Laryngeal mask airway in air transport when intubation fails: case report.
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Aged↗
Biomedical subjects
M G Ochsner
Publications and source records attributed to M G Ochsner.
Subcutaneous tissue oxygen pressure: a reliable index of peripheral perfusion in humans after injury.
The usual initial life-threatening effect of injury is hypovolemic shock. In the hierarchical physiologic response to hypovolemia, perfusion of peripheral tissues is sacrificed early and restored late. But the usual hemodynamic and metabolic measurements of blood pressure, urine output, and base deficit are not reliable indices of peripheral perfusion. Although the Clark electrode can quantitate tissue oxygen pressure and thereby serve as an index of perfusion, its use is compromised by several technical deficiencies. Recently, an optical method (optode) using fluorescent technology has been developed for measurement of oxygen tension in subcutaneous tissue (P sgO2). Our studies compared this device with the Clark electrode in the laboratory and tested its value in both animal and clinical studies of hypovolemic shock. The results of these several studies demonstrated that: (1) the new oximeter tracked a rapid fall or rapid rise of oxygen tension between room air (150 mm Hg) and 0 mm Hg ( a glucose oxidase/catalase solution) as well as the Clark electrode without encountering its technical problems; (2) with an acute hemorrhage to 20% of base line, the PsgO2 was found to decline rapidly in parallel with the decline of mean arterial pressure (MAP). Although the MAP rapidly returned to normal after immediate complete return of all shed blood, the PsgO2 did not reach normal levels for at least 2 hours, suggesting persistent peripheral vasoconstriction. (3) Studies in progress suggest that between 35 and 78% of trauma patients (n = 18) adequately resuscitated for hypovolemia b customary criteria have a decreased level of PsgO2 for as long as 60 hours after resuscitation for injury. If care is taken to prevent other causes of catecholamine induced vasoconstriction such as pain, fear, cold, and arterial hypoxia, these several results suggest that a certain number of injured patients are inadequately resuscitated despite the return to normal of conventional hemodynamic measurements. The serial analysis of PsgO2 may assist in managing patients and promote better understanding of the responses to injury.
Animals↗
A prospective study of surgeon-performed ultrasound as the primary adjuvant modality for injured patient assessment.
Ultrasound diagnostic imaging, having been used in Germany in the trauma setting for more than 15 years, has unique qualities that give it distinct advantages over other tests (DPL, CT), and is gradually gaining acceptance by surgeons in the United States. In this prospective study, experienced surgeon sonographers successfully used ultrasound as the primary adjuvant modality to detect hemoperitoneum and pericardial effusion in injured patients. The ultrasound evaluations of 371 patients demonstrated that in 65 patients with significant injuries, ultrasound detected 53, that is, had an 81.5% sensitivity and 99.7% specificity. They conclude that ultrasound should be the primary adjuvant instrument for the evaluation of injured patients because it is rapid, accurate, and is potentially cost-effective.
Adolescent↗
The evaluation of a two-tier trauma response system at a major trauma center: is it cost effective and safe?
OBJECTIVE: To determine the efficacy and safety of a two-tier trauma response, using prehospital criteria for matching trauma center assets with severity of injury. DESIGN: A prospective iterative study on a consecutive sample of patients to test the hypothesis. MATERIAL AND METHODS: Criteria were developed whereby in-hospital response was determined by information provided by prehospital personnel. Two modifications of these criteria were introduced at 6 and 9 months. Triage and response accuracy were evaluated using outcome variables. Cost savings were estimated using differences between the full and modified teams. Chi-squared analysis was used. MEASUREMENTS AND MAIN RESULTS: Of 1,479 patients evaluated over a 9-month period, 682 (46%) received a full trauma team response, and a modified trauma team responded to 794 (54%). When compared with final designation by outcome variables, the sensitivity, specificity, and accuracy were significantly improved after the first modification of criteria. After the second modification, there was no significant improvement; however, the number of undertriaged patients increased significantly. Estimated cost savings were about $178,000 over the 9-month period. CONCLUSIONS: Utilization of a two-tier response to trauma patients is effective, safe, and results in substantial cost savings.
Adolescent↗
The spectrum of blunt injury to the carotid artery: a multicenter perspective.
