Biomedical subjects

R R Ivatury

Publications and source records attributed to R R Ivatury.

At least 73 records · Page 4Linked to original sources

PubMed1990

Open management of the posttraumatic septic abdomen.

Thirteen patients with abdominal trauma who developed abdominal sepsis resistant to conventional methods of reexploration and drainage were managed by an open method. Eleven of these patients had multiorgan failure. The extent of anatomic and physiologic injury was defined by Abdominal Trauma Index and Acute Physiology and Chronic Health Evaluation (APACHE) scores, respectively. Ten of the 13 patients (76.9%) survived, a significantly improved survival as compared with that predicted by APACHE (50%). Complications attributable to the open technique (enteric fistula and a subphrenic abscess) occurred in two of the ten survivors. It is concluded that the open method of management of abdominal sepsis is effective and feasible. It should be considered in patients with necrotizing wound infections, multiorgan failure, and ongoing abdominal sepsis uncontrolled by conventional methods. Larger, controlled series employing such systems as the APACHE are needed for a better definition of patient selection for the open method.

Abdominal Injuries↗

PubMed1989

The injured heart.

Penetrating and blunt injuries to the heart, ranging from cardiac concussion to rupture, are seen more and more frequently. Prompt diagnosis because of a high index of suspicion and timely, well-executed resuscitative efforts are rewarded by remarkable survival rates, even in the patients presenting in extremis, whereas hesitancy in diagnosis and therapeutic action militates against a successful result.

Emergency Medical Services↗

PubMed1989

Open management of the septic abdomen: therapeutic and prognostic considerations based on APACHE II.

We analyzed the results of open treatment in 30 patients with abdominal sepsis (11 patients after trauma [group 1], five patients with pancreatic abscess [group 2], and 14 patients with acute GI pathology [group 3]) uncontrolled by conventional methods as evidenced by continuing fever with leukocytosis and worsening organ functions. APACHE scores at the time of initial laparotomy and at the time of open management, respectively, were: group 1, 19.8 and 16.6; group 2, 8.4 and 12.4; and group 3, 14.2 and 15.0. Twenty-seven patients had multiple system failure. Sixteen (53%) of the 30 patients survived, 73% in group 1, 60% in group 2, and 36% in group 3. Survival correlated well with age less than 50 yr and the absence of multiple organ failure. The technique was easily performed and many of the pitfalls previously reported were not observed. In patients requiring fascial prosthesis, the absorbable polyglycol acid (Dexon) mesh was found to be superior to the nonabsorbable polypropylene. We conclude that the open technique is feasible, effective, and worthy of consideration in patients with extensive wound necrosis and uncontrolled abdominal sepsis.

Abdomen↗

PubMed1989

Penetrating renovascular trauma.

A 10-year experience with 39 patients having 40 renovascular injuries is presented. The overall mortality rate was 30%, predominantly from extensive associated trauma. Nephrectomy was performed in 20 patients (51%). Only 50% of the patients had attempted repair or ligation of the renal vessels. Renal salvage was possible in 23% of the total group and included 33% of these for isolated renal artery injuries and 43.6% for renal vein injuries. Our experience and a review of the literature suggest that nephrectomy still is the most expeditious method of management of renal vascular injuries. The extent of the associated trauma determines the fate of the involved kidney after renovascular trauma. Renal artery repair rarely is possible and seldom is successful. Renal vein injuries carry a better prognosis.

Adult↗

PubMed1988

Intra-abdominal abscess after penetrating abdominal trauma.

We reviewed our experience with intra-abdominal abscess after penetrating abdominal trauma. Of a total of 872 laparotomies (1980-1986), 29 patients (0.7% of stab wounds and 6% of gunshot wounds) developed abscesses. Pancreatic and duodenal injuries, in the presence of concomitant colon perforation, were most frequently associated with abscess formation. Fourteen of the 29 patients had multiorgan failure (MOF), Group I, and 15 patients did not have MOF, Group II. Group I had a significantly higher Abdominal Trauma Index (ATI) and Acute Physiology and Chronic Health Evaluation (APACHE II), received greater number of perioperative transfusions and underwent a higher number of reoperations for sepsis than Group II patients. Radiologic imaging techniques were frequently inconclusive for the diagnosis and localization of intra-abdominal abscess in Group I. They were highly accurate in Group II. Fifty per cent of Group I patients died from sepsis and MOF. We conclude that the anatomic (ATI) and the physiologic (APACHE) scores are useful predictors of the potential for uncontrolled sepsis. In the presence of ongoing multiorgan failure, reoperation for sepsis is warranted on clinical grounds alone.

