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1.
T C Fabian M A Croce R M Stewart F E Pritchard G Minard K A Kudsk 《Annals of surgery》1993,217(5):557-565
OBJECTIVE: This study was performed to assess current and potential future application for laparoscopy (DL) in the diagnosis of penetrating and blunt injuries. Efficacy, safety, and cost analyses were performed. SUMMARY BACKGROUND DATA: Diagnostic peritoneal lavage (DPL) and computed tomography (CT) have been the mainstays in recent years for diagnosis of equivocal nontherapeutic laparotomy, whereas CT is not helpful for the vast majority of penetrating wounds. DL may be a useful adjunct to fill in these gaps. METHODS: Hemodynamically stable patients with equivocal evidence of intraabdominal injury were prospectively entered into the protocol. DL was performed under general anesthesia; patients with wounds penetrating the peritoneum or blunt injury with significant organ injury underwent laparotomy. RESULTS: Over 19 months, 182 patients (55% stab, 36% GSW, 9% blunt) were studied. No peritoneal penetration was found at DL in 55% of penetrating wounds with 66% of the remainder having therapeutic laparotomy, 17% nontherapeutic laparotomy, and 17% negative laparotomy. Therapeutic laparotomy was performed in 53% of blunt injuries after DL. Tension pneumothorax occurred in one patient and one had an iatrogenic small bowel injury. Charges for DL were $3,325 per patient compared with $3,320 for a similar group undergoing negative laparotomy before this protocol. CONCLUSIONS: DL is a safe modality for trauma. With current technology, DL is most efficacious for evaluation of equivocal penetrating wounds. Significant cost savings would be gained by performance under local anesthesia. Development of miniaturized optics, bowel clamps, retractors, and stapling devices will reduce overall costs and permit some therapeutic applications for laparoscopy in trauma management. 相似文献
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Tracheostomy in ventilator dependent trauma patients: a prospective, randomized intention-to-treat study 总被引:2,自引:0,他引:2
Barquist ES Amortegui J Hallal A Giannotti G Whinney R Alzamel H MacLeod J 《The Journal of trauma》2006,60(1):91-97
BACKGROUND: Tracheostomy is a commonly performed procedure in ventilator dependent patients. Many critical care practitioners believe that performing a tracheostomy early in the postinjury period decreases the length of ventilator dependence as well as having other benefits such as better patient tolerance and lower respiratory dead space. We conducted a randomized, prospective, single institution study comparing the length ventilator dependence in critically ill multiple trauma patients who were randomized to two different strategies for performance of a tracheostomy. We hypothesized that earlier tracheostomy would reduce the number of days of mechanical ventilation, frequency of pneumonia and length of intensive care unit (ICU) stay. METHODS: Patients were eligible if they were older than 15 years and either a Glasgow Coma Score (GCS) >4 with a negative brain computed tomography (CT) (no anatomic head injury), or a GCS >9 with a positive head CT (known anatomic head injury). Patients who required tracheostomy for facial/neck injuries were excluded. Patients were randomized to an intention to treat strategy of tracheostomy placement before day 8 or after day 28. RESULTS: The study was halted after the first interim analysis. There were 60 enrolled patients, who had comparable demographics between groups. There was no significant difference between groups in any outcome variable including length of ventilator support, pneumonia rate, or death. CONCLUSION: A strategy of tracheostomy before day 8 postinjury in this group of trauma patients did not reduce the number of days of mechanical ventilation, frequency of pneumonia or ICU length of stay as compared with the group with a tracheostomy strategy involving the procedure at 28 days postinjury or more. 相似文献
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Vles WJ Veen EJ Roukema JA Meeuwis JD Leenen LP 《Journal of the American College of Surgeons》2003,197(4):596-602