The relative infrequency of blunt carotid artery trauma prompted a multicenter review to determine the spectrum of injuries, treatment strategies, and neurologic outcome. During a six-year period, 60 carotid artery injuries from blunt mechanisms in 49 patients were treated at 11 institutions. There were 11 bilateral injuries. Injury mechanisms were diverse but involved motor vehicles in 35 (72%) patients. In 14 (29%) patients, significant neurologic deficits developed more than 12 hours after a normal admission neurologic examination. The diagnosis was confirmed by angiography in 42 (86%). Duplex ultrasound accurately demonstrated the arterial injury in 12 (86%) of 14 patients. Documented injuries included arterial thrombosis in 20 arteries, arterial dissection alone in 19, dissection with pseudoaneurysm in six, pseudoaneurysm alone in five, frank arterial disruption in seven, and carotid-cavernous fistula in three. Arterial dissection was managed nonsurgically in 15 (79%) of 19 cases, the majority with systemic anticoagulation. Arterial thrombosis was managed with supportive therapy alone for 16 (80%) of 20 arteries; most associated with fixed neurologic deficits. Pseudoaneurysm repair was performed for six (55%) injuries. Carotid-cavernous fistulas were treated in all three instances with balloon occlusion. Overall mortality was 16 of 49 patients (43%). Good neurologic outcome was achieved in 22 (45%) patients. We conclude that: (1) Neurologic symptoms may develop in a delayed fashion; prior clinical suspicion and diagnostic testing are essential; (2) arterial dissection without complete occlusion may effectively be managed by anticoagulation; (3) pseudoaneurysms in accessible anatomic locations can be repaired with good results; and (4) injuries with complete arterial thrombosis are associated with high mortality and poor neurologic outcome in proportion to the initial degree of neurologic impairment.
Adolescent↗
The Ilizarov method for complex fracture nonunions.
INTRODUCTION: Nonunion of complex fractures continues to challenge orthopedic trauma surgeons. Although traditional management results in a successful outcome in 50% to 80% of cases, the Ilizarov method has been reported to be more effective. We evaluated the efficacy of the Ilizarov method for treatment of nonunions. METHODS: Patients were selected based on the presence of nonunion associated with osteomyelitis, treatment failure, or extensive segmental bone loss. Treatment principles include surgical debridement, stabilization, and bone regeneration for correction of defects. Patients were given maximum mobility and were required to function as normally as possible during the course of treatment. RESULTS: Seventeen patients were treated for complex nonunions with the Ilizarov method during a 33-month period. Seven patients were facing the alternative of amputation. Causes of nonunion were osteomyelitis (65%), failure of conventional treatment (23%), and segmental bone loss (12%). Fractures involved the lower (82%) and upper (18%) extremities. Using the Ilizarov method, union was achieved in 94% (16 of 17) of patients over an average time of 6 months. CONCLUSION: Our results indicate that the Ilizarov method is superior to traditional techniques of managing complex nonunions.
Adult↗
Indications for obtaining surveillance thoracic and lumbar spine radiographs.
The purpose of this study was to identify risk factors for thoracic/lumbar spine fractures in patients with blunt injuries and subsequently establish indications for obtaining surveillance thoracolumbar radiographs. Retrospective review of all patients with blunt injuries (n = 1485) admitted in 1992 to a level I trauma center with a discharge diagnosis of thoracolumbar spine fracture established entrance criteria for a 4-month prospective study. Relative risk of fracture (RR) was calculated. Retrospective. Seventy-six percent (176 of 233) had radiographs; 21% had fractures; one diagnosed late. Prospective. One hundred percent (167 of 167) had radiographs; 9% (15 of 167) had fractures; none diagnosed late or missed. Forty percent (26 of 65) of patients with fractures had no pain or tenderness; 35% (9) required surgical spinal fixation. Our data define these indications for obtaining thoracolumbar radiographs in patients with blunt injuries: back pain (RR1), fall > or = 10 feet, ejection from motorcycle/motor vehicle crash > or = 50 mph, GCS score < or = 8, (all RR2), and neurologic deficit (RR10). The sensitivity of our surveillance radiography protocol has increased to 100%. The absence of back pain does not exclude significant thoracolumbar trauma.
Adult↗
Minimizing admission laboratory testing in trauma patients: use of a microanalyzer.