Abdomen↗

PubMed1988

Nonoperative management versus early operation for blunt splenic trauma in adults.

Forty-eight adult patients with isolated splenic trauma from blunt injury were analyzed during a six year period (1980 to 1986). Early laparotomy was performed upon 38 patients and splenic preservation was accomplished in 18. The remaining ten patients who were hemodynamically stable were managed nonoperatively with close monitoring. Splenic injuries were confirmed by one of the imaging methods, such as computed tomography, radionuclide scan or ultrasound. One patient with known hepatic cirrhosis underwent embolization of the splenic artery and recovered. Nonoperative treatment failed in seven of the remaining nine patients, mandating an exploratory laparotomy between the third and tenth day of admission. In six of the seven patients, splenic preservation was unsuccessful, necessitating a splenectomy. The length of hospital stay was longer for this latter group (a mean of 15.8 days) than for patients who had splenorrhaphy (a mean of 7.5 days), or splenectomy (a mean of 8.7 days, p less than 0.001). Patients managed nonoperatively required more units of blood compared with those undergoing splenorrhaphy (4.1 units versus 1.7 units, p less than 0.01). A review of the literature reveals that splenic preservation is possible in less than 25 per cent of the patients who fail to respond to nonoperative management. We conclude that splenic injuries after blunt trauma in adults are treated best by early laparotomy in order to achieve maximal splenic preservation.

Adult↗

PubMed1987

Acid burns of the rectum and colon. Report of a case.

The case of a patient with acid burns of the large bowel from a self-administered enema of 95 percent sulfuric acid solution is reported. The authors were unable to find a similar case in the English medical literature. The patient presented in metabolic acidosis, and flexible sigmoidoscopy was of limited value. Peritoneal signs warranted early laparotomy, which revealed coagulation necrosis of the anus, rectum, and colon up to the hepatic flexure without any free perforation. The extent of damage was more severe than seen in the upper digestive tract from acid ingestion. Juxtaposed small bowel and the appendix sustained serosal burns. Subtotal proctocolectomy and perineal resection were done and the patient made an uneventful recovery. Early laparotomy is warranted, irrespective of endoscopic findings, for appropriate surgical correction.

Administration, Rectal↗

PubMed1987

Is limb loss avoidable in civilian vascular injuries?

Limb salvage is virtually guaranteed when arterial injury is associated with a gunshot or stab wound. In this setting, associated injury is limited, and arterial injury is uniformly suspected, deliberately sought, and expeditiously repaired. Blunt trauma and massive injuries to the soft tissue, bones, and joints of the extremities augur amputation. In a patient with blunt trauma and loss of distal pulses, liberal, early use of angiography helps to avoid amputations secondary to missed or delayed diagnosis. Deliberate local anticoagulation and effective venous drainage is recommended in the management of dual-complex popliteal injuries. Discriminate amputation merits consideration when arterial trauma is accompanied by massive soft tissue and bony injuries with extensive loss of soft tissue.

Amputation, Surgical↗

PubMed1987

The use of peritoneal lavage and urological studies in major fractures of the pelvis--a reassessment.

Fifty patients with major fractures of the pelvis (Trunkey's classification types I and II) treated in an urban Level I Trauma Center were analysed to assess the role of peritoneal lavage and urological studies in the initial evaluation. The mechanisms of injury were automobile v. pedestrian (44 per cent), falls from heights (44 per cent), and motor vehicular accidents (12 per cent). Important hypotension was present in 46 per cent of patients on arrival. Peritoneal tap or lavage was selectively used in 11 patients (22 per cent). Four patients in refractory hypotension despite vigorous resuscitation had positive results. There were no false-positive results or missed intra-abdominal injuries in any of the 50 patients. Laparotomy was carried out in 10 of 50 patients. IVP or cystography was performed in 25 of 50 patients. However, injuries of the urinary tract requiring operative correction (eight injuries in six patients) were all associated with gross haematuria. Urological studies were negative in patients with 1 to 3+ microscopic haematuria. Peritoneal lavage is recommended on a selective basis in patients with pelvic fractures. Microscopic haematuria does not warrant contrast studies of the urinary tract.

Abdominal Injuries↗

PubMed1987

Emergency department thoracotomy for trauma: a collective review.

A decade of experience with resuscitative thoracotomy for the trauma victim in extremis has been gained since the pioneering efforts of Mattox and his associates in 1974. It appears, from a review of the various reports from different trauma centers, that there is an emergence of a consensus as to the best indications for the procedure. It is generally agreed upon that ERT is fruitless in the patient with severe head trauma or when vital signs were absent at the scene of the injury. In the absence of penetrating thoracic injuries ERT yields a very poor survival in patients without vital signs on admission to the emergency center. It is widely accepted that the best results for ERT are in patients with cardiac tamponade. The prognosis is hopeless in patients without vital signs after sustaining blunt trauma.

