Rural trauma. Systems in evolution.
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Humans↗
Biomedical subjects
M B Foil
Publications and source records attributed to M B Foil.
The ripped cava.
Lacerations of the inferior vena cava are associated with a high mortality and may be difficult to repair. The majority of injuries are due to penetrating trauma. Rapid transportation to definitive surgical care with effective resuscitation may improve mortality. Surgical management includes adequate treatment of hypovolemic shock due to blood loss. Placement of intravenous infusion sites below the level of the diaphragm may be effective. Operative control of the inferior vena cava can be accomplished by directed digital compression followed by a proximal and distal control. Injuries of the inferior vena cava above the level of the renal veins are associated with an increased mortality. Retrohepatic and subdiaphragmatic injuries are highly lethal. This article discusses appropriate surgical approaches for repair of the inferior vena cava above and below the diaphragm.
Emergency Medical Services↗
Intravenous ethanol for alcohol detoxification in trauma patients.
Traumatic injury frequently follows alcohol abuse. Between October 1, 1988 and January 31, 1992, 2,219 patients were admitted to the Trauma Service at the University Medical Center of Eastern Carolina-Pitt County. Of the 1,602 who were tested for serum ethanol, 685 (43%) were found to have measurable levels. Thirty-seven patients had alcohol withdrawal and were treated with intravenous ethanol; 34 were male (21 black, 13 white) and 3 female (1 black, 2 white), with an average age of 46 years. Those who had withdrawal had an average serum ethanol level, on presentation, of 239 mg/dL (N = 34). Fourteen patients were involved in motor vehicle crashes, seven were pedestrians struck by cars, and the remaining 16 had various traumatic mechanisms of injury. The most common injuries were long-bone fractures and blunt abdominal trauma. The length of ethanol therapy averaged 4 days. A majority of patients had a favorable response to treatment. Relative contraindications to i.v. ethanol therapy were CNS trauma, liver disease, and pancreatitis. i.v. ethanol is a safe and effective method of alcohol detoxification in the trauma patient.
Adult↗
The cost of not wearing seat belts. A comparison of outcome in 3396 patients.
Data from the North Carolina Trauma Registry were analyzed to determine the effect of seat belt usage on outcome in motor vehicle accidents. Of 6237 persons involved in motor vehicle accidents, data on seat belt usage were available for 3396. Of these, 1916 were not and 1480 were wearing seat belts. The mean hospital charge in belted patients was $10,500 +/- $18,200; and in unbelted patients, $15,250 +/- $26,300 (p < 0.001). The total hospital charges were $23 million for the 1508 patients not wearing seat belts. If the unbelted patients had outcomes similar to belted patients, the charges resulting from caring for the 1508 patients would have been $15.8 million, a potential savings of $7.2 million. There were 135 deaths among the unbelted patients (7.0%) and 47 deaths among the belted patients (3.2%) (p < 0.001). A similar projection of belted outcome for unbelted patients suggests that seat belt usage could have reduced the unbelted mortality rate by over one half. Patients wearing seat belts also had significantly shorter hospital stays, fewer days in the intensive care unit, and fewer days on the ventilator (p < 0.001). Seat belt usage is associated with a significant decrease in mortality rate, hospital charges, length of stay, intensive care unit stay, and ventilator requirements. Seat belts could have saved at least 74 lives and 7.2 million dollars during the period from October 1, 1987 to July 1, 1989 in patients seen in the seven trauma centers in North Carolina.
Accidents, Traffic↗
Civilian field surgery in the rural trauma setting: a proposal for providing optimal care.
Rural trauma presents unique problems for surgical care. While military surgeons are prepared to provide care at or near the scene of battle, civilian literature is devoid of reports for care provided by surgeons at sites of injury occurrences. Although these injuries are infrequent, they are more likely to occur in rural trauma settings. This article describes two cases of extremity injury that required amputation at the scene and presents a proposal for swift mobilization of appropriately trained surgeons to the scene with adequate instrumentation and lighting, which can significantly reduce the morbidity and mortality of these victims.
Accidents, Occupational↗
Increase in renal magnesium overflow following aortotomy-induced hemorrhage in pigs.
