The American surgeon
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The American surgeon · Nov 2010
Role of early thoracoscopy for management of penetrating wounds of the chest.
Most nonlife-threatening penetrating wounds of the chest (PWC) are treated with a chest tube alone. This may be inadequate because missed injuries, retained hemothorax, or foreign material may be difficult to address later. Early thoracoscopy should improve outcome. ⋯ The outcome was compared with the National Trauma Data Bank and controlled for Injury Severity Score. Early VATS reduced length of stay (4.3 vs 9.4 days), days in the intensive care unit (1.3 vs 3.2), and open thoracotomy (0 vs 7). A chest tube undertreats a nonlife-threatening PWC correctable by timely VATs.
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The American surgeon · Nov 2010
Case ReportsThe use of extracorporeal membrane oxygenation in severe necrotizing soft tissue infections complicated by septic shock.
Necrotizing soft tissue infections remain a challenging clinical problem. Delays in diagnosis, incomplete débridement of necrotic tissues, and the hemodynamic instability and end-organ failure associated with overwhelming sepsis all contribute to significant mortality. Extracorporeal support is a well-established tool to support profound cardiopulmonary failure. To broaden the indications for use, we present two cases of young adults with necrotizing soft tissue infections who sustained sepsis-induced hemodynamic collapse and required extracorporeal support to facilitate adequate tissue débridement as a bridge to recovery.
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The American surgeon · Oct 2010
Defining hypotension in moderate to severely injured trauma patients: raising the bar for the elderly.
Hypotension, defined as systolic blood pressure less than 90 mm Hg, is recognized as a sign of hemorrhagic shock and is a validated prognostic indicator. The definition of hypotension, particularly in the elderly population, deserves attention. We hypothesized that the systolic blood pressure associated with increased mortality resulting from hemorrhagic shock increases with increasing age. ⋯ The optimal definition of hypotension was systolic blood pressure of 100 mm Hg for patients 20 to 49 years, 120 mm Hg for patients 50 to 69 years, and 140 mm Hg for patients 70 years and older. The optimal systolic blood pressure for improved mortality in hemorrhagic shock increases significantly with increasing age. Elderly trauma patients without major head injuries should be considered hypotensive for systolic blood pressure less than 140 mm Hg.
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Blood cultures are often obtained in postoperative patients to rule out bloodstream infections. Our study objectives were to determine the efficacy of blood cultures in postoperative patients with suspected sepsis and to determine variables predisposing patients to positive cultures. This was a retrospective study including patients with blood cultures drawn from January to March 2009 at our institution. ⋯ There was no statistical difference (P > 0.05) between patients with positive and negative cultures except that those with negative cultures were more likely to have received preoperative antibiotics (P = 0.0186). Blood cultures are invasive, expensive tests with low yield. We recommend that blood cultures be drawn in patients not receiving preoperative antibiotics who have undergone surgery more than 4 days before culture.
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The American surgeon · Oct 2010
The clinical significance of occult thoracic injury in blunt trauma patients.
Increased use of thoracic CT (TCT) in diagnosis of blunt traumatic injury has identified many injuries previously undetected on screening chest x-ray (CXR), termed "occult injury". The optimal management of occult rib fractures, pneumothoraces (PTX), hemothoraces (HTX), and pulmonary contusions is uncertain. Our objective was to determine the current management and clinical outcome of these occult blunt thoracic injuries. ⋯ Occult and no injury patients had similar ventilator needs and mortality, but occult injury patients remained hospitalized longer. No patient with isolated occult thoracic injury required intubation or tube thoracostomy. Occult injuries, diagnosed by TCT only, have minimal clinical consequences but attract increased hospital resources.