Abdominal Injuries↗

PubMed1987

Penetrating cardiac trauma. Quantifying the severity of anatomic and physiologic injury.

A method of quantifying the anatomic extent of injury to the heart, Penetrating Cardiac Trauma Index, (PCTI) and other thoracic organs has been proposed. The total extent of thoracic injury, Penetrating Thoracic Trauma Index (PTTI), was measured. When associated abdominal injury was present, it was assessed by the Penetrating Abdominal Trauma Index (PATI) of Moore et al. The severity of total injury sustained by the patient, represented by the Penetrating Trauma Index (PTI), was determined by the sum total of these scores. The extent of physiologic abnormality induced by cardiac penetration, (Physiologic Index or PI), was graded on a scale of increasing severity from 5-20 based on the vital signs of patients on admission. Analysis of 112 patients with penetrating cardiac injuries (1973-1983) revealed that the indices, PCTI and PI, showed an excellent correlation with survival (R2 = 0.827 and 0.928, respectively) as did the total extent of trauma (PTI). A composite prognostic score of the sum of PI and PTI demonstrated a significant separation of survivors from nonsurvivors (p less than 0.001). It is concluded that these anatomic (PCTI and PTI) and physiologic (PI) indices are valid and, with additional confirmation, may provide an objective method of evaluating penetrating cardiac injuries.

Adolescent↗

PubMed1987

Portal vein injuries. Noninvasive follow-up of venorrhaphy.

The authors report their experience with 14 patients with portal vein injuries (1976-1986) treated at a level I trauma center. Seven patients (50%) survived and included six of 10 patients (60%) who had venorrhaphy and one in whom the portal vein was ligated. Associated injuries were present in all the patients (mean Abdominal Trauma Index: 39.5) and accounted for the high mortality rate. Follow-up data after repair or ligation of the portal vein seldom are reported in the literature. The authors studied all three patients who survived portal venorrhaphy since 1982 by real-time ultrasonography. Patency of the repair could be established in two patients. In the third patient postvenorrhaphy thrombosis was diagnosed by ultrasonographic examination. Sequential ultrasonographic examinations demonstrated resolution of the thrombus on anticoagulant therapy. Ultrasonography provides a noninvasive and easily reproducible method of studying the portal vein after repair.

Abdominal Injuries↗

PubMed1987

Penetrating colon injuries: exteriorized repair vs. loop colostomy.

Eighty-five patients with penetrating colon injuries, treated either by exteriorized repair (39) or loop colostomy (46), were analyzed. Missile wounds accounted for 75.3% of the injuries. The Penetrating Abdominal Trauma Index (PATI) was the scoring method employed to assess quantitatively the severity of injuries in each patient. Of 21 patients with right colon injuries, eight were treated by exteriorized repair and the remainder by loop colostomy. PATI and other variables were comparable in both groups. Suture line leaks occurred in two patients (25%) with exteriorized repair. The morbidity was similar in both groups. In left colon trauma, exteriorized repair was employed in 31 patients and 33 underwent loop colostomy. The injury severity indices, clinical status, and time lapse to laparotomy were similar in both groups. Colostomy was avoided in 67.7% (21 of 31) patients with exteriorized repair. The incidence of abscesses was significantly higher in the colostomy group compared to the group treated by exteriorized repair (24.2% and 6.4%, respectively; p less than 0.05). The length of hospital stay was shorter after exteriorized repair (17.2 days vs. 23.2 days; p less than 0.05). All three mortalities (3.5%) were related to associated injuries. We conclude that exteriorized repair is a safe and superior alternative to loop colostomy in penetrating colon trauma.

Adolescent↗

PubMed1987

Penetrating right colon trauma. The ever diminishing role for colostomy.

Ninety consecutive patients with penetrating trauma to the right colon were analyzed. The severity of injury to the colon and other abdominal organs was quantified in each patient by the Colon Injury Score (CIS) and the Penetrating Abdominal Trauma Index (PATI). Sixty-five patients (72%) were managed definitively, i.e., by primary repair (46 patients) and by resection-ileocolic anastomosis (19 patients). There was no morbidity related to the colonic repair in these patients. Exteriorized repair was used selectively in eight patients and was successful in six (75%). Thirteen patients underwent loop colostomy and the mean CIS and PATI in this group were comparable to those in primary repair and exteriorized repair groups. Resection colostomy was performed in four patients with extensive colon and associated organ trauma (high CIS, PATI). The overall incidence of intra-abdominal abscess was 2.2 per cent (2 of 90 patients). The mortality was 4.4 per cent (4 of 90 patients) and none of the deaths was related to the management of the colon trauma. It is concluded that the majority of patients with penetrating right colon trauma can be treated effectively by primary repair or resection anastomosis. Exteriorized repair should be the preferred method whenever loop colostomy is considered. Colostomy should be used selectively in unstable patients who require colon resection.

