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Biomedical subjects

J M Burch

Publications and source records attributed to J M Burch.

At least 37 records · Page 2Linked to original sources
PubMed1998

The unrecognized epidemic of blunt carotid arterial injuries: early diagnosis improves neurologic outcome.

OBJECTIVE: To determine the benefit of screening for blunt carotid arterial injuries (BCI) in patients who are asymptomatic. SUMMARY BACKGROUND DATA: Blunt carotid arterial injuries have the potential for devastating complications. Published studies report 23% to 28% mortality rates, with 48% to 58% of survivors having permanent severe neurologic deficits. Most patients have neurologic deficits when the injury is diagnosed. The authors hypothesized that screening patients who are asymptomatic and instituting early therapy would improve neurologic outcome. METHODS: The Trauma Registry of the author's Level I Trauma Center identified patients with BCI from 1990 through 1997. Beginning in August 1996, the authors implemented a screening for BCI. Arteriography was used for diagnosis. Patients without specific contraindications were anticoagulated. Endovascular stents were deployed in the setting of pseudoaneurysms. RESULTS: Thirty-seven patients with BCI were identified among 15,331 blunt-trauma victims (0.24%). During the screening period, 25 patients were diagnosed with BCI among 2902 admissions (0.86%); 13 (52%) were asymptomatic. Overall, eight patients died, and seven of the survivors had permanent severe neurologic deficits. Excluding those dying of massive brain injury and patients admitted with coma and brain injury, mortality associated with BCI was 15%, with severe neurologic morbidity in 16% of survivors. The patients who were asymptomatic at diagnosis had a better neurologic outcome than those who were symptomatic. Symptomatic patients who were anticoagulated showed a trend toward greater neurologic improvement at the time of discharge than those who were not anticoagulated. CONCLUSIONS: Screening allows the identification of asymptomatic BCI and thereby facilitates early systemic anticoagulation, which is associated with improved neurologic outcome. The role of endovascular stents in the treatment of blunt traumatic pseudoaneurysms remains to be defined.

Adolescent↗
PubMed1998

Management of abdominal vascular injuries.

Major abdominal vascular injuries are associated with significant morbidity and mortality. They present a formidable challenge to the most experienced surgeon. Most commonly the result of penetrating trauma, hemorrhagic shock is the usual presentation, and diagnostic maneuvers are unnecessary. Conversely, a high index of suspicion is critical in diagnosing occult injuries. This article reviews the cause, diagnosis, and treatment of major abdominal vascular injuries, with an emphasis on exposures and techniques of repair. In addition, the concepts of repair versus ligation, staged laparotomy, and the abdominal compartment syndrome are discussed.

Abdomen↗
PubMed1997

Selective management of penetrating neck trauma based on cervical level of injury.

BACKGROUND: Selective surgical exploration of penetrating neck wounds is now the standard of care, but the safety and cost effectiveness of selective diagnostic testing remains controversial. We herein review our 18-year prospective evaluation of a progressively selective approach. PATIENTS AND METHODS: Since 1979, 312 patients sustained penetrating trauma to the anterior neck; 75% were stabbed and 24% were shot. Zone I was penetrated in 13%, zone II in 67%, and zone III in 20%. RESULTS: In all, 105 (34%) of the patients had early exploration (16% were nontherapeutic). Of the 207 (66%) observed, 1 (0.5%) required delayed exploration. Length of stay was 8.0 days following exploration, 5.1 days following negative exploration, and 1.5 days following observation. In the last 6 years, 40% have had adjunctive testing: 69% of zone I, 15% of zone II, and 50% of zone III injuries. CONCLUSION: Selective management of penetrating neck injuries is safe and does not mandate routine diagnostic testing for asymptomatic patients with injuries in zones II and III.

Humans↗
PubMed1997

Prospective characterization and selective management of the abdominal compartment syndrome.

