Biomedical subjects

J M Burch

Publications and source records attributed to J M Burch.

At least 55 records · Page 3Linked to original sources

PubMed1994

Transcervical gunshot injuries.

Gunshot injuries across the cervical midline are not addressed in existing trauma algorithms. A retrospective study of 41 patients with transcervical gunshot wounds was undertaken to delineate injury patterns and management principles. Thirty-four of the 41 patients (83%) sustained 52 injuries to major cervical structures. Vascular (22 injuries) and upper airway (13 injuries) structures were most commonly involved. This resulted in presentation with life-threatening problems in 16 patients (39%). The in-hospital mortality was 10%. In 30 of the 36 neck explorations (83%), the findings were positive for injuries to cervical structures. Sixteen bilateral explorations were performed; in each case, cervical injury was observed on at least one side of the neck. These results indicate that transcervical injuries are excellent markers of associated visceral injury. Therefore, a policy of mandatory neck exploration and a particularly "low threshold" for bilateral exploration are the key to managing these injuries.

Adolescent↗

PubMed1994

Cardiac enzymes are irrelevant in the patient with suspected myocardial contusion.

BACKGROUND: Myocardial contusion is commonly diagnosed following blunt chest trauma, and has potentially lethal complications. Cost-effective case management in patients with suspected myocardial contusion is confounded by the low incidence of complications and the lack of a reliable test to predict them. The clinical usefulness of elevated cardiac enzyme levels is controversial. METHODS: We analyzed a 4-year experience of 359 patients with high-risk blunt chest trauma who were assessed using an established practice guideline. Our multivariate statistical model evaluated all of the early risk factors included in the guideline, specifically focusing on cardiac enzyme levels. RESULTS: Myocardial contusion was diagnosed in 30% of patients, and complications (dysrhythmias and cardiogenic shock) occurred in 5%. In no case was cardiac enzyme elevation the sole predictor of a complication. The cost of routine cardiac enzyme assay was substantial. CONCLUSION: Cardiac enzyme determinations have no useful role in the evaluation of patients with suspected myocardial contusion. They should be eliminated from current practice guidelines.

Adolescent↗

PubMed1994

Trauma surgeons can render definitive surgical care for major thoracic injuries.

Restrictions on the operative domain of general surgeons threaten the viability of trauma surgery as a career choice. Our study hypothesis is that an experienced trauma surgeon can provide definitive care for life-threatening thoracic trauma. This analysis is based on clinical outcomes at an ACS-verified level I center in which there are more than 3000 trauma admissions managed annually under the direction of four academic trauma surgeons. We selected penetrating cardiac wounds and blunt tears of the thoracic aorta because these injuries are managed exclusively by the trauma service and the endpoints are distinct. During the past 4 years, 40 patients with cardiac wounds were delivered to the ED; 23 patients arrived dead. In the remaining 17, injury mechanisms were 15 stab wounds (SW), one gunshot wound (GSW), and one shotgun (SGW). Four of these patients required ED thoracotomy, and the remaining 13 underwent some form of prethoracotomy pericardial decompression. Survival rate without neurologic deficit was 94% (16 of 17). During this same period, 19 patients with a torn thoracic aorta from blunt injuries arrived with signs of life. In this group the injury mechanisms were automobile crash in 15, and the mean ISS was 39.7 +/- 2.3. One patient was transferred for total cardiopulmonary bypass; 17 of the remaining patients underwent aortic repair employing partial left heart bypass. Sixteen of our 18 patients lived and none developed paraplegia. In summary, excluding patients who arrived dead, survival for penetrating cardiac wounds was 94% and for blunt thoracic aortic tears 89%. In conclusion, these data support our contention that trauma surgeons can render definitive care for thoracic injuries with survival rates comparable to those reported by cardiothoracic surgeons.

Adolescent↗

PubMed1994

Cardiopulmonary effects of permissive hypercapnia in the management of adult respiratory distress syndrome.

