The American surgeon
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The American surgeon · Jun 1997
Complications of epidural infusions for analgesia in postoperative and trauma patients.
Few studies compare complications of continuous and bolus epidural analgesia. Ninety-eight postoperative and trauma patients receiving epidural infusions over 15 months were retrospectively studied. Continuous epidural analgesia was used for pain management in 60 patients (61%). ⋯ Patients undergoing abdominal surgery had an increased incidence of complications compared with other patients (P < 0.05). Epidural catheters are safe and effective for pain management, but they are not without risk. Hemodynamic stability and pulmonary status should be considered when evaluating patients.
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The spleen is the most commonly injured organ in blunt abdominal trauma. There remains much controversy in the diagnosis and management of the injured spleen, with a recent trend toward nonoperative management. A 5-year period was reviewed at a rural, Level I trauma center to address issues of operative versus nonoperative management. ⋯ Of those initially observed, 10 patients (16%) eventually were operated on. Most of the cases were due to underestimation of the severity of the splenic injury, and most received blood transfusion. This experience suggests that observation for splenic trauma is appropriate in many cases, as long as the surgeon is certain the spleen is not actively bleeding and the patient will not require blood transfusion.
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The American surgeon · Apr 1997
The role of "one-shot" intravenous pyelogram in evaluation of penetrating abdominal trauma.
The role of limited "one-shot" intravenous pyelogram (IVP) in patients sustaining proximity penetrating trauma is not well defined, although formal IVP remains the "gold standard" for evaluating possible urological injuries. This retrospective review evaluates the efficacy and usefulness of limited one-shot IVP in penetrating abdominal trauma patients who are suspected of having urological injuries. The charts of 40 patients with penetrating abdominal trauma who had one-shot IVP performed in the emergency room at presentation were reviewed. ⋯ Eighty per cent of patients with normal one-shot IVP findings had renal injuries not detected by one-shot IVP, and 20 per cent of patients with abnormal IVP findings had no intraoperative evidence of renal injury. The presence of gross hematuria appeared to correlate with the presence of significant urological injuries. We therefore conclude that limited one-shot IVP is of no significant value in assessing penetrating abdominal trauma patients who subsequently undergo exploratory laparotomy for other associated intra-abdominal injuries, and indeed, the delay imposed, before definitive operative intervention in potentially unstable patients, is unjustified.
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The American surgeon · Apr 1997
Case ReportsUnwillingness to lie supine? a sign of pericardial tamponade.
The stable patient with an occult cardiac injury can represent a diagnostic dilemma. The trauma surgeon must maintain a high index of suspicion for cardiac injury with precordial penetrating trauma. Herein are reported two cases of stable patients with penetrating precordial trauma who refused to lie supine because of difficulty breathing, preferring to sit upright, who eventually had positive pericardial windows and sternotomies for repair of cardiac injuries. The presence of this clinical finding, unwillingness to lie supine, should make the trauma surgeon highly suspicious of a cardiac injury and to proceed quickly to echocardiography or, preferably, to subxiphoid pericardial window to rule out cardiac injury.
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The effectiveness and safety of cricothyroidotomy was reviewed at our institution and in the literature. The literature review yielded nine reports on emergent cricothyroidotomy. Out of 320 patients, there were 308 successful airways and 99 survivors. ⋯ Acute complications were: misplacement or failure to obtain an airway (seven), no airway (three), chest tube required (two), and bleeding (one). In the 27 survivors long-term complications were: failure to decannulate (two), and vocal cord paralysis, granulation tissue and hoarseness, one case each. We conclude that emergent cricothyroidotomy is effective in establishing airways in emergency situations, although the survival rate is better if the patient is not in cardiac arrest (49 vs 31% in literature and 41 vs 76% in our study).