Hemorrhage causes an increase in plasma Mg++ levels. This article identifies some of the tissues contributing to the hemorrhage induced increase in plasma Mg++. Anesthetized, splenectomized pigs were subjected to a 5 mm aortotomy. Blood samples from the abdominal aorta, inferior vena cava, pulmonary artery, hepatic portal vein, and renal vein were sampled for Mg++ changes caused by this uncontrolled hemorrhage. Aortotomy produced a rapid drop in arterial pressure and cardiac output, both of which remained depressed for the following 120 minutes (P less than 0.05). By 120 minutes, 6 of the 8 pigs survived, but three of the six survivors showed signs of cardiovascular decompensation. A significant increase in arterial plasma Mg++ was indicated by a paired t-test (P less than 0.05). Analysis of the venous samples also revealed a significant increase during the post-aortotomy period. Renal venous and hepatic portal venous plasmas both showed increases greater than that in the arterial plasma. The renal and splanchnic tissues, then, were partly responsible for the increase in the arterial Mg++ which follows hemorrhage.
Animals↗
The asymptomatic patient with suspected myocardial contusion.
Diagnostic criteria and guidelines for hospital admission for suspected myocardial contusion (MCC) remain unclear. This study defines and examines the clinical sequelae of patients admitted with a suspicion of MCC. Criteria for observation following isolated, minor blunt chest trauma are suggested. Hospital and trauma registry records of patients admitted over a 33-month period with suspected MCC were reviewed. Conventional evaluation criteria, cardiac-related complications, and associated injuries were analyzed for 524 patients. Twenty-eight cardiac-related complications occurred in 27 of 524 patients (5%). These complications included 23 dysrhythmias, 3 infarctions, and 2 pericardial effusions. There were 23 patients with abnormal admission electrocardiograms and 4 with normal ones. Of the latter, one patient developed dysrhythmia 4 hours after admission, and three had other major multi-system injuries requiring admission to the intensive care unit. The overall incidence of cardiac-related complications in minimally injured patients was 0.1%. There were no complications in patients with isolated chest wall contusions, a normal admission electrocardiogram, and a normal rhythm at 4 hours. There was no significant association between creatine phosphokinase isoenzymes or echocardiogram and cardiac-related complications. The complete absence of significant cardiac sequelae in patients with isolated chest wall contusion, normal admission and 4-hour electrocardiograms, and no other associated major injuries suggests that these patients need not be admitted.
Adult↗
Transplantation and the trauma surgeon.
The number of satisfactory vascular organs suitable for organ transplantation can be increased appreciably by a close working relationship between traumatologists and transplant surgeons. Benefits will derive from more precise and rapid field management of brain-injured patients, with subsequent appropriate stabilization. If brain death is declared, prompt referral for organ donation with optimal management should result in well-functioning organs for transplantation. A defined team approach with well-defined protocols could solve most of the medical and moral dilemmas. Compassionate emotional support should be provided for families, particularly minorities, and should extend to inexperienced staff. Underlying these goals are a strong institutional commitment to staff education and an understanding of the lifesaving role that organ transplantation can play.
Adolescent↗
Long-term incompatible kidney survival in outbred higher primates without chronic immunosuppression.
Transplantation between non-identical humans has been limited by the requirement for chronic immunosuppression (CI). This study demonstrates in a nonhuman primate model that long-term acceptance of incompatible kidney allografts can be achieved without the use of CI. Following incompatible kidney transplantation, rhesus monkey recipients were given a 5-day course of clinical rabbit antithymocyte globulin (RATG). On day 12, unfractionated donor bone marrow (BM) was infused intravenously. Recipients were monitored for T-cell levels and T-cell subset levels with monoclonal antibodies and for responses in one way MLR. Graft survival in untreated control animals was 9.2 +/- 2.8 days. In six animals given RATG only, all died of rejection at a mean 35.8 +/- 5.7 days. Of five animals given RATG and donor BM (mean 2.5 RhLA mismatches, mean MLC 12.7), four are alive at 150 days, 248 days, 342 days, and 401 days (median 248 days). The ATG-BM infused group showed a prolonged imbalance of their OKT4/OKT8 cell ratio and cellular suppression of MLR responsiveness. The long-term survival obtained in these outbred primates is apparently due to a synergistic immunoregulatory effect induced by the RATG and donor BM. The model described is apparently the first report of long-term survival of outbred higher primates without CI and may represent a technique for producing tolerance without CI in the human.
Animals↗
Renal allograft tolerance induced with ATG and donor bone marrow in outbred rhesus monkeys.
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Animals↗