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Biomedical subjects

J J Tepas

Publications and source records attributed to J J Tepas.

At least 37 records · Page 2Linked to original sources
PubMed1996

The evaluation of pediatric trauma care using audit filters.

OBJECTIVE: To evaluate the experience of a pediatric trauma system with specific reference to prehospital, trauma center resuscitation, and critical care phases of treatment. DESIGN: Descriptive review of concurrent audit. SETTING: A tertiary care referral adult and pediatric trauma center. PATIENTS: All pediatric trauma victims in the trauma registry (includes patients < or = 14 years old, who died or were hospitalized for > or = 24 hours). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Age, pediatric trauma, injury severity, and Glasgow Coma Scale scores as well as outcome (death or discharge disability score) were analyzed. Primary filters (those with the potential to contribute to morbidity and mortality), secondary filters (minor deviations from care), missed injuries and all deaths were reviewed. Of 250 patients in the registry, 20 died. One hundred thirteen had filters, with 49 having primary filters (34 with one, 14 with two, and one with four filters). Fifty percent of primary filters occurred in the prehospital phase of care with inadequate airway management and venous access accounting for 60%. Overall, primary filters occurred more commonly in patients with severe injuries (lower Pediatric Trauma and Glasgow Coma Scale and higher Injury Severity scores). Primary filters were also statistically more common in patients who died or who were disabled. In three patients (25%) who died, our review suggested that filters may have contributed to demise. Missed injuries were mostly extremity fractures and did not contribute to mortality or long-term morbidity. CONCLUSION: Deviations from care occur, even in a dedicated pediatric trauma system. Mortality of and by itself is not an adequate indicator of the quality of function of a trauma system. Since most primary filters occurred outside of the trauma center, improvement in trauma outcome may be expected with better training of personnel involved in the prehospital care of injured children. A comprehensive review of death and disability should include audit filters of prehospital care, triage, definitive care, and rehabilitation.

Child↗
PubMed1996

Complications of trauma care: risk analysis of pneumonia in 10,001 adult trauma patients.

Five year's experience recorded in the adult registry of a Level I trauma center was reviewed to identify all recorded complications. Patients in whom pneumonia occurred were further analyzed for associated risk factors and for potentially preventable occurrence. Of 10,001 patients, 1027 (10%) sustained a total of 1905 complications. Patients with complications were more severely injured (mean Injury Severity Score = 27.5 versus 9.6;P < 0.01). Pneumonia occurred in 392 patients and was the most frequently encountered complication. Mortality for patients with uncomplicated care was 5.8 per cent in comparison with 46 per cent for those with any complications (P < 0.001), and 30.3 per cent for the pneumonia group (P <0.05). Age >65 years, Injury Severity Score >15, Glasgow coma scale score <8, cervical spine fracture with spinal cord injury, Abbreviated Injury Scale >3 for head, chest, and abdomen regions were associated with an increased risk of pneumonia (P < 0.001). Forty-four patients who developed pneumonia (11%) presented without any risk factor. Two of five related deaths could be considered potentially preventable. We conclude that the incidence of complications related to trauma care increases with injury severity and that complications are associated with a significantly higher mortality. The frequency of pneumonia, 11 percent of which were potentially preventable, emphasizes the critical importance of infection control and aggressive pulmonary toilet in the early care of injured patients.

Adult↗
PubMed1995

Critical care of the injured child.

Critical care of the injured child should be an effective extension of aggressive resuscitation, stabilization, and definitive care. In the hours and days after acute injury, initially unnoticed lesions may emerge, secondary organ dysfunction may develop, and complications of primary injury or initial management may occur. We approach critical care of the severely injured child as a continuation of care begun in the trauma center. We follow an organ system, problem oriented protocol, and attempt to anticipate problems before they occur. This article defines our approach in general terms, with specific emphasis on the more common problems encountered in caring for seriously injured children.

Child↗
PubMed1995

Selective management of pediatric esophageal foreign bodies.

