Biomedical subjects
Publications and source records attributed to S Sclafani.
This article addresses in detail the newer role for interventional angiography, including diagnosis and newer angioembolization techniques used to control bleeding and to deal with complications of vascular injuries.
Pelvic fractures are high energy injuries indicative of significant trauma. Hypotension and significant blood loss is common in skeletally unstable pelvic fractures. Potential sites of intrapelvic bleeding include fractured bone edges, venous injuries and/or arterial vascular injuries. In an attempt to define the relationship of fracture pattern to arterial injury, a specific subset of 39 patients with pelvic fractures who underwent angiography for hemodynamic instability or ongoing blood loss were reviewed retrospectively. In 35 patients with definable arterial injuries, 20 (57%) had multiple bleeding sites. Posterior arterial bleeding (internal iliac or its posterior branches) was statistically more common in patients with unstable posterior pelvic fractures, and anterior arterial bleeding (pudendal or obturator) was more common in patients with lateral compression injuries. The pudendal artery was the most commonly injured vessel in this series. The superior gluteal artery was the most commonly injured vessel associated with posterior pelvic fractures. There was no correlation between fracture pattern and survival. The injury severity score however, did indirectly correlate to survival. In addition, the presence of hypotension (systolic blood pressure < or = 90) at the time of arrival to the trauma center was found to significantly increase mortality.
A penetrating extremity trauma registry was created to prospectively study the physical findings, use of arteriography, nonoperative management with embolization or observation and operation in the management of vascular injuries. During a recent ten month period, 228 patients with 320 injuries of the extremity secondary to firearms were admitted to the Trauma Service. Twenty-four percent of the patients had more than one injury, and there were six perioperative deaths related to associated injuries. Fifty-one patients had 50 arterial and 17 venous injuries. Limb salvage was 100 percent. Twenty-two patients with obvious arterial injuries were taken directly to the operating room without arteriography. Arteriography was performed immediately after admission in 41 patients and the findings were positive in 46.4 percent of the patients; nine required operation. Arteriography was performed for injuries in proximity to a major vessel as the indication in 153 injuries and revealed seven arterial injuries (4.6 percent). Three patients underwent operation. Five patients with arterial injuries had successful embolization during the initial arteriography and five patients with intimal injuries were observed, four healed and one patient was lost to follow-up evaluation. Operative repair of arterial injuries included the use of saphenous vein (21 patients), prosthetic grafts (seven patients) and ligations (four patients). Seventeen venous injuries were either repaired (eight patients) or ligated (nine patients). In the patients undergoing operative repairs, 68.7 percent had fasciotomies performed. The excellent results in the current study (no amputations with 51 survivors of arterial injuries) were obtained by a multidisciplinary approach, involving selective arteriography to avoid unnecessary operation and operative repair in those with extensive vascular injuries. The use of arteriography for proximity characterized a few vascular injuries requiring operation or observation. It should serve as the standard for evaluating noninvasive diagnostic studies and for studying the natural history of asymptomatic injuries.
We report our use of percutaneous antegrade ureteral stenting (PAUS) as an adjunct for the management of dehisced ureteral repairs and delayed-presentation ureteral injuries secondary to penetrating trauma. This procedure was performed in treating six patients with ureteral injuries. Four patients had dehiscence of a lacerated ureter that had been primarily repaired. Two other patients had ureteral contusions that subsequently became full-thickness disruptions postoperatively. One of these patients developed a pancreaticoureteral fistula. The sepsis resolved in all six patients and in five of the six patients the ureteral disruption healed within 2 months after PAUS without operative intervention. In one patient the ureter healed with stricture, necessitating ureteral reanastomosis. All urinomas resolved with percutaneous drainage. The PAUS technique was used to successfully treat four dehisced ureteral repairs and was the primary method used to successfully treat two disrupted ureteral contusions that were associated with multiple collections and fistulas. These techniques can be utilized for complex ureteral injuries associated with pancreatic leaks, colon or duodenal injuries, and multiple abscesses.
