American journal of surgery
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A review of 83 patients with penetrating neck wounds was performed to assess the relative merits of operation versus observation. Fifty patients (60 percent) underwent immediate surgery, 28 of whom (56 percent) had no significant neck injury. There were no deaths and only two complications (4 percent). ⋯ Length of hospital stay did not differ between patients with negative findings on exploration and those observed. When clinical signs as indications for surgery were present, management was more often correct than when signs were absent (82 and 52 percent, respectively), but the presence or absence of signs correctly predicted injury or lack of injury in over 80 percent of the patients. These data demonstrate the safety and efficacy of selective observation of patients with penetrating neck trauma, and confirm that clinical signs are a reliable indicator of significant injury.
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Case Reports
Noncardiogenic pulmonary edema after cardiopulmonary bypass. An anaphylactic reaction to fresh frozen plasma.
Nine episodes of fulminant noncardiogenic pulmonary edema after cardiopulmonary bypass were observed in eight patients between September 1977 and December 1982. All these catastrophic reactions occurred during administration of fresh frozen plasma 30 minutes to 6 hours after discontinuation of cardiopulmonary bypass. In one patient, two episodes of noncardiogenic pulmonary edema occurred 4 hours apart. ⋯ The last two patients in the series showed a steady and remarkable improvement in cardiac output when the wedge pressure was increased to a level above 15 mm Hg with the administration of normal saline solution. Our data suggest the following: (1) noncardiogenic pulmonary edema after cardiopulmonary bypass is most probably an anaphylactic reaction to fresh frozen plasma. (2) The syndrome is reversible within hours; in only one patient (who suffered noncardiogenic pulmonary edema twice) did adult respiratory distress syndrome develop. (3) The three deaths were not related to hypoxia but to the deleterious effects of low cardiac output associated with hypovolemia secondary to fluid loss through the lungs and possibly across other capillary beds. Therefore, treatment should include restoration of adequate left-sided filling pressures to achieve satisfactory cardiac output.
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A review of the surgical management of 21 patients presenting fractures, dislocations of the knee-joint associated with arterial injury, or both has been presented herein.
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Randomized Controlled Trial Comparative Study Clinical Trial
Diuresis with continuous infusion of furosemide after cardiac surgery.
We prospectively evaluated the diuretic effect of furosemide administered by bolus injection and by continuous infusion in 18 cardiac surgery patients. Nine patients were randomly assigned to receive 0.3 mg/kg of furosemide as a bolus injection at time 0 and again 6 hours later (nine patients) or 0.05 mg/kg per hour of furosemide as a constant infusion for 12 hours (nine patients). ⋯ Diuresis during continuous infusion of furosemide was less variable from hour to hour than after bolus injection of furosemide and was sustained throughout the infusion period. Although the continuous infusion of furosemide will not provide the rapid and vigorous diuresis that is necessary in some clinical situations, it may be useful whenever a gentle, sustained diuresis is desired.
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Tar and asphalt burns are unique injuries because the chemical is difficult to remove without inflicting further tissue injury. Since 1978, 42 patients have been treated for hot tar or asphalt injuries, 30 of whom required hospitalization. Inpatients were all male with a mean age of 27.2 years and a mean burn size of 9.3 percent total body surface area (mean full-thickness injury 5.3 percent total body surface area). ⋯ This solvent proved nonirritating and removed tar much faster than other agents. Early excisional therapy was performed in 63.4 percent of the patients, 80 percent of whom returned to work within 6 weeks of injury. Principles of management include rapid cooling of tar or asphalt to solidify the inciting agent and dissipate heat; removal with a new, non-toxic solvent; early excision and grafting of appropriate injuries; and an aggressive, early back-to-work philosophy.