Esophageal foreign body is a relatively common consultation from the Pediatric Emergency Room. This study evaluates optimal selective management of esophageal foreign bodies in the pediatric patient. Eighty-six children have been referred for esophageal foreign body. Fifteen had been symptomatic for 48 or more hours before being seen. In eight, there was a known history of previous repair for esophageal atresia. In 88%, the foreign body was opaque, most frequently a coin. The most common nonopaque foreign body was retained food. Upon diagnosis, 72 children were taken to radiology, where balloon extraction under fluoroscopic control was attempted. Fourteen children went directly to the operating room for endoscopy and foreign body removal. Balloon extraction was successful in 62 cases (86%), and the children were discharged directly from the Emergency Department. The foreign body was successfully removed at esophagoscopy in the 10 cases that failed attempts at balloon extraction. Since 1990, successful extraction has been accomplished in 100% of cases (29/29). Neither balloon extraction nor endoscopy was associated with morbidity or mortality. Endoscopy was, however, associated with total hospital charges approximately 400% higher than balloon extraction. Fluoroscopically guided balloon extraction of appropriate esophageal foreign bodies is a safe and cost-effective alternative to endoscopy. Failure of nonoperative management does not complicate subsequent endoscopic removal. Patients with symptoms > 48 hours, a history of prior esophageal atresia, and/or nonopaque esophageal foreign bodies do not preclude attempt at balloon extraction.

Catheterization↗
PubMed1994

Pediatric and adult thoracic trauma: age-related impact on presentation and outcome.

UNLABELLED: To assess the impact of age on presentation and outcome, 2,415 cases involving blunt and penetrating thoracic trauma over an 8-year period were reviewed retrospectively from a single level I trauma center. Of the 2,073 patients alive on arrival, 79 were 12 years of age or less (children), 137 were 13 to 17 years of age (adolescent), 1,742 were 18 to 59 years of age (adults), and 115 were 60 years of age or more (elderly). Chi-square analysis was performed relative to presentation (blunt versus penetrating), need for thoracotomy, and hospital mortality. Although blunt thoracic trauma comprised 64/79 of children (81%) and 90/115 of the elderly (78%), penetrating thoracic trauma was more common for adolescents 79/137 (58%) and adults 1013/1742 (58%) (p < 0.05). There was no significant difference in need for thoracotomy among the four age groups after blunt thoracic trauma. For penetrating trauma, however, there was a significantly higher incidence of thoracotomy in children as compared with the other three age groups (p < 0.05). IN CONCLUSION: (1) Blunt injuries comprised a greater proportion of thoracic trauma in children and the elderly. (2) In this series, children with penetrating thoracic trauma underwent thoracotomy more frequently. (3) Hospital mortality appeared to be increased for the elderly. (4) Analyses of pediatric thoracic trauma must separate children from adolescent age groups.

Adolescent↗
PubMed1994

Pediatric penetrating thoracic trauma: a five-year experience.

Penetrating thoracic trauma is managed nonoperatively in 85% of adult patients. We hypothesized that similar trauma in children would lead to proportionately more vital tissue damage and a higher rate of operative intervention. The pediatric penetrating thoracic trauma experience of a level one trauma center was analyzed over a five-year period. Data reviewed included circumstances of injury, Pediatric Trauma Score (PTS), interventions performed, and outcome. Of 61 children with thoracic trauma, 13 had penetrating injuries. Of these 13, seven were unintentional (five from firearms); the rest were caused by assaults. Seven patients (54%) underwent thoracotomy or laparotomy. All five patients with a PTS < 8 underwent surgical intervention, whereas only two of the eight patients with a PTS > or = 8 needed surgery (P < 0.05). There was one death. We reached the following conclusions: 1) Children with penetrating thoracic trauma are more likely to require surgical intervention than adults. 2) Penetrating thoracic trauma in children should elicit a thorough search for operative lesions. 3) About half these injuries are unintentional, and thus potentially preventable.

Adolescent↗
PubMed1993

Resident supervision in the operating room: does this impact on outcome?

Resident supervision by faculty is a sine qua non of surgical education, yet objective standards for supervision are difficult to quantify. Over a 12-month period, using departmental data on morbidity, mortality outcome, and faculty status in the operating room, the association between complications, death, and attending physician presence were analyzed by Chi-square tests of association in 2 x 2 contingency tables, or by the Mantel-Haenszel Chi-square to control for a stratifying variable. A total of 4417 cases were reported. Attending physicians were either scrubbed or present in the OR 91.8% of the time, although there was considerable variation among services. The overall mortality rate was 6.2% and complications occurred in 7.0% overall. Greater attending physician presence was significantly associated with lower mortality and complication rates overall. When stratified by service, the association was less marked. However, presence of attending physicians varied significantly by service. To adjust for this variation, elective services were compared with all the "nonelective" services. When this categorization was used as the stratifying variable, the association between increased attending physician involvement and decreased complication and mortality rates was statistically significant (Mantel-Haenszel Chi-square, p < 0.0005 for both).

Clinical Competence↗
PubMed1993

Blunt abdominal trauma in children.