OBJECTIVE: Routine admission laboratory test protocols in injured patients are costly and involve excessive phlebotomy and turnaround time. The purpose of this prospective study was to evaluate the utility of (1) a microanalyzer, NOVA-SP5 (which provides rapid results on minimal blood volume), and (2) each component of our standard laboratory test battery. METHODS: Laboratory test results for 200 consecutive injured patients admitted to a level I trauma center were evaluated by paired sample analysis. Our standard battery [60 mL: ($348): type and screen, complete blood count, PT/PTT, electrolytes, BUN, creatinine, glucose, calcium, amylase, ethanol level, and arterial blood gas] run "stat" in the central laboratory was compared to the microanalyzer profile [< 1 mL: ($182): hemoglobin, hematocrit, electrolytes, glucose, Ca2+, and arterial blood gas] run by the trauma team in the resuscitation area. Patient data and laboratory turnaround time (from time of admission to time results obtained) were recorded. Data were analyzed by linear regression. RESULTS: Components of the paired samples correlated well (r2 0.78 to 0.99). Turnaround times were 64 (+/- 3) and 6 (+/- 1) minutes for standard analysis and microanalysis, respectively. Only two of the 26 patients requiring emergent surgical procedures had standard results available preoperatively. These patients had twice as many laboratory abnormalities as the remainder. Minimal diagnosis or intervention resulted from those values exclusive to standard analysis (white blood count, amylase, ethanol level, BUN, creatinine, platelet count, PT, and PTT). Six of ten abnormal BUN or creatinine results normalized, including two values in patients who received contrast for portable intravenous pyelography, and in all patients without a history of hypertension or diabetes. Platelet count and PT/PTT were normal in 85% of non-head-injured patients, compared with 58% of those with GCS score < or = 8. CONCLUSIONS: Microanalysis is accurate, expedient, conserves blood, and is sufficient for evaluation of most trauma patients. Those with hypertension, diabetes, or severe head trauma may require additional testing. Routine use of this technique could reduce cost substantially ($16,000/100 patients). The role of microanalysis in follow-up laboratory evaluation of injured patients remains to be elucidated.
Adult↗
Major hepatic trauma.
The intraoperative management of complex liver injuries can be extremely challenging. During the past two decades, there have been some changes in philosophy regarding the optimal techniques for controlling hemorrhage and decreasing mortality and morbidity rates. An overview of these techniques is presented.
Debridement↗
Prospective evaluation of surgeons' use of ultrasound in the evaluation of trauma patients.
Ultrasound diagnostic imaging has been demonstrated to be a valuable investigative tool in the evaluation of trauma patients in Europe and Japan. In the United States, however, ultrasound has not been widely used by trauma surgeons because of its lack of availability in the trauma resuscitation area and the associated cost and lack of full-time availability of a technician. In this prospective study, four attending trauma surgeons, four trauma fellows (PGY 6 and 7), and 25 surgical residents (PGY 4) at a level I trauma center were trained in specific ultrasound techniques to identify fluid in trauma patients with thoracoabdominal injuries. Their ultrasound evaluations of 476 patients demonstrated that in 90 patients with clinically significant injuries, ultrasound imaging successfully detected injury in 71, for a 79% sensitivity. Specificity was 95.6%. We conclude that (1) surgeons can rapidly and accurately perform and interpret ultrasound examinations; and (2) ultrasound is a rapid, sensitive, specific diagnostic modality for detecting intraabdominal fluid and pericardial effusion.
Abdominal Injuries↗
Prospective evaluation of thoracoscopy for diagnosing diaphragmatic injury in thoracoabdominal trauma: a preliminary report.
Diagnosis of diaphragmatic injury (DI) can be difficult in patients with penetrating trauma because physical examination, computed tomographic scan, chest x-ray films, and diagnostic peritoneal lavage may miss these injuries. Mandatory exploration has been recommended because of the increased mortality associated with missed DI. Thoracoscopy was prospectively evaluated as a less invasive method for diagnosing DI in patients with penetrating trauma. Over a 14-month period, 14 patients were evaluated by thoracoscopy; video thoracoscopy was used in the last 9. Findings of thoracoscopy were confirmed by laparotomy or laparoscopy. Thoracoscopy correctly identified the presence or absence of DI in nine and five patients, respectively (all patients). Video thoracoscopy was easier and faster to perform than non-video thoracoscopy. This is the first reported series in which video thoracoscopy has been used for trauma. We found this procedure to be safe, accurate, and less invasive than laparotomy for diagnosing DI.
Diaphragm↗
Alkaline phosphatase levels in diagnostic peritoneal lavage fluid as a predictor of hollow visceral injury.
Isolated injuries to hollow viscera may result in equivocal diagnostic peritoneal lavage (DPL) findings. Small bowel injuries cause alkaline phosphatase (AP) levels to increase in DPL effluent. The goal of this study was to better define the role of AP levels in the evaluation of the injured abdomen. We prospectively measured AP levels in 672 patients undergoing DPL. These were retrospectively compared with the clinical findings. All 12 patients with small bowel injuries and three of four with large bowel injuries had an AP level > 10 IU/L. There was one patient with an AP level > 10 IU/L without clinically significant intra-abdominal injury. An AP level > 10 IU/L in the DPL effluent predicted injury requiring laparotomy with a specificity of 99.8% and a sensitivity of 94.7%. We recommend using AP levels only in the management of patients with equivocal findings on DPL who would otherwise not undergo laparotomy. This selective use of AP levels will improve the probability of early diagnosis of bowel injury without increasing the cost of care.
Abdominal Injuries↗
Development and organization for casualty management on a 1,000-bed hospital ship in the Persian Gulf.
