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Biomedical subjects

H Frankel

Publications and source records attributed to H Frankel.

At least 19 recordsLinked to original sources
PubMed2001

Penetrating esophageal injuries: multicenter study of the American Association for the Surgery of Trauma.

OBJECTIVE: The purpose of this study was to define the period of time after which delays in management incurred by investigations cause increased morbidity and mortality. The outcome study is intended to correlate time with death from esophageal causes, overall complications, esophageal related complications, and surgical intensive care unit length of stay. METHODS: This was a retrospective multicenter study involving 34 trauma centers in the United States, under the auspices of the American Association for the Surgery of Trauma Multi-institutional Trials Committee over a span of 10.5 years. Patients surviving to reach the operating room (OR) were divided into two groups: those that underwent diagnostic studies to identify their injuries (preoperative evaluation group) and those that went immediately to the OR (no preoperative evaluation group). Statistical methods included Fisher's exact test, Student's T test, and logistic regression analysis. RESULTS: The study involved 405 patients: 355 male patients (86.5%) and 50 female patients (13.5%). The mean Revised Trauma Score was 6.3, the mean Injury Severity Score was 28, and the mean time interval to the OR was 6.5 hours. There were associated injuries in 356 patients (88%), and an overall complication rate of 53.5%. Overall mortality was 78 of 405 (19%). Three hundred forty-six patients survived to reach the OR: 171 in the preoperative evaluation group and 175 in the no preoperative evaluation group. No statistically significant differences were noted in the two groups in the following parameters: number of patients, age, Injury Severity Score, admission blood pressure, anatomic location of injury (cervical or thoracic), surgical management (primary repair, resection and anastomosis, resection and diversion, flaps), number of associated injuries, and mortality. Average length of time to the OR was 13 hours in the preoperative evaluation group versus 1 hour in the no preoperative evaluation group (p < 0.001). Overall complications occurred in 134 in the preoperative evaluation group versus 87 in the no preoperative evaluation group (p < 0.001), and 74 (41%) esophageal related complications occurred in the preoperative evaluation group versus 32 (19%) in the no preoperative evaluation group (p = 0.003). Mean surgical intensive care unit length of stay was 11 days in the preoperative evaluation group versus 7 days in the no preoperative evaluation group (p = 0.012). Logistic regression analysis identified as independent risk factors for the development of esophageal related complications included time delays in preoperative evaluation (odds ratio, 3.13), American Association for the Surgery of Trauma Organ Injury Scale grade >2 (odds ratio, 2.62), and resection and diversion (odds ratio, 4.47). CONCLUSION: Esophageal injuries carry a high morbidity and mortality. Increased esophageal related morbidity occurs with the diagnostic workup and its inherent delay in operative repair of these injuries. For centers practicing selective management of penetrating neck injuries and transmediastinal gunshot wounds, rapid diagnosis and definitive repair should be made a high priority.

Adolescent↗
PubMed2001

Preoperative radiographic staging for ureteral injuries is not warranted in patients undergoing celiotomy for trauma.

Preoperative radiographic staging of the urinary tract has been shown to be inaccurate with regard to the ureter. The purpose of this study was to assess the need for radiographic staging of the injured patient for the diagnosis of ureteral injury before operative exploration. We conducted a retrospective review of all patients who sustained injury of the ureter as the result of external trauma over an 8 Y2-year period at an urban and suburban Level I trauma center. All patients were injured through penetrating mechanisms and underwent laparotomy. Only three patients had preoperative radiographic staging of the urinary tract. No ureteral injuries were missed. We conclude that surgical exploration of the ureter is sufficiently accurate to obviate the need for preoperative radiographic staging of the ureters in patients who have sustained penetrating injury and warrant laparotomy.

Adolescent↗
PubMed1999

A multi-institutional study of factors associated with fetal death in injured pregnant patients.

