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T M Scalea

Publications and source records attributed to T M Scalea.

At least 73 records · Page 4Linked to original sources
PubMed1990

Geriatric blunt multiple trauma: improved survival with early invasive monitoring.

Geriatric trauma survival rates are reported to approach 85%, but no series to our knowledge has included a predominance of multiply injured patients. In 1985, we treated 60 patients more than 65 years of age who sustained blunt multiple trauma, excluding burns and minor falls. A pedestrian-motor vehicle mechanism, initial BP less than 150 mm Hg, acidosis, multiple fractures, and head injuries all predicted mortality. To investigate this, in 1986, we began invasive monitoring in all patients with any of these risk factors and modified this in 1987 to emergent monitoring, postponing all but the most critical diagnostic studies. All patients included were hemodynamically stable after initial evaluation. Attempts were made to optimize all patients with volume, inotropes, and afterload reduction as needed. There was no difference between 1986 and 1987 in patient age, injury severity, or per cent of patients requiring operation. In 1986, mean time from ED admission to monitoring was 5.5 hours. Eight of 15 patients had an initial cardiac output (CO) less than 3.5 L/M and/or mixed venous saturation (MVO2) less than 50%. All developed progressive pump failure despite therapy and died within 24 hours. The other seven had an initial CO between 3.4-5.5 L/M, but five had an MVO2 less than 50%. All augmented their CO with therapy over 6-12 hours to a mean CO of 6.8 L/M and resolved their MVO2, but six died from MOF. Survival was 7%. In 1987-88, we reduced time to monitoring to 2.2 hours by limiting diagnostic tests. Thirteen of 30 patients treated had an initial CO less than 3.5 L/M.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1989

Evaluation of occult cardiac injuries using subxiphoid pericardial window.

During 1987, we performed diagnostic subxiphoid pericardial windows on all stable patients with juxta-cardiac penetrating injuries. This excluded any patient with clinically diagnosed tamponade or shock. Fifty-one patients underwent subxiphoid diagnostic pericardiotomy for suspected cardiac injuries. Forty patients were normotensive on presentation and 11 experienced transient hypotension. All patients were easily resuscitated in the Emergency Department. The time from admission to operation ranged from 20 minutes to 6 hours (average, 2.5 hours). Twelve patients (23.5%) had hemopericardium at the time of subxiphoid diagnostic pericardiotomy (SDP), and cardiac injury was confirmed at sternotomy in all. Two patients (16%) in the positive group were admitted with systolic blood pressures less than 100 mm Hg compared to nine (23%) in the negative group. One patient had a systolic to diastolic pressure gradient less than 30. Central venous pressures in this group of patients ranged from 8 to 23 cm H2O. Nine patients who had pericardial window solely on the basis of location of the injury had positive findings. All nine patients were normotensive on admission, had CVP's less than 12, and had no other overt clinical signs of injury. This represents an overall occult injury rate of 17.6%. At sternotomy, there were eight ventricular, two pulmonary artery, one aortic root, and one atrial injury, all repaired. Two patients in this group had associated abdominal injuries as did 11 in the negative group, all of whom required operation, and may have explained the hypotension in negative patients. There were no complications of SDP and all negative patients were discharged on the second hospital day.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1989

Management of transpelvic gunshot wounds.

The records of 98 patients with transpelvic gunshot wounds from 1983 to 1988 were reviewed: 22 patients were admitted in shock and required aggressive resuscitation and immediate exploration, and 76 patients were normotensive and were evaluated with diagnostic peritoneal lavage, angiography, cystography, proctoscopy, CT scan, and contrast-enhanced CT enema in various combinations as indicated. Using this approach, 40 stable patients were observed without operation and discharged without complications. Fifty-eight patients were explored: 20 had both arterial and hollow viscus injuries. Thirty-nine major vascular injuries were evaluated: 27 were ligated and 12 repaired. Other injuries were colon, 27; including seven rectal perforations, multiple small bowel perforations, five bladder, one ovarian, four ureteral, three caval, three renal, and two distal aortic injuries. Colon injuries associated with vascular injuries were treated with colostomy and ligation of the vessel with extra-anatomic bypass when revascularization was required. Overall 12 patients died as a result of their injuries, a mortality of 12.2%. However, 50% of the patients who were admitted in shock died. Two external iliac artery injuries and two ureteral injuries were missed at initial operation. Penetrating trauma to the pelvis presents a serious challenge because of the complex anatomy of the region. Patients in shock have a high incidence of vascular injury and subsequent exsanguination, and associated visceral injuries may complicate their management. However, stable patients may be managed without operation, when appropriate diagnostic techniques fail to demonstrate an injury. Arterial ligation and extra-anatomic bypass should be considered for vascular injury with gross fecal contamination.

