Biomedical subjects
Publications and source records attributed to R T Sherman.
Penetrating wounds to the anterior chest are often associated with cardiac tamponade. If these injuries are not evaluated or treated, delayed cardiac tamponade may develop. A case report and a review of the literature are presented.
A patient who had a bullet embolus to the right popliteal vein developed an extensive thrombophlebitis from the popliteal to the common iliac vein. We suggest that following extraction of a bullet that has embolized to a major extremity vein, it may be necessary to anticoagulate the patient.
The estimated 32,600,000 fires that occur annually in the United States produce over 300,000 injuries and 7,500 deaths. Ten percent of hospitalized burn victims die as a direct result of the burn. Initial evaluation and management of the burn patient are critical. The history should include the burn source, time of injury, burn environment, and combustible products. The burn size is best estimated by the Lund and Browder chart, and the burn depth is determined by clinical criteria. Pulmonary involvement and circumferential thoracic or extremity burns require detection and aggressive treatment to maintain organ viability. Hospitalization is usually necessary for adults with burns larger than 10% of the total body surface area (TBSA) or children with burns larger than 5% of TBSA. Major burns, those of 25% or more of TBSA or of 10% or more of full thickness, should be considered for treatment at a burn center, as well as children or elderly victims with burns of greater than 10% TBSA. Lactated Ringer's solution, infused at 4 ml/kg/% TBSA, is generally advocated for initial fluid restoration. After the acute phase (48 hours), replacement of evaporative and hypermetabolic fluid loss is necessary. These losses may constitute 3 to 5 liters per day for a 40% to 70% TBSA burn. Blood transfusion is often required because of persistent loss of red blood cells (8% per day for about ten days). Many electrolyte abnormalities may occur in the first two weeks. Pulmonary injury commonly is lethal. Circumoral burns, oropharyngeal burns, and carbonaceous sputum are indicative of inhalation injury, but arterial blood gas determinations, fiberoptic bronchoscopy, and xenon lung scans are useful for confirming the diagnosis. Humidified oxygen, intubation, positive-pressure ventilation, and pulmonary toilet are the mainstays of therapy for inhalation injury. Wound care is initially directed at preservation of vital function by escharotomy, if restrictive eschar impairs ventilatory or circulatory function. Antibacterial agents may be applied to the burn, but invasive sepsis, defined as greater than 10(5) organisms per gram of tissue with invasion of subjacent viable tissue, requires systemic antibiotic therapy. Wound debridement is done by daily hydrotherapy, tangential excision, chemicals, primary excision, and grafting, tailoring the technique to the individual burn.(ABSTRACT TRUNCATED AT 400 WORDS)
Anorectal melanomas are more aggressive and behave differently from melanomas of the skin. Abdominoperineal amputation of the rectum is the favored procedure for potentially curable patients. Local recurrence in anorectal melanoma is less frequent in patients treated by local or wide excision of the tumor. Improvement in the primary anorectal melanoma survival rate appears to be dependent closely upon early diagnosis. Assessing the penetration of the tumor by the microstaging technique provides important prognostic information and serves for establishing indications for abdominoperineal amputation of the rectum in patients with primary anorectal melanoma. Two patients had a five year local and regional control of a primary anorectal melanoma achieved by abdominoperineal amputation of the rectum without groin dissection. One patient, free of disease, had an adenosquamous carcinoma of the lung develop with metastases to the skin. The carcinoma of the lung was considered as a secondary primary, which caused the death of the patient five years and nine months after the abdominoperineal amputation of the rectum.
A patient with delayed neurologic injury secondary to high-tension current, with recovery, is presented. The mechanism of injury and pathophysiology are felt to be either vascular or direct damage to the spinal cord. This case demonstrates the need for frequent, repeated neurologic examinations of electrical injury victims. The cause of delay in onset of neurologic injury and the mechanism of recovery need further experimental study.
Biliary ascariasis, rarely noted in the western literature, is a common condition in other climates. An increase in infestation may occur with travel to these countries. With the changes in biliary function which follow common duct exploration, invasion can occur in the affected individual. Treatment involves antispasmodics, antihelminthetics, and prevention of superinfection. Surgical intervention is reserved for specific indications of failure of medical therapy.
In a prospective study, thrombosis of the femoral or popoliteal veins was discovered at operation in nine of eighty-one patients requiring amputation of a lower extremity for arterial insufficiency. One week postoperatively, all nine patients had evidence of pulmonary embolism on the lung scan. Embolization was documented by arteriography in two patients and at autopsy in a third patient. In none of these patients was there clinical evidence of venous thrombosis prior to operation. Two of the subjects with proved thrombosis died during study, a mortality of 22 percent, whereas the mortality for the entire group was 10 percent. It is concluded that the deep venous system of patients requiring amputation for ischemia should be examined carefully at operation. These patients have a high incidence of deep venous thrombosis and the discovery of thrombus at the time of operation places them in a particularly high risk group.
Patients requiring amputation of the lower extremity for arteriosclerosis are at high risk for the development of venous thrombosis and pulmonary embolism. Inapparent venous thrombosis was discovered in the amputated leg at operation in eight patients. Pulmonary embolism was documented by angiogram or at autopsy in ten patients. The majority of emboli discovered in this study was not suspected by the physician responsible for the care of the patient. The perfusion lung scan in this elderly group of patients had a false-positive rate of 60 per cent, while a normal lung scan was strong evidence against pulmonary embolsim. Although imperfectly randomized, the prophylactic use of low molecular weight dextran in this study did not decrease the incidence of pulmonary embolism. The pulmonary arteriogram proved a safe procedure in the elderly and should be used before therapy is initiated for suspected pulmonary embolism.
Intestinal obstruction secondary to a mesenteric cyst in childhood, although rare, should be considered in the child between ages 2-10 years with chronic or acute obstruction. A case of mesenteric cyst associated with obstruction is presented, along with a review of the literature.
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