HYPOTHESIS: Factors associated with fetal death in injured pregnant patients are related to increasing injury severity and abnormal maternal physiologic profile. DESIGN: A multi-institutional retrospective study of 13 level I and level II trauma centers from 1992 to 1996. MAIN OUTCOME MEASURE: Fetal survival. RESULTS: Of 27,715 female admissions, there were 372 injured pregnant patients (1.3%); 84% had blunt injuries and 16% had penetrating injuries. There were 14 maternal deaths (3.8%) and 35 fetal deaths (9.4%). The population suffering fetal death had higher injury severity scores (P<.001), lower Glascow Coma Scale scores (P<.001), and lower admitting maternal pH (P = .002). Most women who lost their fetus arrived in shock (P = .005) or had a fetal heart rate of less than 110 beats/min at some time during their hospitalization (P<.001). An Injury Severity Score greater than 25 was associated with a 50% incidence of fetal death. Placental abruption was the most frequent complication, occurring in 3.5% of patients and associated with 54% mortality. Cardiotrophic monitoring to detect potentially threatening fetal heart rates was performed on only 61% of pregnant women in their third trimester. Of these patients, 7 had abnormalities on cardiotrophic monitoring and underwent successful cesarean delivery. CONCLUSIONS: Fetal death was more likely with greater severity of injury. Cardiotrophic monitoring is underused in injured pregnant patients in their third trimester even after admission to major trauma centers. Increased use of cardiotrophic monitoring may decrease the mortality caused by placental abruption.

Female↗
PubMed1999

Hypomagnesemia in trauma patients.

The objective of this study was to determine the incidence of hypomagnesemia in injured patients (versus a general hospital cohort) and to compare total and ionized values with each other and with the incidence of injury severity and ethanol level. It was a descriptive study of consecutive injured patients at a level II trauma center. For 3 months subjects underwent admission paired analysis of blood total magnesium (TMg) and ionized magnesium (IMg). IMg was determined by microanalysis of whole blood (Nova Biomedical, NovaSP9). During the same time period, all hospital samples for TMg (m = 1308) underwent simultaneous IMg testing. Pearson correlation coefficients were determined for IMg versus TMg, Injury Severity Score (ISS), Trauma Score (TS), Glasgow Coma Scale (GCS), and blood units transfused. By convention, hypomagnesemia was defined as TMg < or =1.6 mg/dl and IMg < or = 0.5 mg/dl. Altogether 43% of 113 trauma patients had low magnesium levels compared to 30% of noninjured cohorts (p<0.05). The correlation coefficient (r(2)) for TMg and IMg was 0.74 for TMg values >1.6, but for TMg < or =1.6 the r(2) was 0.35. Coefficients for IMg and ISS, TS, GCS, units transfused, and ethanol level were 0.06, 0.08, 0.10, 0.04, and 0.01, respectively. Mean IMg was 0.57+/-0.09 mg/dl with ethanol ingestion and 0.56+/-0.06 mg/dl without ethanol ingestion (mean +/- SD, p>0.05). It was concluded that hypomagnesia is common in injured patients but does not correlate with indices of injury severity or ethanol level. TMg is not a good predictor of IMg at low levels. Trauma patients may benefit from determination of IMg for accurate diagnosis of a low Mg level to facilitate repletion.

Adult↗
PubMed1999

Spinal cord injuries and attempted suicide: a retrospective review.

STUDY DESIGN: A retrospective review examining the cases of 137 individuals with spinal cord injury (SCI) as a result of a suicide attempt between 1951 - 1992. OBJECTIVE: To ascertain demographic details of this participant sample, explore and identify the type of psychiatric condition evident around the time of injury, and to review outcome information of this sample with specific focus on mortality, especially further evidence of deliberate self harm. SUMMARY OF BACKGROUND DATA: Research examining suicide rates in SCI populations has found such numbers to be significantly higher than in the general population. However, these studies have typically relied on small samples of individuals and have often failed to distinguish between those individuals who sustained SCI as a result of attempted suicide, and those who first attempted suicide following SCI. METHODS: An established database comprising details of 137 people with SCI as a result of attempted suicide was reviewed and updated using patient admission records. The subsequent database comprised: cause, level and completeness of injury; height fallen; psychiatric history; psychiatric diagnosis; date of last contact; further suicide attempts; religious affiliation; previous and present employment; date and cause of death; date and place of discharge; and any other relevant details. From this database the three primary objectives of the study were ascertained: demographic detail; psychiatric condition; and outcome information. RESULTS: The ratio of males to females was 1 : 1 with a mean age of 32. Almost half (48.9%) were single, around a third (32.8%) had children and 42. 3% were employed. Schizophrenia and depression were evident in 32.8% and 27% of cases respectively. Previous suicide attempts had been made by 23% (n=32). The cause of injury in 85% of cases was 'falls'. Thirty-three people are known to have died, of whom eight (24%) committed suicide. During the period between the first and last spinal cord injury examined within this study (1951 - 1992) 1.6% (n=137) of the total sample of patients treated at the rehabilitation centre (n=8347) sustained a spinal cord injury as a result of a suicide attempt. CONCLUSION: Significant findings include; a high proportion of patients with schizophrenia; similar findings concerning age profile and level of injuries with previous research, but different sex ratio; and information on longer-term outcomes. Recommendations for further research include an adaptation of the psychological autopsy approach which would provide information beyond that normally available in actual suicides.