BACKGROUND: Despite numerous advances, the mortality from adult respiratory distress syndrome (ARDS) remains high. Traditional ventilator management in ARDS has been to maintain normal PaCO2 by positive pressure ventilation (PPV). However, high levels of PPV may worsen the lung injury by alveolar overdistension. Permissive hypercapnia (PHC) has been proposed as an alternative method of ventilation, but hypercapnia may affect the hemodynamics of a hyperdynamic, critically ill patient. The purpose of this study was to determine the effect of PHC on ventilator requirement, arterial oxygenation, and hemodynamic performance in patients with severe ARDS. METHODS: Ten men and 5 women with established ARDS (mean Murray lung injury score 3.42 +/- 0.1) were prospectively studied using an established protocol when the static pulmonary plateau pressure (Pplat) exceeded 40 cm H2O. The initial tidal volume (V(t)) was decreased to achieve a Pplat < 40 cm H2O or to a lower limit of 5 cc/kg. Arterial blood gas and hemodynamic data were obtained serially. RESULTS: The V(t) was reduced from 9.9 +/- 0.5 mL/kg to 7.7 +/- 0.5 mL/kg at 24 hours, p < 0.05. This reduction of V(t) produced a decrease in minute ventilation (Ve: 18.0 +/- 1.6 to 11.9 +/- 0.7 L/min, p < 0.05), peak airway pressure (PAP: 55 +/- 2 vs 45 +/- 3 cm H2O, p < 0.05), and Pplat (Pplat 45.4 +/- 1.5 vs. 36.7 +/- 1.9) at 24 hours. The PaCO2 rose from 37.9 +/- 1.3 to 56.7 +/- 3.0 mm Hg (p < 0.05), and the pH decreased from 7.41 +/- 0 to 7.31 +/- 0 (p < 0.05) at 24 hours. There were no significant changes in mean airway pressure, static compliance, arterial oxygenation, pulmonary vascular resistance, systemic vascular resistance, cardiac index, or systemic oxygen delivery and consumption. CONCLUSIONS: Permissive hypercapnia by V(t) reduction: (1) decreased Ve, PAP, and Pplat without a change in mean airway pressure, static compliance or arterial oxygenation; (2) caused a mild partially compensated acidosis; and (3) does not adversely affect pulmonary vascular resistance, systemic vascular resistance, cardiac index, or systemic oxygen delivery and consumption.

Adolescent↗

PubMed1993

Emergency center arteriography in the evaluation of suspected peripheral vascular injuries in children.

During the 6-year period from 1983 to 1989, 109 children aged 3 to 18 years (mean, 16) with suspected peripheral vascular injuries underwent 113 emergency center arteriograms (ECA) performed by hand injection of contrast material using a single roentgenographic film. The most common indication for ECA was the proximity of the injury in 93 (82.3%) of the cases as penetrating injury accounted for 106 (94%) of the cases. There were 89 true-negative, 14 true-positive, 1 false-negative, and no false-positive arteriograms. The remaining 9 arteriograms were either equivocal or technically inadequate. The sensitivity, specificity, and diagnostic accuracy of this procedure were 98.9%, 100%, and 91.2%, respectively. Operative intervention was required for 9 (64.2%) injuries detected by emergency arteriography. The remaining 5 injuries were considered minor and were observed with no complications during a period of 21 months. Sixty-eight children (76.4%) with negative ECA were followed for a mean of 12 months with no vascular complications or growth abnormalities noted. ECA is a rapid, accurate, and cost-effective technique. It is of particular value in detecting the presence of occult arterial injuries that might have deleterious effects in the growing child.

Adolescent↗

PubMed1992

Abbreviated laparotomy and planned reoperation for critically injured patients.

