A simple endoscopic technique for nasoenteric feeding tube placement.
Explore the source record for details and available documents.
Enteral Nutrition↗
Biomedical subjects
J W Meredith
Publications and source records attributed to J W Meredith.
Nonoperative management of blunt hepatic trauma: the exception or the rule?
To evaluate the role of nonoperative management in the treatment of blunt liver trauma we examined all victims of blunt hepatic trauma admitted to our institution during a 36-month period under a protocol of nonoperative management. One hundred twenty-six patients had the diagnosis of blunt hepatic injury confirmed by abdominal computed tomographic (CT) scanning, surgical exploration, or autopsy. Twenty-four patients went to the operating room without CT scanning because of hemodynamic instability (16), peritoneal signs (two), or positive results on DPL (six). Ten other patients died of extra-abdominal trauma before reaching the operating room. The remaining 92 patients had CT scans of the abdomen. Of these 92 patients, 20 required surgery. The indications for surgery were hemodynamic instability (seven), peritoneal signs (six), nonhepatic injuries requiring surgery (five), and massive hemoperitoneum (two). Seventy-two patients were intentionally managed nonoperatively (55% of total liver injuries, 78% of scanned patients). Seventy (97%) of these patients were managed successfully without surgery. Of these 72 liver injuries, 11 were grade I, 28 were grade II, 16 were grade III, ten were grade IV, and five were grade V. The transfusion requirement in the first 24 hours for the nonoperative group was significantly lower than that for the group undergoing surgery (1.2 +/- 1.7 vs. 12.2 +/- 14 units). There were no instances of hemobilia, intrahepatic bile collections, or abdominal abscess in the nonoperative group. The grade of hepatic injury as diagnosed by CT scan does not predict the need for surgery.(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
Femoral catheters and deep venous thrombosis: a prospective evaluation with venous duplex sonography.
Femoral vein cannulation (FVC) with 8.5F Swan-Ganz catheter introducers allows expeditious intravenous access and rapid volume infusion; however, the incidence of associated iliofemoral deep venous thrombosis (DVT) is unknown. Trauma patients (n = 76) requiring unilateral FVC were prospectively entered into a study where they were resuscitated via FVC and serially evaluated with bilateral venous duplex sonography (VDS). The incidence of DVT in catheterized femoral veins was compared with that in uncatheterized femoral veins. Catheters were removed promptly and VDS was performed within 24 hours and weekly for 1 month. Iliofemoral DVTs were identified in 11 of the 76 patients (14%). Iliofemoral DVTs occurred on the cannulated side in 9 (81.8%) compared with 2 (18.2%) on the uncannulated side (p < 0.05). We conclude that the use of the 8.5F FVC is associated with an increased incidence of DVT and that despite its convenience, this technique should not be routine.
Adult↗
The relationship between face or skull fractures and cervical spine and spinal cord injuries: a review of 13,834 patients.
A state trauma registry database containing 13,834 patients was evaluated to determine the relationship among 1,062 skull fractures, 1,329 facial fractures, 339 cervical spine injuries, and 299 spinal cord injuries. Categories studied were all trauma patients, motor vehicle crashes, automobile crashes (drivers, passengers, unknown), and belted and unbelted victims. Odds ratios calculated demonstrated that patients with skull and/or facial fractures did not have a higher likelihood of cervical spine or spinal cord injury as has been suggested. The lack of a relationship emphasizes the need for a greater vigilance for cervical spine and spinal cord injury in the group without facial or skull fractures. It appears that the pathological biomechanical forces causing each injury are a reflection of the different multiple forces associated with motor vehicle trauma.
Accidents, Traffic↗
Greenfield filter prophylaxis of pulmonary embolism in patients undergoing surgery for acetabular fracture.