BACKGROUND: The approach to trauma care has improved in recent decades but delayed diagnoses still occur. This study aimed to analyze the prevalence and consequences of delayed diagnoses in a single European trauma center. The effect of a systematic reexamination of the patient (tertiary survey) and reevaluation of x-rays and CT scans was evaluated. STUDY DESIGN: We prospectively registered complications among all trauma patients admitted to our hospital from January 1, 1996, to January 1, 2000. All relevant trauma and patient-related data were added by the physician to a hospital-wide trauma database with client server architecture. Complications including delay in diagnosis were subsequently added to this database. Admitted trauma patients underwent a tertiary survey and all x-rays and CT scans were reevaluated within 24 hours after admission. RESULTS: A total of 3,879 patients were studied and 1,016 complications were registered. Of all complications 55 concerned delayed diagnoses detected in 49 patients (1.3%). In 28 of these patients (57.1%) the tertiary survey (20 of 49; 40.8%) and reevaluation of x-rays and CT scans (8 of 49; 16.3%) resulted in detection of delayed diagnoses within 24 hours. Detection of the remaining 21 delayed diagnoses occurred after more than 24 hours. Delayed diagnoses resulted in delayed treatment in 27 of the 49 patients (55.1%) and surgery was necessary in 12 patients (24.5%). None of the delayed diagnoses resulted in death. CONCLUSIONS: A prospective trauma and complication registration enables evaluation of the delays in diagnosis. In our study population more than half of the delayed diagnoses could be detected by a tertiary survey and reevaluation of x-rays and CT scans. Attempts to decrease the number of delayed diagnoses should prevent delays in treatment and improve the quality of trauma care. 相似文献
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Markus Figl Linda E. Pelinka Patrick Weninger Christoph Walchetseder Walter Mauritz Harald Hertz Albert Kroepfl Robert Schmidhammer Walter Buchinger Heinz Redl 《Archives of orthopaedic and trauma surgery》2010,130(7):883-887
Introduction
The question as to whether the patient consumed drugs prior to the trauma and which drugs were consumed, is of prime importance for the anesthesia required during surgery. However, many patients are unwilling or unable (including those with multiple trauma or impaired consciousness, or unconscious patients) to answer this question. The purpose of our prospective multicenter study was to collect data about drug consumption in Austria to determine whether drugs are identifiable in the urine of recently injured individuals and to establish the types of drugs consumed. 相似文献5.
Cecilia Ceribelli Ennio Alberto Adami Simona Mattia Bruno Benini 《Surgical endoscopy》2012,26(12):3612-3615
Background
Bedside diagnostic laparoscopy has an important role of diagnosing acute abdomen in critically ill patients hospitalized in the intensive care unit (ICU). Delayed diagnosis of intraabdominal pathology increases the morbidity and mortality rates for these patients, whose clinical signs often are absent due to analgesic medication and sedation.Methods
In this retrospective study performed from January 2007 to December 2009, 62 consecutive ICU patients whose blood test results showed them to be hemodynamically unstable underwent bedside diagnostic laparoscopy. The inclusion criteria specified clinically suspected acute cholecystitis, unknown sepsis, acidosis with a high level of lactate, elevated lab tests (white blood cell count, bilirubin, lactic dehydrogenase, creatine phosphokinase, gamma glutamyl transferase [??GT]), and acute anemia with suspected intraabdominal bleeding. The major contraindications to bedside diagnostic laparoscopy were coagulopathy, endocranic hypertension, and heart failure. Patients with a clear indication for an open surgical procedure were excluded from the study.Results
Of the 62 patients who underwent bedside diagnostic laparoscopy, 43 (69.3?%) had positive findings and 29 (46.7?%) had acute acalculous cholecystitis. The mean operation time was 38 min, and no procedure-related deaths occurred. The procedure was performed for postsurgery patients, especially after cardiac operations, and for trauma or septic patients. Respiratory and hemodynamic parameters were monitored before, during, and after the procedure.Conclusions
As a minimally invasive procedure, bedside diagnostic laparoscopy can be performed in the ICU for hemodynamically unstable patients. It is safe procedure with high diagnostic accuracy for acute intraabdominal conditions that avoids negative laparotomies for unstable patients. The bedside diagnostic laparoscopy procedure is not performed widely, and prospective studies are needed to better evaluate outcome and advantages for critically ill patients. 相似文献6.