Adolescent↗
PubMed1989

Indications for barium enema preceding colostomy closure in trauma patients.

The need for a barium enema (BE) preceding colostomy closure is controversial. In the process of evaluating the usefulness of BE before closure of colostomies performed for colorectal injuries, we reviewed our experience with 84 trauma patients who underwent BE before colostomy closure. Patients who had their colonic injuries repaired or diverted during the initial procedure did not benefit from the precolostomy closure contrast study. In this group of patients artifacts on BE had to be ruled out by endoscopy or repeat radiography in 9.5% of patients. Barium enema was found beneficial in evaluating colorectal injuries below the peritoneal reflection in one out of 20 patients. However, since the rectal injuries are not usually explored and repaired during the initial procedure, investigation by endoscopy and contrast studies may still be indicated preceding colostomy closure.

Adolescent↗
PubMed1988

Changes in extravascular lung water and fatty acids in a hyperdynamic canine model of sepsis.

Several mediators, including fatty acids, have been postulated to induce the increase in permeability of the pulmonary endothelium and subsequent accumulation of extravascular lung water (EVLW) which are generally considered to be among the first events in the development of adult respiratory distress syndrome. In a canine model of hyperdynamic sepsis (hemodynamically similar to human sepsis) changes in EVLW and in concentrations of different fatty acids in the aortic and pulmonary arterial blood were measured. Two days after induction of sepsis, EVLW increased from 6.6 +/- 0.6 to 9.2 +/- 1.0 ml/kg, and the pulmonary arterial concentration of oleic acid increased from 52 +/- 4 to 73 +/- 5 mg/dl. Three days after induction of sepsis, EVLW increased further to 14.4 +/- 3.8 ml/kg and the mean concentration of oleic acid increased to 74 +/- 7 mg/dl. Twenty-four hours later, both EVLW and the mean pulmonary arterial concentration of oleic acid were not different from basal. We postulate that oleic acid, a known inducer of experimental ARDS, is one of the mediators of endothelial damage of the lung during sepsis.

Animals↗
PubMed1988

Release of vasoactive intestinal peptide during hyperdynamic sepsis in dogs.

Vasoactive intestinal peptide (VIP) is a potent vasodilator that has been reported to be a mediator of the hemodynamic changes in endotoxin-induced hypodynamic septic shock. We investigated the release of VIP in a hyperdynamic model of sepsis in awake, conscious dogs similar to that of sepsis in human beings. Sepsis was induced by intraperitoneal implantation of a fibrin clot containing live Escherichia coli (0.9 +/- 0.2 X 10(9) organisms per kilogram of body weight). All dogs developed hyperdynamic sepsis with increased cardiac output and decreased systemic vascular resistance. During the first 24 hours of sepsis, VIP was released without a concomitant decrease in blood pressure, suggesting that during septic shock it was released by a direct mechanism rather than as a result of hypotension. During peak VIP release (2 to 4 hours after induction of sepsis) no decreases in systemic vascular resistance or mean arterial pressure were observed. This suggests that mediators other than VIP may be responsible for the vasodilation observed during sepsis. The precise role of VIP during sepsis is therefore yet to be clarified.

Animals↗
PubMed1988

A technique for controlling injuries of the iliac vein in the patient with trauma.

This has become our preferred way to control deep pelvic hypogastric vein injuries and we have found it to be particularly useful in the patient with multiple nonvascular injuries. It is rapid, entails little ongoing blood and allows for direct exposure of the injury. It minimizes the chances of creating additional iatrogenic injuries from blind clamping or dissection. Thus, this technique should not be used routinely but should be reserved for situations when attempts to obtain proximal and distal control are unsuccessful.

Hemostatic Techniques↗
PubMed1988

Central venous blood oxygen saturation: an early, accurate measurement of volume during hemorrhage.

Accurate and relatively simple monitoring is essential in managing patients with multiple injuries, and becomes particularly important when there is substantial occult blood loss. Tachycardia, said to occur following a 15% blood loss, is generally regarded as the first reliable sign of hemorrhage. However, heart rate is a nonspecific parameter which is affected by factors other than changing intravascular volume. The purpose of this study was to evaluate available means of monitoring volume status and to identify the parameter which is the earliest and most reliable indication of blood loss. Sixteen mongrel dogs were anesthetized and bled by increments of 3% of their total blood volume until the onset of sustained hypotension or a 25% blood loss. All dogs were monitored with a Swan-Ganz catheter and an arterial line. Vital signs, full hemodynamic parameters, and arterial and mixed venous blood gases were measured after each 3% blood loss. Statistical analysis of the data demonstrated that only Cardiac Index and Mixed Venous Oxygen Saturation showed linearity as function of measure blood loss. Linear regression analysis generated r values that ranged from 0.85-0.99 with a mean of 0.95 for Mixed Venous Oxygen Saturation; r values for Cardiac Index ranged from 0.39-0.98 with a mean of 0.85. Furthermore, all dogs had increased tissue oxygen extraction after 3-6% blood loss. Because Central Venous Blood Oxygen Saturation mirrors Mixed Venous Oxygen Saturation and is easily and rapidly measured, we extended our study by repeating all of the previously measured parameters, with the addition of CVP blood gases in an unanesthetized animal model.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗
PubMed1988

Injuries missed at operation: nemesis of the trauma surgeon.