Adolescent↗
PubMed1998

Determining anatomic injury with computed tomography in selected torso gunshot wounds.

BACKGROUND: Changes in the management of torso gunshot wounds (TGSWs) have evolved in recent years as a result of differences between military and civilian injuries and increasing interest in avoiding nontherapeutic invasive procedures. The objective of this study was to establish the utility and accuracy of computed tomography (CT) in the evaluation of selected patients with TGSWs. METHODS: Retrospective review for a 6-year period of patients who sustained TGSWs and underwent CT solely for the purpose of trajectory determination. Patients had complete physical examinations and plain radiographic evaluations by a dedicated group of in-house trauma surgeons. When trajectory was indeterminate after evaluation, CT was performed. In some cases, CT was used when trajectory was determined to be intracavitary but organ injury was believed to be unlikely or amenable to nonoperative management. RESULTS: Fifty TGSW patients underwent 52 computed tomographic scans. Abdominal/pelvic CT was performed in 37 patients, and thoracic CT was performed in 15 patients. All patients were stable and none sustained complications attributable to CT or delay in therapy. Twenty of 37 abdominal/pelvic computed tomographic scans excluded transabdominal or pelvic trajectory. Seventeen of 37 scans proved transabdominal or pelvic trajectory; nine laparotomies were performed, and eight patients were observed. Nine of 15 thoracic computed tomographic scans excluded transmediastinal trajectory. Six of 15 scans suggested vascular proximity and prompted further workup, which was positive in two cases. CONCLUSION: CT of selected TGSW patients is safe and may reduce the incidence of invasive diagnostic procedures. A prospective evaluation of CT for TGSW patients is warranted.

Abdominal Injuries↗
PubMed1997

The use of TRISS methodology to validate prehospital intubation by urban EMS providers.

The purpose of this study was to determine the impact of field orotracheal intubation (OI) by urban emergency medical technician-paramedics (EMT-Ps) on outcome compared with trauma score and injury severity score (TRISS) expectations. The records of all trauma patients intubated by EMT-Ps or hospital personnel were abstracted for OI attempts/ successes, use of neuromuscular blockade (NMB), scene time, discharge neurological status, and hospital survival compared with TRISS. EMT-Ps attempted 43% of all intubations; 81% were successful versus 98% by hospital staff (P < .05). NMB was used by 76% of hospital intubations versus none by EMS (P < .05). Scene time was 10.3 +/- 3.2 minutes versus 11.6 +/- 2.1 for patients intubated by emergency medical services (EMS) and hospital staff (P < .05). Sixty percent of patients intubated by EMS versus 68% by hospital staff had good/moderate discharge neurological status. Survival for patients intubated by EMS versus hospital staff was 11% and 40%, respectively, compared with 2% and 45% expected by TRISS. Field OI by urban EMT-Ps has a favorable impact on survival with good neurological outcome (P < .05).

Adult↗
PubMed1997

Factors associated with acute and chronic pain following traumatic spinal cord injuries.