BACKGROUND: The optimal strategy for identifying patients with abdominal stab wounds requiring surgical repair has not been defined. The potential benefits of diagnostic laparoscopy by incorporating it into the routine diagnostic workup of patients with anterior abdominal stab wounds was evaluated in a two-layer, randomized study. METHODS: From May 1997 through January 2002, stable patients without peritonitis but with demonstrated peritoneal violation were randomized (A) to exploratory laparotomy (AEL) (n = 23) or diagnostic laparoscopy (ADL) (n = 20). Simultaneously, patients with equivocal peritoneal violation on local wound exploration were randomized (B) to diagnostic laparoscopy (BDL) (n = 28) or expectant nonoperative management (BNOM) (n = 31). Hospital morbidity, length of stay, and costs were primary endpoints, with postdischarge disability being a secondary endpoint. RESULTS: In patients with peritoneal penetration (AEL vs. ADL), there were minimal differences in the therapeutic operation rate (8 of 23 [AEL] vs. 8 of 20 [ADL], p = 0.761), mortality (none), morbidity (3 of 23 vs. 2 of 20, p = 0.999), hospital stay (mean +/- SD) (5.7 +/- 2.5 vs. 5.1 +/- 4.0 days, p = 0.049), hospital costs (4.6 +/- 1.3 vs. 4.8 +/- 1.9 x 1,000 EUR, p = 0.576), and length of sick leave (34 +/- 12 vs. 29 +/- 11 days, p = 0.305). In patients with equivocal peritoneal penetration (BDL vs. BNOM), laparoscopy found more mostly minor organ injuries (7 of 28 [BDL] vs. 1 of 31 [BNOM], p = 0.022) with no significant difference in therapeutic operations (3 of 28 vs. 1 of 31, p = 0.337) or morbidity (3 of 28 vs. 0 of 31, p = 0.101), but was associated with increased length of stay (2.6 +/- 2.1 vs. 1.9 +/- 1.8 days, p = 0.022), hospital costs (4.2 +/- 1.3 vs. 1.5 +/- 1.1 x 1,000 EUR, p = 0.000), and sick leave requirements (18 of 23 vs. 8 of 28 of eligible patients, p = 0.001). CONCLUSION: In patients with demonstrated peritoneal violation, laparoscopy offers little benefit over exploratory laparotomy. In patients with equivocal peritoneal penetration on local wound exploration, laparoscopy detects more mostly minor organ injuries than expectant nonoperative management but is associated with increased hospital stay, costs, and sick leave requirements. Overall, diagnostic laparoscopy cannot be recommended as a routine diagnostic tool in anterolateral abdominal and thoracoabdominal stab wounds. 相似文献
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Aspiration in severe trauma: a prospective study 总被引:7,自引:0,他引:7
The incidence and origin of contamination of the vocal cords in 53 trauma patients was studied when tracheal intubation was performed before hospital admission. Eighteen patients (34%) had gross contamination which was blood in 15 patients and gastric contents in three patients. This has implications for prehospital airway management and particularly for use of the laryngeal mask airway. 相似文献
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Kariem El-Boghdadly Desire N. Onwochei Britta Millhoff Imran Ahmad 《Journal canadien d'anesthésie》2017,64(11):1101-1110
Purpose
There is growing evidence to suggest a deficiency in anesthesiologists’ diagnosis of airway pathology and subsequent airway management planning, and conventional instruments have not shown increases in safety. Virtual endoscopy (VE) is a tool that can detail intraluminal anatomical “fly-through” information in a format visually similar to the flexible endoscopic views familiar to anesthesiologists. We aimed to determine the effect of VE on diagnostic accuracy and airway management strategies when compared with conventional tools.Methods
Clinical scenarios, along with computerized tomography (CT) imaging, were presented to 20 anesthesiologists, and structured questions were asked regarding diagnosis of airway pathology and airway management strategy. Virtual endoscopy videos were then provided and the questions were repeated. Following the CT and VE presentations, the anesthesiologists’ responses involving diagnostic accuracy and airway management strategy were compared between the CT and VE techniques. Answers relating to the utility of VE were also sought.Results
Diagnostic accuracy was 54.1% with CT alone and increased to 67.7% when VE was added (P = 0.007). In 48% of cases, the addition of VE to clinical history and CT led to changes in airway management strategy (P < 0.001), and 90.6% of these changes were deemed more cautious (P < 0.001).Conclusion
Virtual endoscopy improves the accuracy in diagnosis of airway pathology when compared with CT alone. Furthermore, it leads to more conservative and potentially safer airway management strategies in patients with head and neck pathology.13.
