American journal of surgery
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A major problem for patients who survive a traumatic injury is morbidity due to infectious complications; this risk increases when there is injury to the liver, pancreas, or colon, the abdominal trauma index is > 25, and/or surgery is prolonged. For major injuries of either the liver or pancreas, the use of closed suction drainage decreases the risk of infection; sump drainage should be avoided. ⋯ A brief course of appropriate antibiotic treatment should be initiated as soon as possible after wounding and should be continued for 24 hours. Prolonged courses of antibiotic provide no added benefits.
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Among the 1,484 patients included in the Renal Trauma Project with evidence of blunt trauma and hematuria, 160 patients were found to have both hematuria and a significant intra-abdominal injury not related to the genitourinary system. The incidence of abdominal injury generally increased with the degree of hematuria, approaching 24% in patients with gross hematuria. ⋯ The incidence of abdominal injury in patients with microscopic hematuria and shock was 29%, and it was 65% for patients with both gross hematuria and shock. All patients with gross hematuria after blunt abdominal trauma and all patients with microscopic hematuria and a history of shock should be evaluated for both urologic and extra-renal abdominal injuries.
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Sixty-three consecutive patients with blunt hepatic trauma were examined. Twenty-four patients underwent immediate operation, and 39 patients were evaluated by computed tomography (CT), of whom 17 underwent operation. Ten patients had no hepatic abnormalities on CT and had operations for associated injuries. ⋯ CT may underestimate the degree of liver injury. Nonoperative management is appropriate in stable patients with grade I to III injuries and a small to moderate hemoperitoneum. These patients should require no more than 2 U of blood, and repeat scans should demonstrate a stable injury.
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Febrile intensive care unit (ICU) patients were evaluated prospectively for sinusitis. Of 598 admissions, 26 patients with transnasal cannulas, ICU stays over 48 hours, and occult fevers were identified. These 26 underwent physical examinations and sinus computed tomographic (CT) scans. ⋯ Most patients respond to nonoperative management. Remote infections are often present. Although radiographic nosocomial ICU sinusitis is common, it is seldom the sole source of fever or the proximate cause of significant morbidity.
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The lower extremity complications of 100 consecutive patients who required the placement of an intra-aortic balloon pump (IABP) during a 3-year period were studied. Indications for the IABP included hypotension during cardiac catheterization (33%) or coronary angioplasty (13%), hemodynamic instability after open heart surgery (35%), unstable angina (5%), and cardiac arrest (14%). The incidence of IABP morbidity was 29%. ⋯ Limb ischemia was treated nonoperatively by removal of the IABP in five patients. Color-flow duplex scans were useful in distinguishing hematomas from pseudoaneurysms as well as for assessing femoral artery flow. We conclude that: (1) limb ischemia remains the primary complication of the IABP; (2) pre-insertion documentation of the severity of existing peripheral arterial disease by noninvasive studies may aid in the management of subsequent acute limb ischemia; (3) femoral artery thrombectomy or endarterectomy is usually sufficient for revascularization; and (4) noninvasive color flow studies are an important diagnostic tool in the nonoperative management of limb complications.