J Trauma
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Superior dislocation of the patella with interlocking osteophytes was only once found roentgenologically documented. Such a dislocation occurs without tendon rupture, and can occur with a hyperextension force. ⋯ Full active motion is present post-reduction. This entity should not be confused with vertical dislocations of the patella.
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Using computerized gamma scintigraphy, 10-cm H2O PEEP did not alter the rate of capillary protein leakage in dogs following pulmonary microvascular injury with 0.01 to 0.2 ml/kg oleic acid. A rising lung:heart radioactivity ratio, or 'slope of injury,' was seen during PEEP which paralleled the 'slope of injury' had PEEP not been used. A sudden decrease in lung and heart count activity (p less than 0.001) and decreased lung:heart radioactivity ratio (p less than 0.001) occurred with PEEP at all doses of oleic acid studied. ⋯ When all vessels leading to and from the heart and lungs were ligated, PEEP produced a 60% fall in count activity over the lung without any change in cardiac radioactivity. The apparent radiographic improvement and 2/3 of the fall in lung radioactivity with PEEP were due to an increased pulmonary air volume and 1/3 due to a decreased pulmonary blood volume. The decreased cardiac output with PEEP must be secondary to decreased ventricular filling rather than decreased ventricular function.
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From 1973 through 1980 144 patients with chest trauma were treated. Concomitant acute respiratory failure was considered severe in 125 (83%). Morbidity and mortality were found to be related to the presence of shock, head injury Glasgow score 3-4, and size of the flail segment, but not by the extent of the thoracic or intrathoracic injuries. ⋯ Treatment was analyzed in two historical periods: In the first, 1973 through 1976, controlled mandatory ventilation and tracheostomy were used in 83 and 70% of the cases, respectively. In the second period, 1977 through 1980, intermittent mandatory ventilation plus soft-cuff endotracheal tube were used in 77% of the cases. Ventilator time did not vary in these two periods but the lung oxygen transport was better in the group treated with intermittent mandatory ventilation.
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While the technique of early excision and grafting has many advantages in the treatment of thermal injuries, it is not without significant complications. Hemorrhage accompanying burn wound excision can be deceptively great, as can the metabolic stress of large surgical procedures performed in the postburn period. In an effort to minimize these complications, we have developed a two-stage technique for excision and grafting of burn wounds. ⋯ Temperature decrease during surgery was also great, with significant hypothermia occurring in 51% of procedures exceeding 2 hours in length. We conclude that performing excision and grafting in two stages limits hemorrhage and heat loss from each individual surgery, thereby permitting the performance of larger procedures. Nonetheless, continued awareness of the magnitude of these complications remains an essential of successful excisional therapy.