The growing popularity of nonoperative treatment of children with splenic injuries has seduced some physicians into a false sense of security regarding care of the injured child. Although it has been established that hemodynamically stable children with splenic, hepatic, and even renal injuries can safely be treated "expectantly," this concept cannot be applied indiscriminately. Accurate diagnosis and effective care of the child with blunt abdominal trauma is an exercise of clinical precision that demands attention to detail and thorough evaluation. This review addresses this process in light of recent advances in diagnostic imaging and in consideration of recent reports analyzing different protocols for therapeutic decision making.

Abdominal Injuries↗
PubMed1991

Error in fluid and calorie calculation in the surgical neonate.

Nutritional management has become an integral part of the care of the surgical neonate. In most teaching institutions, this is the responsibility of the resident staff with varying degrees of supervision. The purpose of this study was to assess the accuracy of this management. Eleven parameters of fluid and nutritional status were determined daily on all surgical newborns in the neonatal intensive care unit (NICU). The values were calculated by the housestaff in traditional fashion, based on available bedside data, and entered into the charts. Similar values were calculated, based on the same data, by a trained clinical nurse specialist using a preprogrammed, hand-held computer. Values were then compared for significant difference. Approximately 2,500 calculations were analyzed. Overall, there was a statistically significant error detected in the housestaff evaluation of both fluid and nutritional status. This discrepancy was greatest in infants weighing less than 2 kg. Similarly, there was an inverse correlation between the degree of error and houseofficer level. These data indicate a potential risk in the management of the surgical neonate. This risk is greatest in the small infant, indicating the need for close supervision of critical physiological computations within the teaching NICU.

Computers↗
PubMed1991

Balloon dilatation of long-segment tracheal stenoses.

Although a rare anomaly, congenital tracheal stenosis is associated with a high mortality. Surgical approaches proposed for this life-threatening lesion have included resection of localized stenoses; tracheoplasty involving interposition of cartilage, periosteum, or pericardium via an anterior tracheal split; or esophageal anastomosis to a posterior tracheal split. None of these techniques have provided uniformly satisfactory results, and all entail significant morbidity associated with the tracheal anastomosis. We have used endoscopic balloon dilatation in four children with critical airway obstruction from long-segment tracheal stenoses. In each of these patients, symptoms began early in life (from 2 weeks to 6 months of age) and consisted of respiratory distress from upper airway obstruction or recurrent episodes of stridor and chest retractions requiring hospitalization. The location of the tracheal stenoses varied, involving the upper third, middle third, middle half, and distal half of the trachea in the patients encountered. At bronchoscopy, the lumen was judged to be less than or equal to 1 mm in three of these patients. Dilatation was accomplished using Gruentzig balloon catheters in sizes ranging from 3 mm to (eventually) 8 mm, and produced a posterior split in the complete tracheal rings responsible for the stenosis in all patients, resulting in great increases in airway lumen. All children were improved following balloon dilatation, and three are currently doing well at 2.5, 3.0, and 3.0+ years postdilatation. One infant eventually died of airway obstruction incurred by severe bronchomalacia distal to the tip of an endotracheal tube that had been passed to the carina after sequential balloon dilatations.(ABSTRACT TRUNCATED AT 250 WORDS)

Airway Obstruction↗
PubMed1991

Does patient age or intestinal pathology influence the bacteria found in cases of necrotizing enterocolitis?

To evaluate the relationship between bacterial colonization in neonatal peritonitis and patient age or intestinal pathology, we retrospectively reviewed peritoneal culture results from 96 infants having surgery for necrotizing enterocolitis. Microorganisms recovered mirrored those usually found as fecal flora within the neonatal intensive care unit. These reflect, in turn, the abnormal colonization intrinsic to care in the intensive care nursery. Analysis revealed no significant correlation between the disease and either age of the infant or intestinal site of disease.

Age Factors↗
PubMed1990

Mortality and head injury: the pediatric perspective.

The records of 10,098 children entered into the National Pediatric Trauma Registry (NPTR) were analyzed to define the characteristics of pediatric head injury and the impact of extracranial trauma on Central Nervous System (CNS) injury. The 4,400 NPTR head injuries were then compared with 16,524 head injuries recently reported from a predominantly adult trauma registry to illustrate potential population differences. Results indicate that children have a lower mortality, that the addition of extracranial injury significantly reduces recovery potential, that CNS injury is the predominant and most common cause of pediatric traumatic death, and that the automobile is the most lethal component of a child's environment.

Adult↗
PubMed1989

National Pediatric Trauma Registry.