Pulmonary embolism is a potentially lethal complication among patients with acetabular fractures requiring surgery. The reliability, safety, and extent of efficacy of pharmacologic as well as existing nonpharmacologic anticoagulation prophylaxis in this patient group has not been determined. A careful analysis of the myriad factors acting on these patients who have had major trauma and have undergone a major surgical procedure about the hip prompted a change in our approach to prophylaxis in this patient group. In the period from March 1984 through October 1987, 51 patients having 52 acetabular fractures underwent osteosynthesis at the Wake Forest University Medical Center. Twenty-four patients had two or more identifiable risk factors and underwent insertion of a Greenfield filter for prevention of pulmonary emboli. Filters were inserted at the time of acetabular surgery with C-arm guidance via the internal jugular vein approach. The average time for insertion was 57 min. Placements were verified by plain roentgenograms. There were no complications during filter insertion. Four patients with filters (17%) developed leg edema; in three the edema was minor, and in one the filter trapped what could have been a fatal embolus but caused lower extremity venous stasis severe enough to result in peripheral lower extremity tissue loss. There were no pulmonary emboli (by clinical criteria). The remaining 27 patients had routine medical prophylaxis and no filters. In this group, two patients had a clinically evident pulmonary embolus (7%), and one of these patients died. Two other patients (7%) had minor chronic leg edema. In one of them, a proximal deep venous thrombosis in the lower extremity was documented with venography, requiring rehospitalization and anticoagulant therapy.(ABSTRACT TRUNCATED AT 250 WORDS)
Academic Medical Centers↗
A comparison of three pulmonary artery oximetry catheters in intensive care unit patients.
OBJECTIVE: To compare the clinical performance of three pulmonary artery oximetry catheters (Oximetrix 3, SAT-2, and HEMOPRO2) in intensive care unit (ICU) patients. DESIGN: Unblinded comparison of performance over 24 h using an IL-282 CO-oximeter as a criterion standard. SETTING: Multispecialty adult ICU at a university teaching hospital. PATIENTS: Thirty critically ill patients selected from those requiring hemodynamic monitoring for medical management. MEASUREMENTS AND MAIN RESULTS: By all measures, performance of the Oximetrix 3 and SAT-2 systems were comparable; bias +/- precision were -1.98 +/- 3.07 and +1.80 +/- 3.49, respectively, vs -2.28 +/- 5.24 for the HEMOPRO2. The Oximetrix 3 and SAT-2 systems demonstrated consistent performance over the range of saturations tested, though Oximetrix 3 tended to underestimate and SAT-2 tended to overestimate the CO-oximeter value. The HEMOPRO2 underestimated the CO-oximetry-derived saturation, although this was not constant across the range of values tested. The 95 percent confidence limits based on intrasubject variability were similar (+/- 4.59, +/- 5.66, and +/- 6.56 for the Oximetrix 3, SAT-2, and HEMOPRO2, respectively); however, the 95 percent confidence limits based on total variability, while similar for Oximetrix 3 (+/- 6.03) and SAT-2 (+/- 6.86), were larger for the HEMOPRO2 (+/- 10.30). The expected SD was similar for the three systems (2.03, 2.50, and 2.90 for the Oximetrix 3, SAT-2, and HEMOPRO2 systems, respectively). None of the systems equaled or exceeded (p greater than 0.05) the manufacturers' published specifications, which, in all cases, are listed as +/- 2 percent (saturation; 1 SD) when compared with bench oximetry. CONCLUSIONS: Although each system measures mixed venous oxygen saturation, the Oximetrix 3 and SAT-2 systems demonstrate closer agreement with CO-oximetry. However, none of these catheters provided statistically significant evidence that they would perform within +/- 2 percent of CO-oximetry. As a continuous monitor used to detect changes or trends, any of the three may be acceptable.
Calibration↗
Blunt upper abdominal trauma: evaluation by CT.
CT is the technique of choice for initial examination of hemodynamically stable patients after blunt abdominal trauma. It is highly sensitive, specific, and accurate for use in detecting the presence or absence of injury and defining its extent. Nonoperative management of many posttraumatic injuries, particularly in the liver, spleen, and kidney, is possible in part because of the diagnostic usefulness of CT. CT can be used effectively to visualize the progression of liver and spleen injuries in those patients chosen for conservative management. CT helps in treatment decisions in patients with renal injury by defining the character and extent and distinguishing minor from severe renal trauma. Posttraumatic injuries to the pancrease, bowel, and mesentery can be detected with CT. In these areas, however, signs may be subtle, and a significant injury may be missed on an initial examination.
Abdominal Injuries↗
Computed tomography and diagnostic peritoneal lavage. Complementary roles in blunt trauma.
