J Trauma
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Case Reports
Endoscopic retrograde cholangiography in the nonsurgical management of blunt liver injury.
Injury to the intrahepatic bile duct has not been routinely examined in patients with blunt liver injury, despite the risk of formation of a biloma and hemobilia. In this study we examined the role of endoscopic retrograde cholangiography (ERC) in the evaluation of blunt liver injuries. ⋯ Patients with hepatic parenchymal injuries that were observed on the CT scans were at greatest risk for injury to the intrahepatic bile duct, and our data suggested that the incidence of injury to the intrahepatic bile duct after blunt hepatic trauma is higher than previously reported. Patients with serious hepatic parenchymal injuries who are candidates for nonsurgical management should be considered for ERC to exclude the possibility of injury to the bile duct.
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Lateral traumatic dislocation of the radial head occurred in a 9-year-old boy with cubitus varus. Reduction of the dislocation and immobilization of the arm in flexion and supination in a plaster cast for 4 weeks were done and after 6 months the boy returned to school, with no problems in daily living.
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Comparative Study
Prospective comparison of diagnostic peritoneal lavage, computed tomographic scanning, and ultrasonography for the diagnosis of blunt abdominal trauma.
From January through December 1990, a prospective study comparing the accuracy of diagnostic peritoneal lavage (DPL), abdominal computed tomographic (CT) scanning, and abdominal ultrasonographic (US) scanning was carried out. Patients with stable vital signs following their initial resuscitation coupled with equivocal physical examination findings received both CT and US scanning. A DPL was then done. ⋯ Problems do exist in identifying isolated small intestinal perforations with ultrasonography. Since more and more trauma centers are using ultrasonography in the emergency department as a screening method in the management of patients with blunt abdominal trauma, it is important to avoid overestimating its capability. Frequent re-evaluation of the patient's condition, repeat ultrasonographic scans, diagnostic peritoneal lavage, and CT scanning are complementary and important in the diagnosis of blunt abdominal trauma.
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Setting priorities in the management of patients with suspected injuries to both the head and the abdomen is difficult and depends on the likelihood of different injuries. Eight hundred trauma patients were retrospectively reviewed to determine the likelihood of a surgically correctable cerebral injury. All 800 patients, at the time of initial evaluation, were thought to have potentially correctable injuries to both the head and the abdomen. Of these, 52 had a head injury requiring craniotomy; 40 required a therapeutic celiotomy. Only three patients required both craniotomy and therapeutic celiotomy. There were more cases of delay in therapeutic celiotomy because of negative results of computed tomographic (CT) scanning of the head (13 cases) than there were delays in craniotomy because of nontherapeutic celiotomy (four cases). Need for craniotomy, based on emergency department evaluation, was indicated by the presence of lateralizing neurologic signs. Low Glasgow Coma Scale score, anisocoria, fixed/dilated pupils, loss of consciousness, facial or scalp injuries, and age were of no independent value in predicting the need for craniotomy. ⋯ Patients with surgically correctable injuries of both the head and the abdomen are rare. In stable patients with altered mental status and potential injuries to both the head and the abdomen, the abdomen is best evaluated first by diagnostic paracentesis. If paracentesis does not return gross blood, CT scanning of the head should be done.(ABSTRACT TRUNCATED AT 250 WORDS)
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Trauma care is in a period of transition from care given by surgeons at the closest community hospital to care given by trauma specialists at trauma centers and within emergency medical systems. It has thus become increasingly important for the educational goals of trauma fellowship training to reflect the needs of the future system as well as the views of future practitioners. These views differ from those of surgical colleagues practicing trauma surgery, and the views of future trauma specialists should be considered during the formulation of training guidelines. ⋯ They made suggestions about their own training, including ways to increase surgical experiences and opportunities for academic pursuits, but gave no insight as to an appropriate mix of critical care training. Although critical care certification is a major attraction for fellowship training, the cohort does not want to be thought of as nonoperating surgical intensivists. A second year of fellowship training is seen as necessary for research and trauma systems-related studies.