The National Pediatric Trauma Registry (NPTR) is a multi-institutional database designed to compile information concerning all aspects of pediatric trauma care. The registry is designed and operated in a manner that maximizes data accuracy and provides this information to all participating investigators. The growth of the database has allowed the NPTR to provide the first accurate epidemiologic description of pediatric trauma as a national disease, as well as to develop national norms for pediatric trauma care. The registry presently contains 10,177 patients, and is undergoing revisions (phase II) to allow a more focused evaluation of various aspects of the clinical care and rehabilitation of the pediatric trauma patient.

Child↗
PubMed1989

The effect of initial operative repair on the recovery of intestinal function in gastroschisis.

Recent reports concerning the treatment of gastroschisis suggest that primary closure results in more rapid return of gastrointestinal function, a shortened hospitalization, diminished perinatal complications, and improved long-term survival. A 4-year retrospective review of infants treated for gastroschisis at the University of Florida yielded 30 infants requiring repair of this abdominal wall defect. The series included 19 males and 11 females, and the average abdominal wall defect measured 4 cm in its greatest dimension. Nine infants (mean weight, 2,275 gm) were repaired using a staged closure using a silastic (six) or cutaneous (three) silo. Complete fascial closure was accomplished in an average of 8 days in the silastic group and 15 days in the infants with skin flaps. Mean age at start of enteral feeds was 23 days, with complete oral feedings at 43 days. Twenty-one infants (mean weight, 2,127 gm) underwent primary fascial closure. Three deaths occurred in the perioperative period: one from acute renal failure and two from sepsis secondary to a segment of necrotic intestine. An additional infant developed postoperative necrotizing entercolitis but recovered. Two infants in this group also had jejuno-ileal atresia requiring extensive small bowel resection. In the remaining 15 infants, oral alimentation was initiated for an average of 23 days, with full oral alimentation at 46 days. The data suggest that the recovery of the gastrointestinal system, adequate enough to support total oral alimentation, is unrelated to the initial surgical procedure chosen to obtain fascial closure in the newborn with gastroschisis. In addition, vigorous attempts at primary fascial closure may jeopardize intestinal viability, diminish ventilatory function, and result in unnecessary morbidity and mortality.

Abdominal Muscles↗
PubMed1989

The 1983 Beirut Airport terrorist bombing. Injury patterns and implications for disaster management.

The casualty profile and results of the medical care provided for the survivors of the terrorist truck bombing of the U.S. Marine Corps facility in Beirut, Lebanon, in 1983 were reviewed to determine the factors that influenced casualty survival. This explosion resulted in 346 casualties, of whom 234 (68%) were immediately killed. The spectrum of injury was determined in 85 survivors using the Injury Severity Score (ISS). There were seven (6.3%) deaths among the 112 immediate survivors. All deaths occurred among the 19 (17%) victims who were critically injured (ISS greater than 15), giving a mortality in this population of 37 per cent. Six (86%) of the seven deaths were associated with an initial delay in treatment. Head injury was the most common fatal injury among both immediate fatalities (71.4%) and immediate survivors (57%). Thoracic injury and burns each accounted for 29 per cent of survivor deaths. Triage efficiency, as determined by the rates of overtriage (80%) and undertriage (0), did not appear adversely to affect mortality. Critical analysis of disasters such as this can contribute to improvements in preparation and casualty care in the event of future disasters.

Disasters↗
PubMed1988

The microbiology of neonatal peritonitis.

To review the bacteriology of neonatal intra-abdominal sepsis, we reviewed peritoneal cultures from 86 newborns undergoing operation for necrotizing enterocolitis (NEC) for the type and incidence of microorganism recovered. As a control, we conducted a similar review in 59 children with perforated appendicitis during the same period. Necrotizing enterocolitis was characterized by a lower incidence of polymicrobial contamination (1.7 organisms per patient vs 2.4 organisms per patient, NEC vs appendicitis) and an uncharacteristic pattern of isolates. Although enteric gram-negative bacilli were recovered in 80% of newborns, the incidence of Escherichia coli was only 21% in the NEC group vs 69% in the appendicitis group, while Klebsiella and Enterobacter species represented the most common gram-negative isolates recovered (63% vs 17%). More than 50% of neonatal cultures yielded gram-positive cocci, most frequently coagulase-negative staphylococci (30% vs 0%) and enterococci (17% vs 5%), as compared with more frequent streptococcal isolates in the appendicitis group (50% vs 10%). Anaerobes were seldom recovered in NEC cases (6%), but they were present in 50% of appendicitis cases. Additionally, Candida isolates were recovered in 10% of NEC cases (0% of appendicitis group). These results indicate the unique bacteriology of peritonitis in the critically ill newborn and probably reflect abnormal colonization in the neonatal intensive care unit.

Appendicitis↗