J Trauma
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The results of emergency room thoracotomy (ERT) and cardiorrhaphy for 91 patients with penetrating cardiac injuries admitted in extremis to Lincoln Medical and Mental Health Center from 1963 to 1981 are reviewed to determine criteria for selection of patients for this procedure. Four groups were defined based on the severity of the effects of their injuries. The survival rates were 32.1 and 33.3%, respectively, for Group I ('fatal') and Group II ('agonal') patients. ⋯ A.') patients for whom ERT is a fruitless procedure. Survival in Group III ('profound shock') patients was only 40%, which might have been improved if ERT had been performed without delay. We conclude that ERT is essential for patients with 'fatal' and 'agonal' wounds and advise prompt ERT for patients in 'profound shock' who do not respond immediately to rapid volume infusion.
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Two surviving patients with traumatic hemipelvectomy are presented. Rapid transport, aggressive initial resuscitation, and attention to detail in the rehabilitation phase are necessary for the successful management of these patients. ⋯ There is need to include this entity in the existing classifications of pelvic fractures. Hemipelvectomy is proposed as an alternative in the management of the severe unilateral open pelvic fracture with uncontrollable bleeding.
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Fourteen thermally injured patients with severe inhalation injury were sequentially studied with the thermal-green dye double indicator dilution technique of extravascular lung water (EVLW) measurement. Eight females and six males (average age, 49 years, and average thermal burn, 37% body surface) were studied for 2-31 days postinjury. All were burned in a closed space, had facial burns, soot in their sputum, and a mean carboxyhemoglobin level of 30%. ⋯ The remaining four cases of permeability edema occurred 4-24 days postinjury and resulted from burn wound or pulmonary sepsis. We thus conclude that increases in EVLW after thermal and inhalational injury are primarily caused by systemic or pulmonary sepsis, and have a delayed onset. Early increases in EVLW may be a result of the chemical toxicity of inhaled gases but are very uncommon, moderate in degree, and are seen only with the severest cases of inhalation injury.
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In the past, myocardial contusions after blunt thoracic trauma have been frequently overlooked or missed unless hemodynamic instability or dramatic electrocardiographic findings were observed. We now know that this entity is more common than once believed. ⋯ Chest roentgenograms, electrocardiograms, and radionuclide imaging have had less than optimal success. We believe that the serial determination of creatine phosphokinase-myocardial band isoenzymes and subsequent two-dimensional echocardiographic sector scanning are the most sensitive indicators of structural and functional cardiac injury presently available.