The triad of hypothermia, acidosis, and coagulopathy in critically injured patients is a vicious cycle that, if uninterrupted, is rapidly fatal. During the past 7.5 years, 200 patients were treated with unorthodox techniques to abruptly terminate the laparotomy and break the cycle. One hundred seventy patients (85%) suffered penetrating injuries and 30 (15%) were victims of blunt trauma. The mean Revised Trauma Score, Injury Severity Score, and Trauma Index Severity Score age combination index predicted survival were 5.06%, 33.2%, and 57%, respectively. Resuscitative thoracotomies were performed in 60 (30%) patients. After major sources of hemorrhage were controlled, the following clinical and laboratory mean values were observed: red cell transfusions--22 units, core temperature--32.1 C, and pH--7.09. Techniques to abbreviate the operation included the ligation of enteric injuries in 34 patients, retained vascular clamps in 13, temporary intravascular shunts in four, packing of diffusely bleeding surfaces in 171, and the use of multiple towel clips to close only the skin of the abdominal wall in 178. Patients then were transported to the surgical intensive care unit for vigorous correction of metabolic derangements and coagulopathies. Ninety-eight patients (49%) survived to undergo planned reoperation (mean delay 48.1 hours), and 66 of 98 (67%) survived to leave the hospital. With the exception of intravascular shunts, there were survivors who were treated by each of the unorthodox techniques. Of 102 patients who died before reoperation 68 (67%) did so within 2 hours of the initial procedure. Logistic regression showed that red cell transfusion rate and pH may be helpful in determining when to consider abbreviated laparotomy. The authors conclude that patients with hypothermia, acidosis, and coagulopathy are at high risk for imminent death, and that prompt termination of laparotomy with the use of the above techniques is a rational approach to an apparently hopeless situation.

Acidosis↗

PubMed1992

Emergency center arteriography.

From 1983 through 1989, 1,882 emergency center arteriograms were performed on 1,802 patients suspected of having peripheral vascular injuries. The most common indication for emergency center arteriography (ECA) was the proximity of an injury to a major vascular structure. This was the only indication in 1,712 injured extremities (91%). There were 1,510 true negative arteriograms, 294 true positives, 7 false negatives, and 14 false positives. Accordingly, the sensitivity was 95.5% and the specificity was 97.7%. The remaining 57 arteriograms were either equivocal or technically inadequate. Further evaluation of these patients uncovered an additional 11 vascular injuries. Operative intervention was required for 196 (64.3%) injuries detected by emergency arteriography. The remaining 109 injuries were considered minor and were not repaired. No complications developed in 91 patients (88%) with minor vascular injuries who were available for a mean follow-up duration of 12 months. One thousand forty-eight patients (69.4%) with negative arteriograms were followed for a mean of 18 months, and no vascular complications were noted. Emergency center arteriography is a rapid, accurate, and cost-effective technique. It is of particular value in detecting the presence of occult arterial injuries when proximity of a major vascular structure is the sole indication for arteriography. When formal arteriographic support is either unavailable or time consuming, ECA is recommended.

Adolescent↗

PubMed1992

Prospective evaluation of preoperative fluid resuscitation in hypotensive patients with penetrating truncal injury: a preliminary report.

Although intravenous (IV) fluid therapy is routinely prescribed for hypotensive injury victims, there are concerns that elevating the blood pressure before hemorrhage is controlled may be detrimental. This is a preliminary report of an ongoing randomized study designed to evaluate the effect fluid resuscitation, delayed until surgical intervention, has on the outcome for hypotensive victims of penetrating truncal injury. In the first year, 300 consecutive patients with gunshot or stab wounds to the trunk who had a systolic blood pressure of 90 mm Hg or less were entered into the study. Patients were excluded from the outcome analysis because of death at the scene or minor injury not requiring surgical intervention. The remaining study patients were randomized into (1) an immediate resuscitation group (n = 96) for whom IV fluid resuscitation was initiated in the ambulance and in the emergency center before surgical intervention, or (2) a delayed resuscitation group (n = 81) for whom IV fluid resuscitation was delayed until the time of surgical intervention. The two study groups were found to be well balanced with respect to anatomic injury severity, pretreatment vital signs, survival probability, and preoperative treatment times. There were no significant differences in the rate of survival to hospital discharge (immediate resuscitation group, 56%; delayed resuscitation group, 69%). There were no significant differences in the rate of postoperative complications. Further study is necessary to determine if it is advantageous to delay fluid resuscitation until surgical intervention.