BACKGROUND: The abdominal compartment syndrome (ACS) is now recognized as a frequent confounder of surgical critical care following major trauma; however, few prospective data exist concerning its characterization, evolution, and response to decompression. METHODS: Acutely injured patients with an injury severity scale (ISS) score >15 requiring emergent laparotomy and intensive care unit (ICU) admission were prospectively evaluated for the development of ACS. The syndrome was defined as an intra-abdominal pressure (IAP) >20 mm Hg complicated by one of the following: peak airway pressure (PAP) >40 cm H2O, oxygen delivery index (DO2I) <600 mL O2/min/m2, or urine output (UO) <0.5 mL/kg/hr. Physiologic response to decompression was similarly documented prospectively. RESULTS: Over a 14-month period ending December 1995, 21 (14%) of 145 patients (ISS >15) requiring laparotomy and admitted to our surgical ICU developed ACS; mean age was 39 +/- 9 years; injury mechanism was blunt in 60%; ISS 26 +/- 6. At initial laparotomy, 67% underwent abdominal packing (57% for major liver injuries). Mean IAP was 27 +/- 2.3 mm Hg, and time from laparotomy to decompression was 27 +/- 4 hours; 24% were planned whereas the remaining were prompted by deteriorating organ function as defined above (cardiopulmonary in 43%; renal in 19%; both renal and cardiopulmonary in 14%). Following decompression, there was an increase in cardiac index, oxygen delivery, urine output, and static compliance while there was a decrease in pulmonary capillary wedge pressure, systemic vascular resistance, and peak airway pressure. CONCLUSIONS: The abdominal compartment syndrome occurs in a significant number of severely injured patients, and it develops quickly (27 +/- 4 hours). Cardiopulmonary deterioration is the most frequent reason prompting decompression. Timely decompression of the ACS results in improvements in cardiopulmonary and renal function. These data support the use of the proposed ACS grading system for selective management of the syndrome.

Abdomen↗
PubMed1997

Physiologic rationale for abbreviated laparotomy.

Trauma patients who succumb to their injuries do so by one of several mechanisms discussed in this article. The most common include head injury, exsanguination, sepsis, and multiple organ failure. The article also discusses adverse consequences of hypothermia, including a model for calculating total heat loss.

Animals↗
PubMed1997

Predicting life-threatening coagulopathy in the massively transfused trauma patient: hypothermia and acidoses revisited.

BACKGROUND: Recalcitrant coagulopathy "the bloody vicious cycle," produces the majority of deaths after torso trauma. A model predicting this life-threatening complication may facilitate clinical decision-making. METHODS: We prospectively analyzed patients > 15 years old who received a massive transfusion (> 10 units of packed red blood cells (PRBC)/24 h) over a 2-year period. Excluding massive head injuries and pre-existing disease, the 58 study patients had a mean age = 35.4 years, Injury Severity Score (ISS) = 30.6, and PRBC = 24.2 units/24 h. RESULTS: Defined as prothrombin time of two times that of normal laboratory controls and partial thromboplastin time as two times that of normal laboratory controls, 27 patients (47%) developed life-threatening coagulopathy. Using a multiple logistic regression model, the four significant risk factors (with odds ratio) were (1) pH < 7.10 (12.3), (2) temperature < 34 degrees C (8.7), (3) ISS > 25 (7.7), and (4) systolic blood pressure < 70 mm Hg (5.8). The conditional probability of developing coagulopathy was ISS > 25 + systolic blood pressure < 70 mm Hg = 39%, ISS > 25 + temperature < 34 degrees C = 49%, ISS > 25 + pH < 7.10 = 49%; with all four risk factors the incidence was 98%. CONCLUSION: Postinjury life-threatening coagulopathy in the seriously injured requiring massive transfusion is predicted by persistent hypothermia and progressive metabolic acidosis.

Abdominal Injuries↗
PubMed1997

Ultrasound based key clinical pathway reduces the use of hospital resources for the evaluation of blunt abdominal trauma.

BACKGROUND: Evaluating blunt abdominal trauma remains a resource intensive aspect of trauma care. Recently, emergency department ultrasound has been promulgated as a noninvasive diagnostic alternative. Consequently, we hypothesized that an ultrasound based key clinical pathway (KCP) would reduce the number of diagnostic peritoneal lavage (DPL) and computed tomographic (CT) scans required to evaluate blunt abdominal trauma without increased risk to the patient. METHODS: This study was a prospective analysis of patients evaluated for blunt abdominal trauma during a 3-month period using this KCP compared with a 3-month historical cohort. RESULTS: Data were collected for 486 KCP patients and were compared with 516 patients in the study cohort. No differences were noted regarding demographics, number of laparotomies, or type of injuries. Using the KCP, DPL was reduced from 17 to 4%, and computed tomography from 56 to 26%. Furthermore, the injury severity score increased from 11.6 to 21.5 for DPL patients and from 4.6 to 8.3 for computed tomography patients. Ultrasound exams were used exclusively in 65% of patients. CONCLUSIONS: An ultrasound based KCP resulted in significant reductions in the use of invasive DPL and costly CT scanning in the evaluation of blunt abdominal trauma without risk to the patient.