Injuries missed at initial operation have the potential to cause the most disastrous complications in trauma patients. Over the past 5 years, 12 patients have required re-operation for 14 injuries missed at initial laparotomy and/or thoracotomy. Six missed injuries were vascular, two each in the thorax, pelvis, and retroperitoneum. The other eight were visceral: three small bowel (one patient), two pancreatic, and one each of the heart, ureter, and diaphragm. Five patients (42%) died, three with missed vascular and two with missed visceral injuries. Three died due to complications directly related to their missed injuries, while the unrecognized injury did not play a significant role in the other two. Indications for re-operation in patients with vascular injuries were hypotension in two patients, persistent output from drains in three, and refractory acidosis in one. Re-exploration in visceral injuries was for clinical sepsis in three patients, DIC in one, cardiac tamponade in one, and persistent chest tube drainage in one. Eleven of the 12 patients presented to the E.D. in shock. All patients had multiple injuries with a mean of 3.25 organ systems injured. Hypotension, coagulopathy, and/or hypothermia (T less than 92 degrees) were felt to have contributed to missing the injury in five of the patients with vascular, and three of the patients with visceral injuries. In the four other patients, injuries were missed due to inadequate exploration or a low index of suspicion in the presence of multiple injuries.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1987

Intussusception following abdominal trauma.

We reviewed the charts of 21 patients on the Trauma Service who were operated on for intestinal obstruction for the years 1983 through 1985. Six (28.6%) of the 21 patients had intussusception as the cause of their obstruction post-laparotomy for trauma. All were males ages 17 to 25 years. The mechanisms of injury were gunshot wounds in three, stab wounds in two, and blunt trauma in one. Five patients were hypotensive on admission with systolic BP less than 70, and two patients received uncrossmatched blood preoperatively. Injuries at exploration included liver laceration (six patients), gastric perforation (two patients), and diaphragmatic lacerations, splenic laceration, renal injury, and ventricular injury, one each. No patient suffered small intestinal injuries and we cannot explain the occurrence of intussusception. Intussusception occurred in the first 8 postoperative days in four patients and at 21 days, and 10 months, in the remaining two. The diagnosis was made twice by CT scan preoperatively. Jejunojejunal intussusception was common (five patients), jejunoileal in one and ileocolic in one (who also had a jejunojejunal intussusception). All patients were treated with manual reduction alone and none recurred. There were no postoperative complications and all patients were discharged by the eighth postoperative day. Our study suggests that early postoperative obstruction is caused by intussusception with unexpected frequency in trauma patients, and can be diagnosed by CT scan in some cases. Treatment with operative reduction has an excellent prognosis.

Abdominal Injuries↗
PubMed1987

Lumbar arterial injury: radiologic diagnosis and management.

Injury of the lumbar arteries is a cause of potentially life-threatening retroperitoneal hemorrhage. Twelve patients who sustained massive hemorrhage of the lumbar arteries associated with lumbar spinal fractures and/or pelvic fractures are described. Computed tomography (CT) was helpful by revealing a distinct separation of the lumbar hemorrhage from the hematomas associated with pelvic fracture. On arteriograms, stasis within lumbar extravasation was manifested as globular or streaky accumulations of contrast medium, pseudoaneurysms or diffuse "staining," or opacification of a fracture site. Multiple lumbar bleeding sites were seen frequently. Embolization with pledgets of absorbable gelatin sterile sponge controlled bleeding in ten patients. Abdominal aortography should be an essential part of the arteriographic evaluation of retroperitoneal hematomas associated with pelvic fractures, especially when there are lumbar fractures. Selective lumbar arteriography should be performed for confirmation when there is suspicion of lumbar artery injury on the basis of aortographic findings. Embolization with pledgets of surgical gelatin is effective in controlling hemorrhage from these injuries.

Accidental Falls↗
PubMed1985

Factors encouraging laparotomy in acalculous cholecystitis.

