The American surgeon
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Missed injuries in trauma continue to be a nemesis to the trauma surgeon. Missed injuries in adult trauma patients range in frequency from 9 to 28 per cent, with some being life threatening or permanently disabling. ⋯ These missed injuries, however, were neither life threatening nor permanently disabling. We also found that mechanism of injury and patient age affected the incidence of missed injuries in our population.
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The American surgeon · Nov 1999
High-frequency oscillatory ventilation can be effective as rescue therapy for refractory acute lung dysfunction.
High-frequency oscillatory ventilation (HFOV) is a technique with limited use in adult patients. The main purpose of this pilot study was to evaluate HFOV on adult trauma patients with refractory lung dysfunction. Refractory lung dysfunction was defined as a PaO2:FiO2 ratio <75 for 1 hour despite maximum support via conventional mechanical ventilation (CMV). ⋯ The mean peak pressure was 52.4 +3.0 cm H2O at time zero and was 35.8+/-3.01 after termination of HFOV. Survival was 80.0 per cent (four of five patients). In conclusion, all patients improved after initiation of HFOV, and HFOV should be considered in the treatment of patients with acute refractory lung dysfunction.
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The American surgeon · Nov 1999
Pressure control inverse ratio ventilation in the treatment of adult respiratory distress syndrome in patients with blunt chest trauma.
The objective of this study was to evaluate the efficacy of pressure control inverse ratio ventilation (PCIRV) in improving oxygenation in trauma patients with adult respiratory distress syndrome (ARDS) and to assess the potential risks associated with this form of treatment. This was a cohort study assessing the trends in hemodynamic and ventilatory parameters after the initiation of PCIRV, conducted at a community Level I trauma center intensive care unit. The study comprised 15 trauma patients developing severe, progressive ARDS [two or more of the following criteria: positive end-expiratory pressure (PEEP) >10 cm H2O; arterial partial pressure of oxygen divided by fraction of inspired oxygen (PaO2:FiO2) ratio <150; and peak inspiratory pressure (PIP) >45 cm H2O]: ten due to blunt chest injuries, three due to sepsis, and two due to fat emboli syndrome. ⋯ Within 24 hours of conversion to PCIRV, the patients stabilized and the mean PaO2:FiO2 ratio rose from 96.3+/-57.8 to 146.8+/-91.1 (P<0.05) and PIP fell from 47.9+/-13.8 to 38.8+/-8.4 cm H2O; auto-PEEP increased from 0.5+/-1.9 to 7.5+/-5.6 cm H2O (P<0.05); oxygen delivery index remained stable (563+/-152 to 497+/-175 mL/min/m2); three patients developed evidence of barotrauma, one patient developed critical illness polyneuropathy, and two patients died (13%). PCIRV is an effective salvage mode of ventilation in patients with severe ARDS, but it is not without complications. Auto-PEEP levels and cardiac index should be monitored to ensure tissue oxygen delivery is maintained.
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The American surgeon · Nov 1999
Managing intractable pain with an intrathecal catheter and injection port: technique and guidelines.
The objective of our study was to describe an effective technique for the management of chronic intractable pain in patients with intermediate life expectancy or as a long-term screening device prior to implantable pump therapy. In the study, an InDura intraspinal catheter is connected to a BardPort, which is accessed transdermally. We describe our surgical technique, recommended dosage calculations, cost comparison to an implantable infusion pump, and our experience with 13 cases. ⋯ One case was converted to an implantable pump. There were no malfunctions or infections of the intrathecal infusion system in the 12 cancer patients. This intrathecal drug infusion system should be considered in the treatment armamentarium for chronic intractable pain and cancer pain.
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Scrotal and perineal gangrene of the male genitalia was first described by Fournier in 1883. Treatment of the disease remains surgical despite the availability of modern antibiotics. Many authors advocate a wide debridement of all tissue superficial to the involved fascial layers. ⋯ The mean hospital stay of this group was 62+/-12 days. The specific flora included: Bacteroidis fragilis in 87 per cent, Peptostreptococcus and Streptococcus in 75 per cent, Clostridia group, Escherichia coli, Enterobacter and Pseudomonas in 62 per cent, Klebsiella in 50 per cent, Staphylococcus in 37 per cent, and Proteus in 12 per cent of the patients. In the surgical management of Fournier's gangrene, wide drainage with minimal debridement resulted in similar morbidity and shorter hospital stay when compared with extensive debridement.