Abdominal Injuries↗
PubMed1997

Clinical utility of human polymerized hemoglobin as a blood substitute after acute trauma and urgent surgery.

We have previously documented the safety of 1 unit (50 gram) of human polymerized hemoglobin (Poly SFH-P) in healthy volunteers. This report describes the first patient trial to assess the therapeutic benefit of Poly SFH-P in acute blood loss. Thirty-nine patients received 1 (n = 14), 2 (n = 2), 3 (n = 15), or 6 (n = 8) units of Poly SFH-P instead of red cells as part of their blood replacement after trauma and urgent surgery. There were no safety issues related to the infusion of Poly SFH-P. The plasma hemoglobin concentration ([Hb]) after the infusion of 6 units (300 gram) of Poly SFH-P was 4.8 +/- 0.8 g/dL (mean +/- SD). Although the red cell [Hb] fell to 2.9 +/- 1.2 g/dL, the total [Hb] was maintained at 7.5 +/- 1.2 g/dL. Poly SFH-P maintained total [Hb], despite the marked fall in red cell [Hb] due to blood loss. The utilization of O2 (extraction ratio) was 27 +/- 16% from the red cells and 37 +/- 13% from the Poly SFH-P. Twenty-three patients (59%) avoided allogeneic transfusions during the first 24 hours after blood loss. Poly SFH-P effectively loads and unloads O2 and maintains total hemoglobin in lieu of red cells after acute blood loss, thereby reducing allogeneic transfusions. Poly SFH-P seems to be a clinically useful blood substitute.

Adult↗
PubMed1996

Tracheal gas insufflation is a useful adjunct in permissive hypercapnic management of acute respiratory distress syndrome.

BACKGROUND: Despite numerous advances in critical care, the mortality of postinjury acute respiratory distress syndrome (ARDS) remains high. Recently, permissive hypercapnia (PHC) has been shown to be a viable alternative to traditional ventilator management in patients with ARDS. However, lowering tidal volume, as employed in PHC, below 5 cc/kg impinges upon anatomic dead space and precipitates a significant rise in PaCO2 The purpose of this study was to determine if continuous tracheal gas insufflation (cTGI) is a useful adjunct to PHC by lowering PaCO2, thus allowing adequate reduction in minute ventilation to achieve alveolar protection. METHODS: Over a 5-year period, 68 trauma patients with ARDS were placed on permissive hypercapnia. Nine of these patients additionally received cTGI at 7 L/min. Arterial blood gas determinations and ventilatory parameters were examined immediately prior to the implementation of cTGI and after 6h. RESULTS: The cTGI produced significant improvement in pH (7.25 +/- 0.03 to 7.33 +/- 0.03), PaCO2 (72 +/- 5 to 59 +/- 5 torr), tidal volume (7.9 +/- 0.6 to 7.2 +/- 0.6 cc/kg), and minute ventilation (13 +/- 1 to 11 +/- 1 L/min; P < 0.05). CONCLUSIONS: Continuous TGI is a useful adjunct to permissive hypercapnia, allowing maintenance of an acceptable pH and PaCO2 while allowing further reduction in tidal volume and minute ventilation.

Adolescent↗
PubMed1996

The abdominal compartment syndrome.

1. ACS is caused by an acute increase in intra-abdominal pressure, usually as a result of intra-abdominal hemorrhage. 2. The most common and significant complications are respiratory and renal failure. 3. Abdominal decompression promptly reverses the complications of ACS. 4. Failure to recognize and treat ACS is inevitably fatal.

Abdomen↗
PubMed1996

Infant survival after cesarean section for trauma.