Abdominal Injuries↗

PubMed1991

Evolution of the treatment of the injured colon in the 1980s.

During the past 10 years, 1006 patients with colon injuries were treated in an urban trauma center. Primary repair, including suture repair and resection with anastomosis, was performed in 614 patients (61%), colostomy in 284 patients (28%), and exteriorized repairs in 83 patients (8.3%). In the remaining 25 patients (2.5%) who were exsanguinating, the colon injuries were ligated. Independent risk factors for adverse outcomes (defined as a fecal fistula, abdominal abscess, stomal complication, or death from multisystem failure) were identified using multiple logistic regression analysis. These factors were used to match patients at similar risk within different treatment groups, and odds ratios for each treatment were calculated. The odds ratios for primary repair, colostomy, and exteriorized repair were 1.0, 1.9, and 2.0, respectively. Therefore, the chance of an adverse outcome was twice as great for both exteriorized repair or colostomy as for primary repair. It is concluded that further increases in the use of primary repair are warranted.

Abscess↗

PubMed1991

Management of the difficult duodenal stump.

Leakage from the duodenal stump has been the most feared complication of the Billroth II reconstruction following gastric resection. The purpose of our study was to evaluate four methods of duodenal stump closure in 200 patients. One hundred and forty-seven (74%) patients had duodenal ulcers; 28 (14%) had gastric ulcers; and 25 (13%) had a variety of other inflammatory conditions. The most common indication for operation was acute hemorrhage (51%), followed by perforation (24%), intractability (15%), and obstruction (10%). Conventional duodenal closures were performed in 160 (80%) patients, Nissen's closure in 25 (13%), Bancroft's closure in 6 (3%), and tube duodenostomy in 9 (5%). Duodenal leaks occurred in four (2.5%) patients with conventional closures and in three (33%) patients with tube duodenostomies. No leaks occurred in patients with Nissen's or Bancroft's closures. The hospital mortality rate for the series was 9.5%; however, no patient who developed a duodenal leak died. We conclude that Nissen's and Bancroft's closures were safe and effective, but that tube duodenostomy did not reliably prevent uncontrolled leakage.

Adolescent↗

PubMed1991

Prehospital hypertonic saline/dextran infusion for post-traumatic hypotension. The U.S.A. Multicenter Trial.

The safety and efficacy of 7.5% sodium chloride in 6% dextran 70 (HSD) in posttraumatic hypotension was evaluated in Houston, Denver, and Milwaukee. Multicentered, blinded, prospective randomized studies were developed comparing 250 mL of HSD versus 250 mL of normal crystalloid solution administered before routine prehospital and emergency center resuscitation. During a 13-month period, 422 patients were enrolled, 211 of whom subsequently underwent operative procedures. Three hundred fifty-nine patients met criteria for efficacy analysis, 51% of whom were in the HSD group. Seventy-two per cent of all patients were victims of penetrating trauma. The mean injury severity score (19), Trauma Score plus Injury Severity Score (TRISS) probability of survival, revised trauma scores (5.9), age, ambulance times, preinfusion blood pressure, and etiology distribution were identical between groups. The total amount of fluid administered, white blood cell count, arterial blood gases, potassium, or bicarbonate also were identical between groups. The HSD group had an improved blood pressure (p = 0.024). Hematocrit, sodium chloride, and osmolality levels were significantly elevated in the Emergency Center. Although no difference in overall survival was demonstrated, the HSD group requiring surgery did have a better survival (p = 0.02), with some variance among centers. The HSD group had fewer complications that the standard treatment group (7 versus 24). A greater incidence of adult respiratory distress syndrome, renal failure, and coagulopathy occurred in the standard treatment group. No anaphylactoid nor Dextran-related coagulopathies occurred in the HSD group. Although this trial demonstrated trends supportive of HSD in hypotensive hemorrhagic shock patients requiring surgery, a larger sample size will be required to establish which subgroups of trauma patients might maximally benefit from the prehospital use of a small volume of hyperosmolar solution. This study demonstrates the safety of administering 250 mL 7.5% HDS to this group of patients.

