J Trauma
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The diagnosis and management of occult vascular injuries caused by penetrating proximity extremity trauma (PPET) remains controversial. Over 18 months, we prospectively screened 37 patients (43 lower extremities) with PPET for occult arterial and venous injuries using noninvasive studies (physical examination, ankle-brachial indices, color-flow duplex ultrasonography (CFD)) and angiography (arteriography, venography). Eight isolated, occult venous injuries were detected (incidence, 22%). ⋯ Major thromboembolic complications (pulmonary embolism, symptomatic deep vein thrombosis, venous claudication) occurred in 50% of the patients identified with femoral-popliteal vein injuries. Arterial injuries were detected in 4 of 42 (10%) extremities (arteriography, n = 3; CFD, n = 1) and were clinically benign. We conclude that following PPET, (1) isolated, occult venous injuries are common and are associated with significant complications and (2) CFD is useful for screening for occult venous injuries.
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Penoscrotal avulsion injuries are rare surgical emergencies. The best treatment for penile avulsions is split skin graft, although late results of split-grafted scrotal avulsions are not superior. Scrotal skin avulsions require additional judgment for the treatment, because there are several available treatment options. Scrotal skin remnants must be used to cover whenever possible.
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Ventilator-associated pneumonia (PN) is difficult to distinguish from trauma-induced systemic inflammatory response syndrome (SIRS), especially in patients with multiple injuries. Previous work using bronchoscopy and quantitative cultures demonstrated significant bacterial growth in about one-third of patients with clinical evidence of PN. In this prospective study, antibiotic therapy for PN was based solely on quantitative bronchoalveolar lavage (BAL) cultures. ⋯ SIRS, which can mimic PN, is common in trauma patients. These entities can be distinguished by bronchoscopy with BAL. Basing antibiotic therapy solely on quantitative BAL cultures is efficacious in trauma patients.
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Therapies to lower intracranial pressure (ICP) after traumatic brain injury (TBI) include hyperventilation (HV), intravenous mannitol (IM), and cerebrospinal fluid drainage from a ventriculostomy (DV). To determine the effects of these therapies on cerebral blood flow (CBF), fiberoptic oximetry was used to measure jugular venous O2 saturation (SjvO2) as an index of the CBF to cerebral metabolic rate for O2 (CMRO2) ratio after IM (25 g IV for more than 5 min), DV (3 min), or HV (increase respiratory rate by 4) therapy for elevated ICP. Assuming CMRO2 is constant, changes in SjvO2 reflect changes in CBF. ⋯ Therapy was initiated a total of 196 times when ICP was > 15 mm Hg for > 5 minutes, and measurements made at 20 minutes after treatment were compared with those made just before. After DV, ICP fell in 90% of the observations by 8.6 +/- 0.7 mm Hg (mean +/- SEM, n = 119); after IM, ICP fell in 90% of the observations by 7.4 +/- 0.7 mm Hg (n = 43); and after HV, ICP fell in 88% of the observations by 6.3 +/- 1.2 mm Hg (n = 14). In patients where ICP fell, SjvO2 increased by 2.49 +/- 0.7% saturation (from 68.0 +/- 1.3%) with IM, but only by 0.39 +/- 0.4% saturation (from 67.2 +/- 0.9%) with DV.(ABSTRACT TRUNCATED AT 250 WORDS)
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A retrospective review of 145 patients with thoracic or lumbar spine fractures from blunt trauma was conducted to identify the clinical presentation of these patients. The presence of back pain or tenderness (BPT), neurologic injury, altered sensorium from head injury or alcohol intoxication, and concomitant major injury were determined. Any delayed or missed diagnoses were analyzed. ⋯ Of the 27 (19%) patients with a negative finding of BPT, all (100%) had an altered sensorium, concomitant major injury, or neurologic deficit. There were no asymptomatic thoracic or lumbar spine fractures in neurologically intact patients with clear sensoriums and no concomitant major injuries. These patients do not need routine thoracolumbar radiography.