HYPOTHESIS: Emergency cesarean sections in trauma patients are not justified and should be abandoned. SETTING AND DESIGN: A multi-institutional, retrospective cohort study was conducted of level 1 trauma centers. METHODS: Trauma admissions from nine level 1 trauma centers from January 1986 through December 1994 were reviewed. Pregnant women who underwent emergency cesarean sections were identified. Demographic and clinical data were obtained on all patients undergoing a cesarean section. Fetal distress was defined by bradycardia, deceleration, or lack of fetal heart tones (FHTs). Maternal distress was defined by shock (systolic blood pressure < 90) or acute decompensation. Statistical analyses were performed. RESULTS: Of the 114,952 consecutive trauma admissions, more than 441 pregnant women required 32 emergency cesarean sections. All were performed for fetal distress, maternal distress, or both. Overall, 15 (45%) of the fetuses and 23 (72%) of the mothers survived. Of 33 fetuses delivered, 13 had no FHTs and none survived. Twenty infants (potential survivors) had FHTs and an estimated gestational age (EGA) of greater than or equal to 26 weeks, and 75% survived. Infant survival was independent of maternal distress or maternal Injury Severity Score. The five infant deaths in the group of potential survivors resulted from delayed recognition of fetal distress, and 60% of these deaths were in mothers with mild to moderate injuries (Injury Severity Score < 16). CONCLUSIONS: In pregnant trauma patients, infant viability is defined by the presence of FHTs, estimated gestational age greater than or equal to 26 weeks. In viable infants, survival after emergency cesarean section is acceptable (75%). Infant survival is independent of maternal distress or Injury Severity Score. Sixty percent of infant deaths resulted from delay in recognition of fetal distress and cesarean section. These were potentially preventable. Given the definition of fetal viability, our initial hypothesis is invalid.

Adolescent↗
PubMed1996

Postinjury multiple organ failure: a bimodal phenomenon.

To better define the epidemiology of postinjury multiple organ failure (MOF), we prospectively evaluated 457 high-risk trauma patients who survived more than 48 hours. Overall, 70 (15%) developed MOF. In 27 (39%) patients, the occurrence was early, while in 43 (61%) patients the presentation was delayed. At presentation, early MOF had more cardiac dysfunction, while late MOF had greater hepatic failure. Indices of shock were more critical risk factors for early MOF, while advanced age was more important for late MOF. While early and late MOF had a similar high incidence of major infections, these appeared to be more important in precipitating late MOF. Finally, while mortality is similar, early MOF patients appear to succumb faster. In conclusion, postinjury MOF remains a significant challenge and appears to present in at least two patterns (i.e., early versus late). Better understanding of the relative roles of the dysfunctional inflammation and infections in early MOF versus late MOF may facilitate the development of new strategies for the prevention and treatment of morbid syndrome.

Adolescent↗
PubMed1996

In situ fixation of the slipped capital femoral epiphysis with a single screw.

We made a retrospective analysis of a consecutive series of patients with slipped capital femoral epiphyses (SCFE) surgically treated at the Shriners Hospitals for Crippled Children at Lexington, Kentucky. The clinical outcome was correlated to the number of pins and the incidence of chondrolysis, ischemic necrosis, and progressive slipping after the initial fixation. An evaluation made of the Walters-Simon theoretic pin penetration formula was of no value in this series. We compiled results in the medical literature and compared them with ours; all information indicated that a single pin through an anterior portal significantly reduces complications and provides reliable fixation. However, ischemic necrosis still occurs in the unstable slip, although at a lesser rate than in cases treated with multiple pin fixation.

Bone Screws↗
PubMed1995

Jack A. Barney Resident Research Award. Cardiopulmonary hazards of perihepatic packing for major liver injuries.

