoneal approach should be attempted to minimize blood losses and, due to the size of the iliac vessels, an interposition graft should be used for reconstruction.
Adolescent↗