Previous studies have estimated that between 25% and 45% of people with spinal cord injury report severe levels of chronic pain. Few studies have examined this longitudinally. This study examines the primary pain sites, intensity and variability of perceived pain in 76 patients, 6 weeks post injury and 45 patients from the same cohort, 8 year post discharge. Demographic information reveals a close similarity with the database (40,000) from Stover and Fine's cohort (1986). Data was assessed using visual analogue scales, measures were also taken of functional independence (FIM), emotional status and coping. At 6 weeks post injury, most pain is sited in the thoracic spine area, and in the upper and lower limbs. At 1 year post discharge, most pain is reported to be in the thoracic spine area, the lumbar region and the chest. Twenty-three per cent of the 6 week group reported that the intensity of their pain was severe, whilst at 1 year, 41% of the sample complained of severe pain. Factors associated with the pain at both time points were explored using correlational analyses. The emotional, functional and psychological factors that predict pain severity were explored using multiple regression analysis. Twenty-four per cent of those reporting moderate to severe pain at 6 weeks post injury were still reporting pain at 1 year post discharge. This study examines the relative contribution of psychological factors in reported pain.

Activities of Daily Living↗
PubMed1996

A clinical magnetic resonance imaging study of the traumatised spinal cord more than 20 years following injury.

One hundred and fifty three patients who had sustained a spinal cord injury more than 20 years previously were assessed neurologically and by MRI scanning of their spinal cords. The spinal cord pathologies shown were, in order of prevalence, extended atrophy, malacia, syrinx, cyst, disruption and tethering. There was no relationship between the prevalence of any type of pathology and the degree of spinal canal compromise or angulation of the spine adjacent to the level of injury. Neurological changes after initial neurological stabilisation were seen only in patients with extended atrophy, malacia or a syrinx, not in those with only a cyst or cord disruption. Tethering is always associated with other lesion(s). Longer syrinxes were more likely to have associated neurological changes than shorter ones. The most common neurological change was pain.

Adult↗
PubMed1996

Subcutaneous tissue oxygen pressure: a reliable index of peripheral perfusion in humans after injury.

The usual initial life-threatening effect of injury is hypovolemic shock. In the hierarchical physiologic response to hypovolemia, perfusion of peripheral tissues is sacrificed early and restored late. But the usual hemodynamic and metabolic measurements of blood pressure, urine output, and base deficit are not reliable indices of peripheral perfusion. Although the Clark electrode can quantitate tissue oxygen pressure and thereby serve as an index of perfusion, its use is compromised by several technical deficiencies. Recently, an optical method (optode) using fluorescent technology has been developed for measurement of oxygen tension in subcutaneous tissue (P sgO2). Our studies compared this device with the Clark electrode in the laboratory and tested its value in both animal and clinical studies of hypovolemic shock. The results of these several studies demonstrated that: (1) the new oximeter tracked a rapid fall or rapid rise of oxygen tension between room air (150 mm Hg) and 0 mm Hg ( a glucose oxidase/catalase solution) as well as the Clark electrode without encountering its technical problems; (2) with an acute hemorrhage to 20% of base line, the PsgO2 was found to decline rapidly in parallel with the decline of mean arterial pressure (MAP). Although the MAP rapidly returned to normal after immediate complete return of all shed blood, the PsgO2 did not reach normal levels for at least 2 hours, suggesting persistent peripheral vasoconstriction. (3) Studies in progress suggest that between 35 and 78% of trauma patients (n = 18) adequately resuscitated for hypovolemia b customary criteria have a decreased level of PsgO2 for as long as 60 hours after resuscitation for injury. If care is taken to prevent other causes of catecholamine induced vasoconstriction such as pain, fear, cold, and arterial hypoxia, these several results suggest that a certain number of injured patients are inadequately resuscitated despite the return to normal of conventional hemodynamic measurements. The serial analysis of PsgO2 may assist in managing patients and promote better understanding of the responses to injury.

Animals↗
PubMed1996

The impact of implementation of neuromuscular blockade monitoring standards in a surgical intensive care unit.