BACKGROUND: Perihepatic packing has been shown to result in pathologic intra-abdominal hypertension. Although now recognized as impairing abdominal organ perfusion, the extent to which perihepatic packing affects cardiopulmonary function has not been elucidated. METHODS: We analyzed a 3-year experience with 11 patients who sustained major hepatic injuries requiring perihepatic packing to control hemorrhage. Pertinent hemodynamic indices consisting of pulmonary capillary wedge pressure (PCWP), cardiac index (CI), oxygen delivery index (DO2), and systemic vascular resistance (SVR), and pulmonary indices consisting of peak airway pressure (PAP), mean airway pressure (MAP), static compliance (CST), and PaO2/FiO2 were measured in the surgical intensive care unit immediately before and after packs were removed. RESULTS: Unpacking resulted in a significant increase in CI (3.1 +/- 0.4 to 4.2 +/- 0.6 L/min/m2), DO2 (539 +/- 41 to 689 +/- 43 mL min/m2), CST (26 +/- 6 to 36 +/- 4 mL/cm H2O), and PaO2/FiO2 (162 +/- 44 to 237 +/- 53 cm H2O), as well as a significant decrease in PAP (47 +/- 9 to 29 +/- 6 cm H2O), MAP (34 +/- 4 to 27 +/- 3 cm H2O), PCWP (21 +/- 4 to 13 +/- 3 mm Hg), and SVR (1,239 +/- 162 to 887 +/- 130 dyne/cm5). CONCLUSIONS: Abdominal compartment syndrome following temporary perihepatic packing can result in significant cardiopulmonary compromise. While perihepatic packing can be an early life-saving procedure, timely alleviation of the secondary syndrome may be critical to the ultimate salvage of patients with marginal cardiopulmonary reserve.

Adolescent↗
PubMed1995

Are corticosteroids salvage therapy for refractory acute respiratory distress syndrome?

BACKGROUND: Late acute respiratory distress syndrome (ARDS), characterized by progressive pulmonary interstitial fibroproliferation, is associated with mortality > 80%. Although previous large prospective trials failed to show a benefit of steroids in early ARDS, recent small reports describe improved survival in patients with late ARDS. Recognizing the pathogenetic differences between early and late ARDS, we employed steroid therapy in patients with refractory late ARDS. PATIENTS AND METHODS: Over a 5-year period, we treated 6 patients who were dying of isolated refractory ARDS with methylprednisolone sodium succinate (1 to 2 mg/kg every 6 hours). Ventilatory parameters and lung injury scores were serially recorded, and steroids were weaned based on clinical response. RESULTS: Steroids were instituted after 16 days of advanced mechanical ventilatory support. By day 7 of steroid therapy, there was clinically significant improvement in PaO2/FiO2 ratios (84 to 172) and lung injury scores (3.6 to 2.9); 5 patients (83%) survived. CONCLUSIONS: Steroid therapy appears to be effective in patients with refractory late ARDS. Prospective trials are needed to define the indications, timing of intervention, dose and duration, and precautions of steroid therapy.

Acute Disease↗
PubMed1995

Extrapleural bupivacaine for amelioration of multiple rib fracture pain.

OBJECTIVE: The pain associated with multiple rib fractures can be surprisingly variable. The objective of this study was to determine the efficacy of an indwelling, percutaneously placed intercostal catheter in relieving the pain associated with multiple rib fractures. DESIGN: Prospective nonrandomized study setting: Surgical intensive care unit in a level 1 trauma center. SUBJECTS: Fifteen blunt chest trauma patients with a minimum of three rib fractures who had failed an intravenous patient controlled analgesia protocol. INTERVENTIONS: Insertion of an epidural catheter within the intercostal space. Bupivacaine 0.25% with epinephrine was injected in a volume of 20 mL. Subsequent doses were limited to a total of 400 mg per 24 hours. MEASUREMENTS AND MAIN RESULTS: Severity of injury was estimated by using the Injury Severity Score. For each patient a preinjection visual analogue scale (VAS) and incentive spirometry (IS) lung volume were determined. Fifteen minutes following injection of 0.25% bupivacaine with epinephrine the VAS and IS were repeated. The Injury Severity Score ranged from 9 to 32 (mean 19.0 +/- 1.6). Overall, mean VAS pain scores improved significantly following the initial bolus of bupivacaine (before VAS = 7.5 +/- 0.6, after VAS = 3.5 +/- 0.5, p < 0.05) and this was associated with significant increase in IS lung volumes (before IS = 0.77 +/- 0.09, after IS = 1.3 +/- 0.13, p < 0.05). No patient experienced either insertion-related or drug administration complications. CONCLUSIONS: These results confirm that an indwelling intercostal catheter provides a continuous nerve block resulting in a simple, safe procedure that can ameliorate the pain and splinting associated with multiple rib fractures. Although we experienced no complications, additional investigation is clearly needed.

Adult↗