The Surgical clinics of North America
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Surg. Clin. North Am. · Feb 1989
ReviewAcute post-traumatic respiratory physiology and insufficiency.
This article reviews the physiologic mechanisms by which acute injury results in respiratory insufficiency. It delineates the need for oxygenation versus ventilatory support and provides a pragmatic approach to dealing with the proper early respiratory support of the victim of chest trauma as well as the rationale for various immediate treatment modalities. In addition, it discusses various assessment techniques and clinical clues that predict the onset of late respiratory complications in the patient with serious injuries.
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Chest wall injuries range from relatively trivial to fatal flail chest or huge defects. Significant chest wall injury is present in about one third of patients admitted after severe trauma. In management, the principal areas to be considered are pain control, open wounds, pneumothorax, flail chest, and pulmonary contusion.
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Technologic aid is available for the three central problems of hemorrhage, lung damage, and cardiac damage. Autotransfusion, new modes of ventilator support, extracorporeal oxygenation, balloon pumping, and left ventricular assist are available for the trauma patient. The author explains these new devices and their role in thoracic trauma cases.
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The presence of a urologic injury must be considered in all patients with pelvic fracture. Uroradiographic evaluation starting with retrograde urethrography is indicated in all male patients with concomitant gross hematuria, bloody urethral discharge, scrotal or perineal ecchymosis, a nonpalpable prostate on rectal examination, or an inability to urinate. If the urethra is normal, a catheter may be passed, and in the presence of gross hematuria, a cystogram must be performed. ⋯ Selected cases of extraperitoneal bladder perforation may be safely managed solely by catheter drainage. Intraperitoneal perforations require surgical exploration and repair. Urethral disruption (partial or complete) may be safely managed by primary cystostomy drainage with management of potential complications (stricture, impotence, incontinence) in 4 to 6 months.
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Abdominal vascular injuries remain rare in centers that primarily treat victims of blunt trauma, but when penetrating wounds of the abdomen are commonly treated, the incidence of abdominal vascular injuries is surprisingly high. With suitable management, many of these patients survive.