Colon↗

PubMed1987

Penetrating cardiac injuries: twenty-year experience.

Analysis of 228 patients who sustained penetrating cardiac injuries (1963-1983) reveals that among patients who arrived with vital signs, survival was 73 per cent as opposed to 29 per cent of patients who arrived in extremis; and delay in thoracotomy contributed to an increased mortality among patients in profound shock who failed to respond promptly to volume expansion and agonal patients who were transported to the operating room for thoracotomy. An increasing incidence of gunshot wounds and a greater frequency of patients presenting in extremis was noted in the latter years of the study as compared with the earlier period. Our data indicate that there is an increasing need for emergency room thoracotomy in the management of cardiac injuries. Urban trauma centers should be equipped for major procedures in the emergency room and, ideally, should have operating rooms in this area.

Adolescent↗

PubMed1987

Pyogenic splenic abscess in intravenous drug addiction.

Among the surgical complications of intravenous drug addiction, pyogenic splenic abscess is considered to be a rare entity. A review of the literature reveals only 24 cases of splenic abscess secondary to this particular etiology. The authors report five patients with intravenous drug addiction who underwent splenectomy for pyogenic splenic abscess within 1 year. Fever and abdominal pain were the only constant physical signs. Three patients had associated infective endocarditis, and the other two patients sustained blunt trauma to the left side of the trunk weeks earlier. Computed tomography (CT) and ultrasound were diagnostic in all five patients preoperatively, and they were complementary when combined. Four of the five patients had Staphylococcus aureus septicemia at the time of splenectomy. Three patients recovered from their operations, and the other two, both with endocarditis, died postoperatively from causes unrelated to splenic abscess and splenectomy. A high index of suspicion is warranted in this susceptible group of patients with vague abdominal signs and persistent sepsis to rule out splenic suppuration. The noninvasive imaging methods, CT scan and ultrasound, facilitate early diagnosis in these patients.

Abscess↗

PubMed1987

Penetrating thoracic injuries: in-field stabilization vs. prompt transport.

One hundred patients who were in extremis and required Emergency Room Thoracotomy (ERT) after sustaining penetrating thoracic injuries were analyzed to compare the results of attempted stabilization in the field (n = 51) with those who had immediate transportation (n = 49). The clinical status of the patients in the field and in the E.R. was quantified by Trauma Score (TS) as well as Physiologic Index (PI), ranging in severity from 20 (clinically dead) to 5 (stable). The anatomic injury severity was expressed by Penetrating Trauma Index (PTI). Survival was analyzed according to the type of injuries: noncardiac and cardiac. The overall survival was 10%. There was only one survivor with noncardiac injuries. Sixty-nine patients had cardiac penetration, 33 in Group I (stabilization) and 36 in Group II (immediate transport). Despite attempts at stabilization, none of the patients in Group I showed an improvement in clinical status from the scene to the emergency room. There were a higher number of patients arriving at the E.R. with signs of life in Group II compared to Group I. In Group II patients, survival was significantly improved overall (p = 0.01), in patients with signs of life on arrival at the hospital (p = 0.02) and in patients with isolated right ventricular wounds (p = 0.01) compared with Group I. The anatomic injury severity (PTI) as well as the mode of injury in the two groups was similar.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

PubMed1987

Craniocervical necrotizing fasciitis: critical factors in management.

Necrotizing fasciitis involving the head and neck is rare. The authors describe two such patients treated at their institution and analyse 39 cases reported in the literature. This entity may be divided into two groups based on the site of origin of the infection: group 1 (13 cases) infections, originating in the scalp and eyelids, mostly secondary to trauma, do not progress rapidly, respond well to medical and operative measures and result in minimal permanent disability. These infections usually are caused by hemolytic streptococci and Staphylococcus aureus. Group 2 (28 cases) infections, originating in the face or neck and mostly complications of dental and pharyngeal sepsis, progress rapidly to adjoining sites including the chest wall and mediastinum. These infections are caused by a wide variety of microorganisms including anaerobes; fatal complications are frequent and the death rate is high (32%). Early and very aggressive débridement and drainage are mandatory and should be repeated if warranted.

Adult↗