We retrospectively reviewed the clinical records of 11 patients admitted to the trauma service at Kings County Hospital who underwent packing and temporary closure for severe nonhepatic injuries. The mean ISS was 37 and the mean Abdominal Trauma Index value was 48. Operative findings included 17 major vascular injuries. Although the mean blood pressure was 105 mm Hg during the procedure, the patients required an average of 17 units of blood and all were acidotic, hypothermic, and coagulopathic. Acidosis persisted in all patients and the mean base excess was -13 at closure. A conscious decision was made to terminate the procedure when surgical bleeding was controlled. Patients were resuscitated and warmed in the ICU and returned to the operating room within 48 hours. Seven of the 11 patients survived. Of the eight patients who survived to return to the operating room, all required gastrointestinal procedures at re-exploration. This preliminary experience supports packing to control coagulopathic bleeding, use of temporary abdominal closure, and further ICU resuscitation with a planned second laparotomy for definitive management of gastrointestinal injuries in patients with severe nonhepatic injuries.
Treatment principles for penetrating neck trauma are well described yet few exist for facial injuries. To help delineate these issues, we viewed our recent experience with gunshot wounds to the face. Since 1986 we have treated 100 patients with such injuries. Their mean age was 28.9 years (range, 12-77 years). There were 89 male patients and 11 female patients. Ninety-six patients were considered stable on initial examination. Yet 35 patients required urgent airway control in the ED; only two needed a surgical airway. Emergency angiography was performed in 37 patients; 19 vascular injuries were identified. Eleven required therapy for vascular injuries, five by neck exploration and six by embolization. In 15 patients the trajectory suggested an intracranial injury, i.e., across the base of the skull. Although 14 of 16 patients were awake and alert at examination, head CT scans demonstrated serious intracranial pathologic processes in 9 patients. Sixty-seven patients sustained bony injury, 19 patients a significant nonvascular soft-tissue injury, and 38 patients a significant neurologic injury (26 peripheral, one spinal and 20 cerebral injuries). Ultimately, 44% of all patients required some surgical treatment and 25% had a complication from their injury. Six patients died, three of CNS injury, one of exsanguination, and two of sepsis. The bony, soft tissue, nervous, and vascular anatomy make the management of gunshot wounds to the face challenging. Although initially stable, many patients require early airway control and urgent work-up for vascular and intracranial injuries. Early subspecialty input is helpful in delineating the often complex injury pattern and planning an optimal management strategy.
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A hemiparetic and aphasic patient, 3 days after acute traumatic transection of the left internal carotid artery requiring life-saving total embolic occlusion, revealed ipsilateral increased peripheral hemispheric 99mTc-HMPAO activity. Ten days postocclusion, HMPAO peripheral cortical flow normalized as hemiparesis and aphasia significantly cleared. The initial lateralized HMPAO hyperactivity pattern may reflect reactive hyperemia, a sign previously identified by contrast angiography and often associated with a better prognosis in evolving CVA. Evanescent peripheral cerebral hyperemia may represent beneficial cortical collateralization of the periinfarct area of a deeper lacunar (white matter) CVA.
Despite the widespread availability of firearms, stab wounds to the abdomen, back, and flank continue to account for a significant number of injuries. The proper sequencing of diagnostic modalities in this patient group is constantly undergoing change. We report our experience with these injuries and present a new algorithm for the use of currently available diagnostic procedures. In 1987, 162 patients were seen, 103 with anterior abdominal wounds and 59 with back and flank wounds. Patients with shock, peritonitis, and evisceration were resuscitated and explored. The remainder of the cohort underwent tap and lavage, and patients with a negative study were observed. Patients with back and flank wounds underwent contrast enhanced computerized tomographic enemas (CECTE). Seventeen patients underwent immediate exploration and 108 of the 162 patients were spared exploration. Fifty-four patients were explored with six negative laparotomies. Of the 126 taps and lavages, the false positive rate was zero, and only one patient had a false negative study. Of the 47 CECTE studies, only three were interpreted as an indication for angiography which proved negative, and all patients were safely observed. The overall mortality was 4.3%, including three patients without vital signs on admission and four who expired intraoperatively due to irreversible shock. We concluded that this algorithm can be safely applied to patients with these injuries with a high degree of specificity and sensitivity.