A 1,000-bed hospital ship designed for trauma patients was deployed to the Middle East with the objectives of preparing for large numbers of casualties resulting from Operation Desert Storm from conventional, chemical, and biological weapons. Plans for receipt and decontamination of casualties, triage, and optimal utilization of the 1,000-bed facility were developed. Mass casualty drills were conducted, involving all aspects of patient care from the flight deck to the wards. Trauma and critical care registries were developed to collect casualty data that could then be analyzed for specific military purposes and compared with current civilian registries. Attempts were made to identify the advances in shock resuscitation, systems management, and operative treatment from the civilian community that could be applied to care of combat casualties. Difficulties with accomplishing these objectives included limited trauma experience and supplies and poorly defined medical regulating and evacuation policies. The development of these programs, as well as the unique difficulties encountered, are discussed.
Disaster Planning↗
Associated aortic rupture-pelvic fracture: an alert for orthopedic and general surgeons.
Blunt trauma patients with pelvic fractures have been shown to have a two-fold to five-fold increased risk of aortic rupture compared with the overall blunt trauma population. A retrospective review was performed to determine whether the relationship between aortic rupture and pelvic fracture could be further delineated using a pelvic fracture classification based on mechanism of injury. Of 4,157 consecutive blunt trauma patients, 371 (8.9%) had pelvic fractures, 34 (0.8%) had ruptured thoracic aortas and 12 had both injuries. When pelvic fractures were classified according to vector of force, 10 of 12 (83%) aortic ruptures occurred in patients with an anterior-posterior compression fracture pattern, an incidence of aortic rupture eight times greater than that of the overall blunt trauma population. There was no increased incidence of aortic rupture among patients with any other pelvic fracture pattern. We conclude that the previously reported association between aortic rupture and pelvic fracture can be further specified to include, predominantly, those patients with an anterior-posterior compression fracture pattern.
Adolescent↗
A modified Seldinger technique for peritoneal lavage in trauma patients who are obese.
We have devised a technique of peritoneal lavage that combines the semi-open and the Seldinger techniques for use in trauma patients who are morbidly obese that is fast, safe and obviates the extensive incision that is required to adequately visualize the peritoneum when using the open method. We have successfully used this technique in six patients whose weight exceeded the weight limit of 135 kilograms of our CT scanner.
Abdominal Injuries↗
Fibrin glue as a hemostatic agent in hepatic and splenic trauma.
Fibrin glue is a biologic hemostatic agent that coagulates and seals upon application. It is made by combining human fibrinogen concentrate with standard thrombin solutions containing calcium. Similar to epoxy glue, the two components are applied simultaneously in equal volumes resulting in an almost instantaneous formation of a coagulum. Fibrinogen concentrate is prepared in the blood bank from single donor plasma. Fibrin glue can be applied topically or injected into the parenchyma of solid organs. Twenty-six patients sustained hepatic or splenic trauma from May through August 1989--17 liver and nine splenic injuries. The glue was effective after one application in 21 patients and after a second in five. Hemostasis was achieved despite coagulopathy and thrombocytopenia in eight patients. There were no re-explorations for bleeding, and nine complications occurred in six patients. Our experience suggests fibrin glue is an effective, underutilized adjunctive hemostatic agent in trauma.
Fibrin Tissue Adhesive↗
Diagnostic pneumoperitoneum in the pediatric patient with a unilateral inguinal hernia.
Controversy continues among surgeons over the management of pediatric patients with unilateral groin hernias. Currently, advocated treatment modalities include repair of only the clinically apparent side, exploration of the contralateral side when the ipsilateral hernia is repaired, or performance of contrast herniography before surgery. Another technique for consideration--diagnostic intraoperative pneumoperitoneum--is a simple, quick, safe, and highly accurate means of detecting a clinically inapparent contralateral inguinal hernia during the initial surgery. This technique, the results of its use, and a review of the literature are included.
Adolescent↗
Pelvic fracture as an indicator of increased risk of thoracic aortic rupture.
Thoracic aortic rupture is a lethal injury associated with severe blunt trauma. Survival is directly related to early diagnosis and operative treatment. Establishing the diagnosis requires a high index of suspicion, recognition of radiologic evidence of mediastinal bleeding, and identification of injuries frequently associated with aortic rupture. A retrospective review of blunt trauma patients at the Washington Hospital Center Trauma Unit and data from the Major Trauma Outcome Study identified a two- to fivefold increase in the incidence of aortic injury among patients with pelvic fracture. Twenty to forty-five per cent of patients with aortic rupture had associated pelvic fracture. Our study documents that pelvic fracture is as reliable an indicator of associated aortic rupture as many currently accepted injuries. Its presence should raise suspicion for aortic injury.
Aorta, Thoracic↗