The American surgeon
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Although percutaneous dilatational tracheostomy (PDT) has been shown to be a cost-effective bedside alternative to open tracheostomy (OT), prior reports of the complications of the procedure are contradictory. Reported complications range from minor events to fatal ones, in varying percentages. This prospective study was designed to identify the type and severity of complications accompanying the introduction of PDT to a tertiary medical center. ⋯ Twenty-three major and minor complications occurred, including two perioperative deaths, in 15 patients (15.8%). A total of 37 PDT patients (38.9%) died in the hospital, indicative of the severity of illness of patients requiring tracheostomy. Based on the experience to date, Cedars-Sinai Medical Center (Los Angeles, CA) continues to require a surgeon privileged to perform OT to participate in all PDT procedures.
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The American surgeon · Sep 1999
Review Case ReportsTraumatic fracture of the hyoid bone: three case presentations of cardiorespiratory compromise secondary to missed diagnosis.
Hyoid bone fractures secondary to blunt trauma other than strangulation are rare (ML Bagnoli et al., J Oral Maxillofac Surg 1988; 46: 326-8), accounting for only 0.002 per cent of all fractures. The world literature reports only 21 cases. Surgical intervention involves airway management, treatment of associated pharyngeal perforations, and management of painful symptomatology. ⋯ With endotracheal intubation prohibited by obstruction, a surgical airway must be established and maintained. Recognition of subtle clinical and physical findings are critical to the diagnosis of laryngotracheal complex injuries and may be life-saving in many instances. To ensure a positive outcome, a strong degree of suspicion based on mechanism of injury is mandated.
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The American surgeon · Sep 1999
Comparative StudyBedside placement of inferior vena cava filters in the intensive care unit.
The objective of this study was to determine the feasibility, cost-effectiveness, and complications of bedside placement of inferior vena cava (IVC) filters in the intensive care unit (ICU) in the trauma patient. A prospective trial involving 25 trauma patients admitted to Memorial Regional Hospital (Hollywood, Florida), a Level I trauma center, from April 1997 to April 1998, meeting the criteria for insertion of a prophylactic IVC filter according to Eastern Association for the Surgery of Trauma trauma practice guidelines was conducted. IVC filters were placed in the ICU with the use of a digital C-arm (Siemens) and strict adherence to sterile technique. ⋯ Average time for insertion was 47 minutes for the series and 20 minutes for the last five cases. Savings of $1844 or $2245 per filter are obtained when IVC filters are placed in the ICU when compared with the operating room or radiology suite, respectively. Bedside placement of IVC filters in the ICU is a safe, cost-effective method that can be performed without compromising the patient and avoids the potential disasters involved in transporting critically ill patients.
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The American surgeon · Sep 1999
Comparative StudyPenetrating cardiac trauma at an urban trauma center: a 22-year perspective.
This is a report of a 22-year experience with penetrating cardiac trauma at a single urban Level I trauma center. We conducted a retrospective chart review supplemented by computerized patient log. Comparisons of mortality between Period 1 (1975-1985; 113 patients) and Period 2 (1986-1996; 79 patients) were by chi2 or Fisher's exact tests. ⋯ The mortality associated with gunshot wounds was increased compared with that of stab wounds. Similarly, mortality for patients who arrested in the emergency center was increased compared with those patients who did not arrest. We conclude: 1) cardiac tamponade is the most common presentation in patients with cardiac wounds; 2) pericardiocentesis in the emergency center has essentially disappeared; 3) surgeon-performed ultrasound of the pericardium should improve survival of future patients who are normotensive or mildly hypotensive; 4) over the last 11 years, there has been a substantial decrease in mortality in patients with stab wounds and a statistically significant decrease in arrested patients; and 5) overall mortality for penetrating cardiac trauma has not changed during the 22-year interval.
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The American surgeon · Sep 1999
Comparative StudyPrognostic factors in patients with inferior vena cava injuries.
Inferior vena cava (IVC) injuries are potentially devastating insults that continue to be associated with high mortality despite advances in prehospital and in-hospital critical care. Between 1987 and 1996, 37 patients (32 males and 5 females; average age, 30 years) were identified from the trauma registry as having sustained IVC trauma. Overall mortality was 51 per cent (n = 19), with 13 intraoperative deaths and five patients dying within the first 48 hours. ⋯ Interestingly, neither time from injury to hospital arrival (47.4 minutes versus 33.0 minutes) nor time in the emergency department before surgery (45.6 minutes versus 42.6 minutes) differed between survivors and fatalities. Mortality remained high in the 34 patients who had operative control of their IVC injuries [lateral repair (n = 27)-44% versus ligation (n = 6)-66% versus Gortex graft (n = 1)-0%]. As wounding agent, anatomical location, associated injuries, and physiological status seem to most directly impact mortality, future efforts must focus both on establishing prevention programs directed at reducing the incidence of this injury, as well as on advancing the management of those who do survive to hospitalization, if we are to improve on the outcome of these devastating injuries.