American journal of surgery
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Injury to the diaphragm from penetrating or blunt thoracoabdominal trauma is notoriously difficult to diagnose. Chest radiography, computed tomography scan, contrast studies, diagnostic peritoneal lavage, and laparoscopy are inadequate; thus, celiotomy is commonly performed in patients with suspected diaphragmatic injury. We compared the diagnostic accuracy of video-assisted thoracoscopic surgery (VATS) with that of exploratory celiotomy in the evaluation of diaphragmatic and thoracoabdominal injury. ⋯ Video-assisted thoracoscopy is a safe, expeditious, and accurate method of evaluating the diaphragm in injured patients, and is comparable in diagnostic accuracy to exploratory celiotomy.
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Because severe acidosis is an indicator of poor prognosis in trauma patients, medical records of these patients were analyzed to determine whether aggressive resuscitation was appropriate. ⋯ Severe acidosis alone is not a sufficiently powerful predictor of outcome to justify withholding resuscitation; however, when combined with coma and shock, this condition had no survivors in this small series.
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Routine performance of thoraco-lumbar (TL) spinal radiology in patients with blunt trauma is controversial. ⋯ These data suggest that patients who are awake, alert, and with no clinical evidence of injury do not require radiologic study of the TL spine. Patients with equivocal or positive clinical findings or with altered levels of consciousness should have complete TL spine evaluation.
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The orthopedic surgeon has several options available for blood conservation. Preoperative autologous donation (PAD) of blood is a cost-effective measure when the cost of managing transfusion-transmitted infectious disease is considered; overuse and underuse are expensive problems, however. Hemodilution, while used successfully in prostate surgery, is logistically impractical in joint replacement centers. ⋯ Studies are under way to determine whether this method of blood conservation alters transfusion requirements. Recombinant human erythropoietin (Epoetin alfa) has a role in elective procedures with significant blood loss, including complex revision joint replacement, bilateral joint arthroplasty, and spinal fusion. Preoperative Epoetin alfa administration enhances preoperative autologous blood collection and increases perioperative red blood cell mass.