Adolescent↗

PubMed1991

Outcome for delayed operation of penetrating colon injuries.

It has been stated that delay in operative repair of penetrating injuries to the gastrointestinal tract will result in a high rate of complications related to infection. To test this assertion, a group of patients with penetrating injuries to the colon were analyzed who had operative repair delayed (usually because of triage considerations) more than 6 hours after admission to the hospital. Nine hundred six patients who survived at least 48 hours after injury were divided into two groups. The immediate group of 769 patients was treated within 6 hours of admission and the delayed group of 137 patients was treated more than 6 hours after admission. The mortality for the immediate group was 4.0% vs. 1.5% for the delayed group. Colon-related infectious complications, defined as abscess or colon suture-line failure, occurred in 10% of the immediate group and 4.4% of the delayed group. To eliminate the effect of associated injuries, the group of patients with colon injuries only was analyzed separately. There was no mortality for 128 patients with colon injuries only operated on within 12 hours of injury, and the colon-related infectious morbidity rate was 3%. Eleven patients with colon injuries only were treated after 12 hours with a mortality of 9% and colon-related infectious morbidity of 18%. These data demonstrate that even patients with fecal contamination can have operative repair delayed for up to 12 hours without undue morbidity related to infection.

Adult↗

PubMed1990

Gallstone pancreatitis. The question of time.

Two hundred consecutive patients with gallstone pancreatitis were treated during a 6-year period; 92 patients were operated on after the acute attack subsided but during the same admission (group 1), 102 patients were discharged after recovery and scheduled for elective surgery (group 2), and the conditions of 6 patients deteriorated and they underwent emergency operation (group 3). All patients in group 3 had hemorrhagic pancreatitis. Mortalities for groups 1, 2, and 3 were 0%, 0%, and 50%, respectively. Although the outcome of patients in groups 1 and 2 was similar, only 60 of 102 patients in group 2 had their treatment completed. Furthermore, 29 (44%) of 65 patients who were followed up in group 2 suffered recurrent pancreatitis or biliary tract disease before elective surgery. The timing of surgery in patients whose conditions improve is not critical; however, patients whose conditions deteriorate after admission have severe disease with high morbidity and mortality.

Adolescent↗

PubMed1990

Balloon catheter tamponade in cardiovascular wounds.

From 1980 to 1990, operative balloon catheter tamponade was used in 12 patients with cardiac or vascular injuries from penetrating wounds. In nine patients, a balloon catheter was passed into a bleeding site through a bullet track or proximal artery and inflated with saline or radiologic dye. In two of these patients, the proximal balloon catheter was folded on itself, tied in that position, and left in the patient permanently. In the other seven patients in this group, the balloon catheter was attached to a three-way stopcock and left temporarily inflated postoperatively. These patients were then observed in the intensive care unit for 3 to 4 days, at which time the balloon was withdrawn. Eight of nine patients survived without recurrent hemorrhage after removal of the balloon catheter, while one patient with a Fogarty balloon placed in the carotid siphon died of a cerebral infarction. Balloon catheter tamponade was also used on a temporary basis in one patient with a posterior cardiac wound and in one patient with an anterior stab wound of the inferior vena cava at the renal veins, whereas in two patients with high cervical arteriovenous fistulas, one had permanent placement of the balloon catheter while the other had temporary placement. One of the latter patients also had acute hemorrhage. Although all four patients survived, one of the patients with a fistula developed a recurrence and another required two separate operative procedures for correct placement of the balloon to cure the fistula.

