The American surgeon
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No dependable test exists for diagnosis of diaphragmatic injury in asymptomatic patients with thoraco-abdominal stab wounds. Forty-one consecutive patients with anterior stab wounds of the lower left chest were treated in a 30-month period. In the 21 patients seen during the first 15 months, operations were reserved for those with peritoneal signs or continuing blood loss. ⋯ The true incidence of occult diaphragm injuries may be underestimated. In the prospectively studied group, the policy of routine celiotomy for anterior stab wounds of the lower left chest resulted in recognition and repair of a fivefold greater number of isolated diaphragm injuries. In the absence of a reliable, noninvasive test to diagnose penetration of the diaphragm, celiotomy should be considered in light of the risks of late strangulation.
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The American surgeon · Apr 1992
Vascular complications following intra-aortic balloon pump insertion.
The intra-aortic balloon pump (IABP) has been used for 23 years to treat cardiogenic shock from various causes. A retrospective review was conducted to evaluate the morbidity, mortality, and risk factors associated with insertion of this device. Over a recent 3-year period, 415 such pumps were inserted either by percutaneous (323) or cut-down (92) technique in 404 patients. ⋯ In patients with known peripheral vascular disease, the risk of a vascular complication was 17.9 per cent when a surgical cut-down technique was used to insert the IABP, and 38.9 per cent when a percutaneous insertion was performed. The mortality doubled in those patients who had a vascular complication as compared to those who did not (34% vs 17%). A more liberal use of an open surgical technique in those patients with peripheral vascular disease, obesity, and who are women may help to reduce complications after the insertion of the intra-aortic balloon pump.
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Significant external forces are required to fracture a normal pelvis. These forces usually result from rapid deceleration or crushing injuries, and energy often is delivered to multiple anatomic sites in addition to the pelvis. Associated injuries are common, and numerous complications can occur in patients with pelvic fractures. ⋯ Patients with complications had higher Injury Severity Scores, lower Trauma Scores, increased transfusion requirements, longer hospital stays, and greater hospital charges compared to those without complications (P less than 0.01 for all variables). There was no association of complications with patient age, sex, mechanism of injury, anatomic site or amount of displacement of the pelvic fracture, or vector of injury. Patients with unstable pelvic fractures were much more likely to have complications than were those with stable pelvic fractures (P = 0.013).(ABSTRACT TRUNCATED AT 250 WORDS)
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The American surgeon · Mar 1992
Case ReportsSurviving gastrointestinal infarction due to polyarteritis nodosa: a rare event.
Poly arteritis nodosa (PAN) is a systemic vasculitis with a male: female ratio of 2:1 and a peak incidence in the fifth decade. Small to medium-sized arteries are involved by focal transmural inflammatory necrosis. Aneurysms with inflammatory destruction of the media also occur. ⋯ She was treated with high-dose cyclophosphamide and steroids for 6 months and has continued on low-dose cyclophosphamide. She is now 36 months from her original operation and is doing well on oral nutrition. Intestinal hemorrhage from aneurysm rupture or gangrene with perforation are gastrointestinal complications of PAN that the surgeon may be called upon to treat.(ABSTRACT TRUNCATED AT 250 WORDS)
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The American surgeon · Feb 1992
Randomized Controlled Trial Clinical TrialIs hemoglobin level alone a reliable predictor of outcome in the severely anemic surgical patient?
The relationship between outcome and hemoglobin (Hgb), oxygen extraction ratio (ER), history of cardiac, renal, pulmonary, and/or hepatic disease, diabetes, malignancy, sepsis, hypertension, and active bleeding was analyzed in 47 patients with severe anemia (Hgb less than 7.0 gm/dl, mean = 4.6 +/- .2 gm/dl) to evaluate the effect of Hgb on survival and to look for other predictors of outcome. All patients had refused blood transfusion on religious grounds and were participants in a randomized, controlled study of the blood substitute Fluosol DA-20 per cent. Patients were analyzed as a group and after stratifying by Hgb into four levels: (Hgb less than 3.0 gm/dl, N = 7; Hgb less than 3.5 gm/dl, N = 12; Hgb less than 4.0 gm/dl, N = 17; Hgb less than 4.5 gm/dl, N = 23) and by ER into two levels of less than 50 per cent and greater than 50 per cent. ⋯ Extraction ratio interacted with Hgb only below 3 gm/dl (P less than .05). Multiple independent factors influence outcome in the severely anemic patient, the strongest being sepsis and active bleeding. Prevention of sepsis and early intervention to stop bleeding should improve survival in the patient who refuses transfusion.