The purpose was to determine whether implementation of standards for peripheral nerve monitoring could decrease the incidence of neuromuscular dysfunction related to the administration of paralytic agents. Over a 2-year period, consecutive patients admitted to a surgical intensive care unit who received continuously-infused or >6 daily doses of neuromuscular blocking agents were subjected to train-of-four (TOF) monitoring of the adductor pollicis. Therapy was titrated to the maintenance of one to two twitches at all times. The incidence of prolonged (>12 h) paralysis after drug discontinuation was documented in these patients and compared to that in patients treated in the previous 12 months. The presence of electrolyte abnormalities, organ dysfunction, and concomitant medications was also recorded. Chi-square analysis with Yates correction was employed. Before implementation of routine TOF monitoring, there were five instances of paralytic-associated neuromuscular dysfunction (5/43). After implementation of the TOF protocol, no instances of paralytic-associated neuromuscular dysfunction occurred (0/90), despite the same incidence of risk factors (100%) (P < 0.05). A protocol for neuromuscular blockade monitoring is efficacious in preventing paralytic-associated neuromuscular dysfunction. This can be a cost-effective measure, minimizing the prolonged mechanical ventilation and intensive rehabilitation required secondary to unmonitored use of neuromuscular blocking agents.

Aged↗
PubMed1992

The cardiovascular, endocrine and renal response of tetraplegic and paraplegic subjects to dietary sodium restriction.

1. The effects of change from a high to low sodium diet upon renal sodium and water excretion and hormone responses were studied in patients with dissociated sympathetic control (DS, tetraplegic) and controls with sympathetic control largely intact (IS, paraplegic). 2. Total and fractional urinary sodium excretion fell in response to sodium restriction in both groups, but the fall in fractional sodium excretion was greater in the DS group compared with the IS group (DS, 1.34 +/- 0.12 to 0.42 +/- 0.05%; IS, 0.96 +/- 0.08 to 0.52 +/- 0.06%). 3. Supine mean arterial pressure fell during the low salt period in the DS group (80.2 +/- 2.7 to 74.4 +/- 2.3 mmHg) but was unaffected by salt restriction in the IS group (101 +/- 2.3 to 98.8 +/- 2.7 mmHg). In the DS group, creatinine clearance remained constant throughout the low salt period (103.7 +/- 7.9 to 98.3 +/- 9.7 ml min-1), but fell during salt restriction in the IS group (101.4 +/- 8.5 to 83.2 +/- 5 ml min-1). 4. Plasma renin activity was lower during salt loading in DS subjects but increased more rapidly and to higher levels in response to salt restriction (DS, 1021 +/- 142 to 4439 +/- 355; IS, 1765 +/- 269 to 3683 +/- 465 pg angiotensin I ml-1 h-1). Plasma atrial natriuretic peptide concentration was higher in the DS group during salt loading and salt restriction (DS, 37.6 +/- 5.6 to 22 +/- 3.8; IS, 20.2 +/- 2.3 to 11 +/- 1.6 pg ml-1).(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1989

Effect of carbon dioxide on the utilization of brain capillary reserve and flow.

This study investigated effects of increased arterial carbon dioxide on the brain capillary perfusion pattern. Conscious rats were exposed to a 0%, 8% or 12% CO2 in air gas mixture. Arterial blood pressure, heart rate, arterial blood gases and pH were recorded, and either regional cerebral blood flow or the percent of capillary volume/mm3 or number/mm2 perfused were determined in cortical, hypothalamic, pontine or medullary regions of the brain. Arterial PCO2 increased from 37 +/- 1 in control to 74 +/- 1 torr in the high CO2 group. A position linear relationship was found between cerebral blood flow and arterial PCO2 in all examined regions. Approximately half of the capillaries in the examined regions were perfused under normocapnic conditions. Increasing arterial PCO2 had no effect on the percent of the capillary bed perfused in the cortex or hypothalamus. However, there was a significant linear relationship between carbon dioxide tension and the percent of the microvasculature perfused in the hindbrain. The percent of capillaries/mm2 perfused increased significantly in the medulla (to 60 +/- 5%) and pons (70 +/- 4%) with 12% CO2 in air. These data suggest that carbon dioxide may have differential effects on diffusion distances affecting the hindbrain to a greater extent than the forebrain.

Animals↗