Viewpoints regarding the use of computed tomography (CT) and diagnostic peritoneal lavage (DPL) in the evaluation of stable blunt abdominal trauma patients remain polarized and their respective roles are ill-defined. To further clarify their independent and combined value, the authors report the results of a prospective study of their use in adult patients satisfying the entry criteria of major blunt torso trauma, hemodynamic stability, equivocal and unreliable abdominal examination, and absence of both before abdominal surgery and unstable pelvic fractures. The 116 patients admitted to the study over an 11-month period were first submitted to a CT scan using a 9800 series GE scanner (General Electric Medical Systems; Milwaukee, WI). After its review with the faculty CT radiologist, the surgeon recorded his decision as to the need for the laparotomy. All patients were then subjected to DPL and the results recorded as recommending laparotomy based on finding aspiration of greater than 10 cc of blood or greater than or equal to 100,000 RBC/mm3 greater than W 500 WBC/mm3, or positive gram stain. A final decision was then formulated based on information gained from both studies. Actual need for operation or observation was recorded based on ultimate outcome in observed patients or upon findings at laparotomy. Initial laparotomy was performed in 22 patients; yet only 17 had injuries requiring repair. Unnecessary laparotomy was recommended by DPL in 15.5 percent of patients vs 0.8 percent by CT (P greater than .01), while inappropriate observation was recommended by DPL in 1.7% vs 6.9% by CT (P less than .01).(ABSTRACT TRUNCATED AT 250 WORDS)
Abdominal Injuries↗
Modified retrograde intubation technique for rapid airway access.
To reverse accidental extubation in the burn patient, a guide-wire can be passed retrograde through the cricothyroid membrane, and a thin tube changer can be placed over the guide-wire and down through the edematous airway and vocal cords. An endotracheal tube can then be passed over the tube changer to rapidly regain airway access.
Burns↗
Visceral protein levels in trauma patients are greater with peptide diet than with intact protein diet.
Early enteral nutrition may preserve gut function and prevent bacterial translocation after trauma. Standard enteral nutrition uses products which contain intact protein and require digestion for absorption. Peptide-based enteral nutritional products are better absorbed and stimulate the release of gut trophic hormones. This study was performed to determine whether a peptide-based (PEP) product (Reabilan HN) was better tolerated and/or produced better hepatic protein responses in patients after trauma when compared to an intact-protein (PRO) formula (Osmolite HN). Eighteen trauma patients were prospectively randomized to PEP (n = 9) or PRO (n = 9) enteral diets administered via nasoduodenal tubes (within 1-2 days of injury). Visceral protein synthesis was assessed by measuring baseline and 1 week pre-albumin and transferrin levels. Diarrhea was defined as greater than 300 gm/day of stool. Groups were similar in age, Injury Severity Score (ISS), caloric intake, and protein intake. Protein levels increased significantly faster in PEP patients despite similar urea nitrogen excretion. Diarrhea developed in four (44%) PRO patients and none of the PEP patients. Three of the PRO patients were switched to PEP after one week and diarrhea subsided in all three patients. Peptide-based enteral diets are associated with better hepatic protein responses and less diarrhea compared to intact-protein diets.
Adolescent↗
Microscopic hematuria after blunt trauma. Is pyelography necessary?
Hematuria after blunt abdominal trauma is common with multiple organ system injuries, and many trauma centers routinely perform intravenous pyelography (IVP) on all trauma patients having any degree of hematuria. However, it has been suggested that many IVPs could be avoided if more selective criteria were used. To help determine the need for an IVP, we reviewed the records of 102 consecutive patients undergoing IVP after blunt abdominal trauma over a 17-month period. Twenty-six (25%) patients had gross hematuria. Of these, seven (27%) had abnormal IVPs, and two (7.7%) of those required urologic surgery. Seventy-six (75%) patients had microscopic hematuria. Of these, one (1.3%) had an abnormal IVP but required no urologic surgery. Thus, if IVP had been performed only when gross hematuria was present, then all surgically significant urinary tract lesions would have been recognized, and 75 per cent of these 102 patients would have been spared IVPs. We agree with others that microscopic hematuria alone is not an indication for emergency IVP in these trauma patients. However, gross hematuria or other strong clinical evidence of renal injury still mandates IVP early during the assessment of patients who have suffered blunt abdominal trauma.
Abdominal Injuries↗
Case 1--1988. A 73-year-old man sustains an acute aortic disruption after aortic valve replacement.
Explore the source record for details and available documents.
Aged↗
CT scanning in acute abdominal injuries.