Adult↗

PubMed1990

Retroperitoneal vascular injury.

Retroperitoneal vascular injuries are among the greatest challenges that confront the surgeon. Problems in resuscitation, exposure, and repair are numerous. Techniques to improve such perioperative tactics result in improved survival.

Blood Vessels↗

PubMed1990

Splenorrhaphy. The alternative.

From 1980 to 1989, 240 adult patients underwent splenorrhaphy at one urban trauma center. This represents 43.4% of all splenic injuries seen during this time interval. Splenic injuries were graded I to V, and splenorrhaphy was attempted except when the spleen was shattered or when multiple injuries with associated hypotension were present. Penetrating wounds, blunt trauma, or iatrogenic/unknown etiologies were present in 54.2%, 41.6%, and 4.2% of patients, respectively. Grade I or II injuries were present in 51.7% of patients, grade III in 34.6%, grade IV or V in 9.6%, and unknown grade in 4.1%. The technique of splenorrhaphy was simple suture (usually chromic) with or without the addition of topical hemostatic agents in 200 patients (83.3%), topical agents alone in 12 (5%), unknown type of repair in 12 (5%), compression, cautery, or nonbleeding injury in 9 (3.8%), and partial or hemisplenectomy in 7 (2.9%). Postoperative rebleeding occurred in three patients (1.3%) with grade II, III, and IV injuries, respectively, and led to splenectomy at reoperation. In another patient who had a hemisplenectomy performed for a grade IV injury, subphrenic abscesses and septic shock led to the death of the patient. Splenorrhaphy can be safely performed in properly selected adult patients after a variety of injuries. The risk of rebleeding is practically nil when the spleen is fully mobilized and visualized during repair.

Adult↗

PubMed1990

Penetrating iliac vascular injuries: recent experience with 233 consecutive patients.

During a recent 11-year period, 233 consecutive patients with 358 penetrating iliac vascular injuries were treated at our institution. Injuries of the common and external iliac arteries were most often repaired with lateral suture (31%) although several other techniques were also employed. Lateral suture and ligation were used with nearly equal frequency in the management of venous injuries. The hospital mortality rate for the series was 28%, and 56/66 deaths (85%) were due to exsanguination or shock. One patient, initially treated with an end-to-end anastomosis of the iliac artery, died a year after discharge from a ruptured false aneurysm. Two patients treated with lateral suture of venous injuries died of pulmonary embolism. Arterial complications occurred in 15% of patients with arterial injuries and three patients required amputation. No graft infections occurred in 16 patients treated with PTFE interpositions, including four with associated colorectal injuries. Venous complications occurred in 12% of patients with venous injuries, and most were noted in those treated with ligation. Four patients treated by venous ligation developed chronic venous insufficiency. The prevention of death from exsanguination is the greatest problem in the management of patients with iliac vascular injuries. Although some late deaths and many complications may be related to the technique of vascular repair, circumstances often prohibit alternative methods. Despite two deaths from pulmonary embolism, insufficient data exist to condemn lateral suture of venous injuries.

Adult↗

PubMed1989

Extraanatomic bypass for peripheral arterial injuries.

Over an 8-year period, extraanatomic bypass grafting was performed for peripheral arterial injuries or infections in 12 patients. The indications for use of the technique were as follows: (1) extensive loss of soft tissue over arterial injury or avulsion; (2) wound infection with rupture of a previous arterial repair; or (3) combined infections in soft tissue and the underlying artery due to illicit drug injection. The technique involved excision of the injured or infected artery beyond the margins of the debrided wound and insertion of an autogenous saphenous vein as an extraanatomic bypass graft in a medial or lateral position around the wound. Shotgun wounds were the mechanism of injury in six patients, whereas an extensive injury or infection in the brachial artery was present in eight patients. Successful wound coverage or closure was accomplished and distal arterial flow preserved in 11 patients, 5 of whom had residual neuromuscular or bony defects related to the magnitude of the original injury.

Adult↗