Large doses of heparin given as a bolus may produce hypotension; however, conflicting reports exist about the mechanisms involved. This study was undertaken to determine the role of histamine in beef lung heparin-induced hypotension and the efficacy of histamine-receptor blockade in attenuating this undesirable side effect in patients undergoing cardiac surgery. Two hundred patients with good ventricular function were studied after they were randomized into four equal groups. Group I (control) received no histamine-receptor blockade, group II received 1 mg/kg of diphenhydramine 30 minutes prior to heparin administration, group III received 5 mg/kg of cimetidine 4 hours and again 30 minutes before heparin administration, and group IV received 1 mg/kg of diphenhydramine 30 minutes prior to heparin administration and 5 mg/kg of cimetidine 4 hours and 30 minutes before heparin administration. Hemodynamic variables, plasma histamine, and ionized calcium levels were measured before and after heparin administration. Significant hypotension occurred in group I patients after heparin administration. Mean arterial pressure decreased from 95 +/- 5 to 67 +/- 1.5 mm Hg (P less than 0.005) after 1 minute and to 85 +/- 2 mm Hg (P less than 0.05) at 4 minutes. Those changes were significantly greater than in group II (P less than 0.025) and Group IV (P less than 0.005) patients, in whom no significant hypotension was found. In group III, mean arterial pressure decreased from 92 +/- 3 to 75 +/- 1 mm Hg (P less than 0.05) after 1 minute and returned toward baseline values after 4 minutes. Histamine levels increased significantly in all groups of patients.(ABSTRACT TRUNCATED AT 250 WORDS)
Internal carotid injuries in zone III near the base of the skull are technically the most challenging of the carotid injuries. Diagnostic angiography is important to evaluate the exact site and extent of injury and the presence or absence of prograde flow in the injured segment. Vascular repair in this area is highly dependent on the adequacy of surgical exposure. Previous approaches have emphasized displacement of the mandible either by subluxation or mandibulotomy. Problems related to mandibulotomy, such as intraoral contamination, infection, and nonunion, are potential complications of this approach to the high carotid artery. In addition, it does not give adequate exposure of the internal carotid artery at the critical area, near the base of the skull. Experience gained from the extended radical neck dissection exposing the internal carotid artery up to the skull base has demonstrated that a posterolateral anatomic approach can provide superior exposure of the high carotid artery with lower morbidity and shortened operative time. This surgical approach involves cutting the sternomastoid muscle close to the mastoid and dissecting all the tissues away from the surface of the mastoid. Dividing the posterior belly of the digastric and styloid group of muscles assists in exposure of the internal carotid artery. Rarely, dissection of the facial nerve and removal of the tail of parotid add additional access to this area. This article describes the stepwise anatomic approach to the internal carotid artery near the base of the skull.
Tinnitus and hearing loss can occur in patients with a high-riding abnormal jugular bulb. Jugular vein ligation in selected patients can cure tinnitus and reverse hearing loss. A 39-year-old woman reported a 4-year history of right-sided tinnitus of increasing intensity associated with a mild hearing loss. Extensive evaluation revealed only an enlarged right jugular bulb with dehiscence of the normal petrous bony septum between the bulb and the middle ear. The patient underwent ligation of the right internal jugular vein and noted immediate cessation of tinnitus and the return of normal hearing. Review of the literature suggests that jugular vein ligation is appropriate in selected cases of venous tinnitus.
The literature on vascular trauma contains little information on the management of vertebral artery injuries. We have reviewed our experience consisting of 23 patients with vertebral artery injuries caused by 19 gunshot wounds, two stab wounds, one shotgun wound, and one blunt injury. Twelve patients sustained unilateral vertebral artery thrombosis, seven patients had vertebral AV fistulae (three jugular vein, four vertebral vein) and four patients sustained mural injury without thrombosis. Six patients (26.1%) developed major neurologic deficits of which five could be directly attributed to CNS missile injury. One patient had transient vertebrobasilar ischemia on the basis of a vertebral AV fistula. Four of the seven vertebral AV fistulae were managed solely by therapeutic embolization and two patients early in the series underwent surgical management alone. One patient had therapeutic embolization of the proximal vertebral artery and operative distal vertebral artery ligation for an AV fistula. The four patients who died (17.4%) did so as a direct result of their CNS missile injury. We conclude that: 1) unilateral vertebral artery occlusion seldom results in a neurologic deficit if there is a normal contralateral vertebral artery and PICA (posterior inferior cerebellar artery) blood supply is preserved; 2) accurate assessment of a vertebral artery injury requires contralateral vertebral arteriogram; 3) management of vertebral artery injury is simplified by proximal, and if possible distal, therapeutic embolization; 4) an anterior approach to the C1-2 vertebral artery is a satisfactory method of obtaining distal surgical control, obviating the need to unroof the bony canal of the vertebral artery; 5) angiography is necessary in penetrating neck trauma to identify occult vascular injuries.
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Presence of gas in the prosthetic graft bed does not necessarily represent infection, but may rather be indicative of the presence of benign gas. The diagnostic and therapeutic implications of this finding are discussed.