The American surgeon
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The American surgeon · Aug 1999
Comparative StudyEarly versus delayed repair of facial fractures in the multiply injured patient.
The management of facial fractures in the polytrauma patient requires the coordination of multiple surgical disciplines to optimize the functional and cosmetic outcome while minimizing overall morbidity and mortality. Although the plastic surgery literature historically advocates the early repair of facial fractures, the risk of general anesthesia in patients with associated injuries sometimes makes early repair unsafe. We compared early operative repair versus delayed operative repair of facial fractures in multitrauma patients. ⋯ Our results indicate that in a similar cohort of multitrauma patients, delayed repair did not increase length of ICU stay or hospital stay. The wound infection rate was negligible, and the complication rate was similar in the two groups. We conclude that a delay in repair of facial fractures in the critically ill patient has an acceptably low complication rate and may be advantageous in decreasing operative risk and minimizing cost by coordinating multiple procedures with various surgical subspecialties.
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The American surgeon · Aug 1999
Serial pHi measurement as a predictor of mortality, organ failure, and hospital stay in surgical patients.
Intestinal ischemia is a common condition in critically ill patients and has been postulated to play a role in the development of organ failure and death. This has resulted in the recent interest in monitoring gastric intramucosal pH (pHi) in critically ill patients to provide earlier evidence of inadequate resuscitation, cardiogenic dysfunction, or sepsis. Several reports have indicated that low pHi values obtained during the initial 24 to 48 hours of intensive care unit (ICU) admission were associated with the development of organ failure and death. ⋯ A retrospective analysis of critically ill trauma, burn, and surgical patients who had frequent pHi determinations during ICU treatment was performed. When stratified by pHi values, there were no significant differences in length of stay, organ dysfunction, or mortality. Our findings suggest that serial pHi determinations obtained beyond the early critical care period are less reliable predictors of poor outcome.
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The American surgeon · Aug 1999
The utility of physical examination in proximity penetrating extremity trauma.
This study assessed the efficacy of physical examination as a screening modality for the diagnosis of surgically significant arterial injury in proximity penetrating extremity trauma (PPET). All cases of PPET were assessed and admitted per established protocol over a 30-month period from January 1, 1993, to June 30, 1995. No patients were excluded if other body regions were also injured. ⋯ The overall sensitivity and specificity for physical examination was 92 per cent and 95 per cent, respectively, for surgically significant injury. Physical examination is a highly sensitive and specific screening modality for the identification of surgically significant arterial injury in PPET. Patients who present with diminished, but appreciable, pulses by physical examination or doppler, large nonexpanding hematomas as the only sign, bilateral pulse deficits and nonappreciable pulses with unreconstructable trajectory benefit from further investigation with angiography.
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Our objective was to evaluate whether physical examination in conjunction with chest X-ray can accurately diagnose the presence of significant vascular injury in penetrating periclavicular trauma. Results from a management protocol for penetrating periclavicular trauma were reviewed for the period January 1992 through December 1996 at an urban Level I trauma center. All patients requiring angiography for periclavicular penetrating trauma with trajectory of the injury falling between the lateral border of the manubrium and the anterior axillary line were entered into the management protocol. ⋯ The missed injury was a pseudoaneurysm of an axillary artery secondary to a self-inflicted shotgun wound. One mortality occurred in this series, which was a death in the operating room secondary to blood loss from an axillary artery injury. We conclude that clinical assessment can adequately diagnose the presence of surgically significant vascular injury in periclavicular penetrating injuries with trajectories lateral to the manubrium.