Because it is difficult to diagnose, acalculous cholecystitis in critically ill patients is treated frequently in an advanced stage. Three of 1600 cardiac surgery ICU admission cases and five of 500 general surgical ICU admission cases were analyzed retrospectively to determine which variables expedited diagnosis and might have encouraged earlier surgery. Vague right upper quadrant physical findings and nonspecific changes in liver function chemistries led frequently to radiologic evaluations. Noninvasive diagnostic procedures such as ultrasound and hepatobiliary scans were helpful but frequently inconclusive. Of the eight patients, the five survivors were diagnosed while still in the hyperdynamic hemodynamic state of early sepsis. Cholecystostomy performed early under local anesthesia was the safest procedure in this group of critically ill patients. After other sources of sepsis such as suppurative phlebitis, yeast septicemia, catheter sepsis, and other extra-abdominal sources such as soft-tissue, urinary, and pulmonary infections have been ruled out, hemodynamic data obtained from pulmonary artery catheters inserted during the early phase of sepsis increase diagnostic accuracy and should expedite surgical exploration.

Bacterial Infections↗
PubMed1985

The metabolic cost of breathing in critical surgical patients.

Twenty ventilator-dependent patients, 14 male and six female, age 47.9 +/- 14, status post polytrauma (14), emergency surgery (three), and coronary artery bypass (three) were evaluated to compare measured energy expenditure (MEE) between the intermittent mandatory ventilation mode (IMV) and assist mode ventilation (AMV) utilizing indirect calorimetry. The MEE was then compared to the predicted basal energy expenditure (PEE) utilizing the Harris-Benedict equation (HBE) and appropriate correction factors dependent on disease and injury status (mean 1.65 +/- 0.24). The mean oxygen consumption (VO2) (IMV) was 347.5 +/- 54.6 ml/min; (VO2) (AMV) was 307.1 +/- 51.4 ml/min (p less than 0.001). The mean MEE (IMV) was 2,380 +/- 369 kcal/day; MEE (AMV) was 2,128 +/- 342 kcal/day (p less than 0.05). The mean predicted energy expenditure (PEE) was 2,731 +/- 416 kcal/day. The IMV mode required 11.6% more pulmonary work when compared to AMV (VO2 IMV - VO2 AMV). The PEE overestimated caloric needs in ventilator-dependent patients by 12.8% on IMV and 22.1% on AMV. The MEE (IMV) required 10.7% more energy than MEE (AMV). Assist mode ventilation resulted in decreased work of breathing and decreased energy expenditure, and the (HBE) inaccurately predicted caloric needs in ventilator dependent patients.

Adult↗
PubMedDate not supplied

Transverse bayonet dislocation of the distal interphalangeal joint--a case report.

Transverse bayonet dislocation of an interphalangeal joint is an unstable injury caused by the disruption of both collateral ligaments. This injury pattern in proximal interphalangeal joint was first described by Patel et al. (Clin Orthop Rel Res. 1978;133:219), who coined the term "bayonet dislocation" to describe this particular type of injury. The case of a distal interphalangeal transverse dislocation is presented. This dislocation was successfully treated by closed reduction and immobilization with an aluminum splint and buddy taping to the adjacent finger.

Adult↗
PubMedDate not supplied

Emergency department repair of hand lacerations using absorbable vicryl sutures.

The use of absorbable suture material has a number of potential advantages when compared to nonabsorbable suture. We conducted a 5-year retrospective study of 102 patients with hand lacerations and compared the quality of scar formation and healing in these patients. Those patients who did not have tendon, nerve, or bone injury were included in the study. Lacerations were repaired with either 5-0 Vicryl or nylon. There were no reported complications or infections in any study group patient. The quality of scar, when compared visually and by palpation, was the same at the end of 6 months. In addition, there was no difference in the incidence of scar retraction. We conclude that the use of absorbable suture material is an acceptable alternative in the repair of hand lacerations.

Biocompatible Materials↗
PubMedDate not supplied

Interventional radiology in the treatment of internal carotid artery gunshot wounds.

PURPOSE: To review the indications for and techniques and results of interventional radiology in the management of internal carotid artery gunshot wounds. PATIENTS AND METHODS: The demographics, clinical presentations, angiographic findings, methods of treatment, and outcomes were reviewed in 20 patients who underwent 21 interventional procedures. RESULTS: Seventeen coil embolizations were successful in controlling hemorrhage. One intimal flap was compressed with balloon angioplasty, with subsequent nonoperative healing. Temporary balloon occlusions were used as a method of preoperative assessment of intracranial collateral circulation or of preoperative vascular control in three patients. There were no complications. The mortality rate was 20%. CONCLUSION: Penetration of the internal carotid artery is a very severe injury with a high mortality rate due to neurologic sequelae. Interventional radiology plays an important role in the management of these wounds, and it often obviates surgical exploration.

Adolescent↗