The Surgical clinics of North America
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The previous 20 years have truly opened a new era of orthopedic trauma care. Rapid advances in the development of systems for internal and external fixation have been made. Improvements in technology and surgical technique have allowed fracture reduction and fixation to be achieved with less-invasive surgical approaches. ⋯ A new understanding of processes at the cellular and molecular levels offers the possibility, for the first time, of directly influencing the biology of fracture union and soft-tissue healing. Transitional research has introduced new therapies that are moving rapidly from the laboratory to biotech industry and the clinical arena. Given the present state of scientific acceleration, orthopedic trauma care in the new millennium will be shaped by important developments that physicians can now only imagine.
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Despite its proven clinical application for protection-preservation of the brain and heart during cardiac surgery, hypothermia research has fallen in and out of favor many times since its inception. Since the 1980s, there has been renewed research and clinical interest in therapeutic hypothermia for resuscitation of the brain after cardiac arrest or TBI and for preservation-resuscitation of extracerebral organs, particularly the abdominal viscera in low-flow states such as HS. Although some of the fears regarding the side effects of hypothermia are warranted, others are not. ⋯ The authors believe that the new millennium will witness remarkable advantages of the use of controlled hypothermia in trauma. Starting in the prehospital phase, mild hypothermia will be induced in hypovolemic patients, which will not only decrease the immediate mortality rate but perhaps also will protect cells and reduce the likelihood of secondary inflammatory response syndrome, multiple organ failure, and late deaths. The most futuristic applications will be hypothermic strategies to achieve prolonged suspended animation for delayed resuscitation in traumatic exsanguination cardiac arrest.
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Surg. Clin. North Am. · Dec 1999
ReviewNonoperative management of solid organ injuries. Past, present, and future.
All patients with injuries to the solid organs of the abdomen and who are hemodynamically stable should be considered candidates for nonoperative management after their injuries have been staged by abdominal CT scanning, but because the CT stage of the injury does not always predict which patients require laparotomy, these patients must remain under the care of experienced trauma surgeons who can not only recognize the presence of an associated hollow viscus injury in need of repair but also will be readily available to operate if the nonoperative approach fails. Until continued bleeding can be safely ruled out, a period of close monitoring in an ICU-like setting seems warranted. Although delayed bleeding from the liver seems extremely rare, delayed rupture of the spleen and continued hemorrhage into the retroperitoneum from an injured kidney are not unusual, so patients with splenic and renal injuries should be considered candidates for repeat imaging procedures before discharge. ⋯ Selected patients with penetrating injuries may also be candidates for the nonoperative approach, but further research in this area is needed before this approach can be widely embraced. As we approach the year 2000, the nonoperative approach to hepatic, splenic, and renal injuries will continue to have a major role in the treatment of trauma patients. Currently, the morbidity and mortality rates of nonoperative management are acceptably low, but surgeons still must monitor their results carefully as they apply these methods more liberally among injured patients.
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Surg. Clin. North Am. · Dec 1999
Use of portable CT in the R Adams Cowley Shock Trauma Center. Experiences in the admitting area, ICU, and operating room.
The author's experience with portable CT has been positive. Nurses and clinical physicians have been pleased with this new imaging capability also, and have written testimonial letters endorsing its value. Recently, the STC extended availability of the mobile CT to the University of Maryland Hospital, an adjoining 600-bed center with numerous medical and surgical patients in ICU. ⋯ The capability of portable CT scanning for emergency, intensive care, and intraoperative studies exists now. The commercially marketed cost for this system is between $400,000 and $500,000. Further studies are anticipated to clarify the economic and clinical benefits of this technology.
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This article discusses resuscitation from a historical perspective; physiology; the optimal timing and volume for and fluids and endpoints of resuscitation; and the role of resuscitation in the future. Whether different types of victims of trauma should be resuscitated using different endpoints also is discussed.