Surgery, gynecology & obstetrics
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Although individual reports have indicated that a fracture of the first or second rib is predictive of injury to the thoracic aorta and its major branches, the results of a careful review of the literature do not support this contention. In patients suffering blunt trauma, the risk of disruption of the aorta is not greater in patients with fracture of the upper two ribs, compared with victims of trauma with fracture of other ribs or those without fracture of ribs. Clinical manifestations are often absent in patients with disruption of the aorta or the innominate artery, but evidence of mediastinal hemorrhage is almost always present on roentgenograms of the chest. ⋯ Repeat examinations must be performed and serial roentgenograms of the chest must be obtained for several days after injury to assess the possibility of unrecognized vascular trauma. If clinical or roentgenographic evidence of vascular injury is revealed, arteriography is mandatory. Thoracic CT scanning in patients with evidence of mediastinal hemorrhage on plain film may be of value in selecting patients for angiography, but additional experience must be obtained before such a protocol becomes an established policy.
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Stab wounds of the chest may be associated with a spectrum of injuries ranging from the lethal to the insignificant. The management of asymptomatic patients with stab wounds of the chest is controversial. The results of previous reports have asserted that asymptomatic patients with stab wounds of the chest do not have delayed complications develop if roentgenograms of the chest taken six hours after the injury are normal. ⋯ An asymptomatic patient with a stab wound of the chest that is not precordial, not in proximity to the subclavian artery and not suspected of diaphragmatic penetration should be serially examined and have a follow-up roentgenogram of the chest at six hours. If the patient remains asymptomatic and the six hour film is normal, delayed complications are rarely, if ever, encountered and the patient does not require further studies or hospitalization. The six hour rule for stab wounds of the chest is valid.
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Surg Gynecol Obstet · Sep 1989
Percutaneous insertion of subclavian venous catheters in infants and children.
All attempts at subclavian venous catheterization by the Pediatric Surgery Service done during a one and one-half year period at the Children's Hospital of Los Angeles were prospectively studied. Catheterization was attempted in 107 patients with a mean age of 9.8 years. Cannulation of the vein was successful 89 times (71 per cent) with the major complications being arterial puncture (8.0 per cent), pneumothorax (2.4 per cent) and abnormal position (12.8 per cent). ⋯ Percutaneous insertion of subclavian venous catheters can be accomplished in infants and children with low morbidity. Cannulation of the left subclavian vein can be accomplished with a similar success rate and a lower malposition rate than the right side. Fluoroscopy is a useful tool to assist in the correct placement of the catheter.