Canadian journal of surgery. Journal canadien de chirurgie
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Accelerated coronary atherosclerosis (ACA) has been documented at autopsy and was noted at coronary angiography in seven patients, 11 to 48 months after cardiac transplantation. To delineate the importance of this problem, the risk factors and the therapeutic approaches in 7 patients who had ACA after heart transplantation were compared with those in 28 patients free of ACA at annual coronary angiography. Ischemic cardiomyopathy was the preoperative diagnosis in all but one patient in the ACA group. ⋯ Stepwise discriminant analysis showed that older donors and higher pretransplant triglyceride levels were independently related to the development of ACA after cardiac transplantation. In conclusion ACA remains an important cause of late death after heart transplantation. Although therapeutic measures are limited, prevention should focus on strict control of serum lipid levels after transplantation.
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Post-traumatic compartment syndrome in the foot is an unusual but well-recognized entity. If there is an awareness of the condition at the time of presentation it can be diagnosed and treated effectively. A case of compartment syndrome in the foot of a 17-year-old boy after massive lower-extremity trauma is described. The simple and readily available diagnostic techniques are emphasized and an alternative approach to plantar decompression, which avoids exposure of and potential damage to the posterior tibial neurovascular bundle, is presented.
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Selective conservatism is the key to the rational management of pediatric trauma, realizing that children may harbour severe occult injuries. The modern treatment of childhood abdominal trauma best exemplifies this approach: nonoperative management of splenic trauma is now standard for children, and a selective conservative approach is advised in the handling of childhood liver and pancreatic injuries. ⋯ The development of a national database of childhood trauma should provide the basis for action to educate and legislate for prevention. When prevention fails, however, up-to-date quality pediatric trauma care is the key.
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Trauma may be accompanied by hypothermia in all climates. Because of the associated increased death rate due to hypothermia (core body temperature less than 35 degrees C), traumatized patients must be protected from it. ⋯ Decreased core temperature causes generalized physiologic deceleration and homeostatic disturbances in all organ systems. To prevent hypothermia in polytraumatized patients a number of methods may be used: warming crystalloid, increasing ambient temperature, the use of warming devices, irrigation of body cavities with warmed fluids, heating of inspired gases and, in severe cases when there is circulatory instability, the use of extracorporeal membrane oxygenation.
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There are three phases of acute hemorrhagic shock after trauma. In phase I (from injury to operation for control of bleeding) the patient suffers from low cardiac output, tachycardia, reduced organ perfusion, oliguria and decreased capillary hydrostatic pressure, which in turn reduces extravascular fluid loss. Contraction of the interstitial space matrix replenishes plasma volume. ⋯ The albumin causes salt and water retention in the nephron, leading to weight gain, higher central filing pressures and worsening pulmonary function, and a greater need for diuretic and inotropic therapy. Albumin therapy also induces relocation of non-albumin proteins into the interstitial space, leading to impaired immunocompetence and coagulation. Successful resuscitation is facilitated by adaptation to these physiologic responses of hemorrhagic shock rather than manipulation of them.