Computed tomography has become an important adjunct in the evaluation of the patient with blunt abdominal trauma. It provides quantitative information about hemoperitoneum as well as qualitative information about the source of hemoperitoneum. CT scanning also evaluates the retroperitoneal organs and retroperitoneal hematoma more accurately than any other available imaging technique. Like any other diagnostic tool, the CT scan must not be overused or abused. This technique should be applied only to stable patients and only in institutions with up-to-date equipment, a committed radiology and surgery staff, and appropriate monitoring equipment in the CT suite. If proper technique is used, then high-quality scans can be obtained which, if interpreted by experienced personnel in the light of the clinical findings, can improve our management of selected trauma patients.
Abdominal Injuries↗
Failure of prophylaxis with fresh frozen plasma after cardiopulmonary bypass.
Explore the source record for details and available documents.
Albumins↗
Management of injuries from liquid lye ingestion.
The simultaneous admission of nine youths to our institution following their ingestion of concentrated sodium hydroxide (which had been mistaken for wine) provided us with a unique opportunity to manage corrosive esophageal injuries ranging in severity from second-degree oral mucosal injury alone to full-thickness hypopharyngeal, esophageal, and gastric injury. The severity of injury was graded first on the basis of symptoms and physical examination of the mouth, and then in the operating room by rigid esophagoscopy. This procedure provided a logical approach to management. Three patients with second-degree oral burns required no surgery. Six patients required laparotomy with gastrostomy and/or chimney feeding jejunostomy, one required immediate esophagogastrectomy, and three required immediate total or subtotal gastrectomy. There were no deaths. Three patients have subsequently required esophageal replacement and three others have required repeated dilatations. At 2-year followup, all nine maintain their nutritional status orally, and all except for the previously mute patient can phonate. Ingestion of liquid lye requires a much more aggressive diagnostic and therapeutic approach than is currently recommended for ingestion of caustics in general. On the basis of our experience with these nine patients, we suggest the following for esophageal liquid lye injury: 1) early evaluation of the esophagus by esophagoscopy; 2) with esophageal burns, urgent laparotomy to assess gastric damage and gastrostomy to pass a string for subsequent retrograde dilatations; 3) adequate resection of stomach for gastric burns; 4) with deep esophageal burns, early esophagectomy.
Adolescent↗
Possibility of A-V shunting upon cardiopulmonary bypass discontinuation.
Explore the source record for details and available documents.
Aged↗
Adhesive bacterial colonization of exposed traumatized tendon.
Recent studies of compromised or damaged tissues, as well as biomaterials, have shown that they provide a particularly fertile substratum for bacterial colonization. Colonization in these environments is mediated by a process of microbial adhesion to surfaces of the substrata. In this report, we present electron microscopic studies of a portion of damaged and infected tendon. These studies demonstrate colonies of bacteria surrounded by a ruthenium red-staining exopolysaccharide biofilm and adhesion to the surface of the tendon by means of an exopolysaccharide polymer. We suggest that this adhesive form of bacterial colonization may partially explain the resistance of exposed tendon to effective debridement by simple mechanical measures and to coverage with granulation tissue, partial-thickness skin grafts, and vascularized tissue grafts.
Adult↗
The management of snake and spider bites in the southeastern United States.
Of all snake bites reported in the United States of America each year, 75 per cent occur in the states that form the Southeastern Surgical Congress. Pit vipers, coral snakes, and exotic imported snakes are all found in that area. Deaths from those snake bites are rare, but morbidity is high and it is often due to overtreatment rather than undertreatment. Treatment in the field is rarely necessary for the victim who is less than 1 hour away from definitive care. The type and size of the snake and the age, size, and health of the patient are important guides to therapy. Envenomation may not occur. When envenomation occurs from pit viper bites, antivenom is not always necessary, and its inherent dangers (serum sickness and possible hypersensitivity) must be weighed against the severity of systemic and local manifestations. All coral snake bites resulting in envenomation must be treated vigorously with coral snake antivenom. The Oklahoma City Poison Control Center can guide the treatment of bites from exotic snakes. The most frequently encountered toxic spider bites in the Southeast are those of the black widow and brown recluse spiders. The symptoms of black widow envenomation are best controlled with calcium gluconate or a muscle relaxant. Antivenom should be reserved for severe reactions. Brown recluse necrotic lesions are best controlled with dapsone.
Humans↗