Effects of morphine analgesia on diagnostic accuracy in Emergency Department patients with abdominal pain: a prospective,randomized trial 总被引:5,自引:0,他引:5
Thomas SH Silen W Cheema F Reisner A Aman S Goldstein JN Kumar AM Stair TO 《Journal of the American College of Surgeons》2003,196(1):18-31
BACKGROUND: Because of concerns about masking important physical findings, there is controversy surrounding whether it is safe to provide analgesia to patients with undifferentiated abdominal pain. The purpose of this study was to address the effects of analgesia on the physical examination and diagnostic accuracy for patients with abdominal pain. STUDY DESIGN: The study was a prospective, double-blind clinical trial in which adult Emergency Department (ED) patients with undifferentiated abdominal pain were randomized to receive placebo (control group, n = 36) or morphine sulphate (MS group, n = 38). Diagnostic and physical examination assessments were recorded before and after a 60-minute period during which study medication was titrated. Diagnostic accuracy and physical examination changes were compared between groups using univariate statistical analyses. RESULTS: There were no differences between control and MS groups with respect to changes in physical or diagnostic accuracy. The overall likelihood of change in severity of tenderness was similar in MS (37.7%) as compared with control (35.3%) patients (risk ratio [RR] 1.07, 95% confidence interval [CI] 0.64-1.78). MS patients were no more likely than controls to have a change in pain location (34.0% versus 41.2%, RR 0.82, 95% CI 0.50-1.36). Diagnostic accuracy did not differ between MS and control groups (64.2% versus 66.7%, RR 0.96, 95% CI 0.73-1.27). There were no differences between groups with respect to likelihood of any change occurring in the diagnostic list (37.7% versus 31.4%, RR 1.20, 95% CI 0.71-2.05). Correlation with clinical course and final diagnosis revealed no instance of masking of physical examination findings. CONCLUSIONS: Results of this study support a practice of early provision of analgesia to patients with undifferentiated abdominal pain. 相似文献
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The tertiary trauma survey: a prospective study of missed injury 总被引:3,自引:0,他引:3
B L Enderson D B Reath J Meadors W Dallas J M DeBoo K I Maull 《The Journal of trauma》1990,30(6):666-9; discussion 669-70
The Advanced Trauma Life Support Course defines a primary and a secondary survey to rapidly identify life-threatening and associated injuries, respectively, in multiple trauma patients. However, circumstances during resuscitation, including multiple casualties, emergent operation, unconsciousness, etc., may interfere with this process. An initial review of our trauma registry data yielded a modest 2% incidence of missed injuries in a 90% blunt trauma population. In order to determine the true incidence of missed injuries, a tertiary survey was performed prospectively on all injured patients (N = 399) admitted during a recent 3-month period. After completion of the primary and secondary surveys (including appropriate roentgenographs), all injuries were listed in the trauma admission record. Patients were later reexamined immediately before ambulation or, in head-injured patients, upon regaining consciousness. All missed injuries were documented, including site and type of injury, reason missed, how identified, and attendant morbidity. Forty-one missed injuries were found in 36 patients (9%). These included: 21 extremity fractures, five spinal fractures, two facial fractures, five thoracic injuries, six abdominal injuries (including five splenic lacerations), and two vascular injuries. The most common reason for injuries to be missed was altered level of consciousness due to head injury or alcohol. Other reasons included severity of injury and instability requiring immediate operation, lack of symptoms at admission, technical problems, and low index of suspicion by the examiner. None of the missed injuries resulted in death. However, one missed injury caused serious disability and seven required operative correction.(ABSTRACT TRUNCATED AT 250 WORDS) 相似文献
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《Injury》2016,47(2):383-388
BackgroundExamination of missed injuries in our physician-led pre-hospital trauma service indicated that the significant injuries missed were often pelvic fractures. We therefore conducted a study whose aim was to evaluate the pre-hospital diagnostic accuracy of pelvic girdle injuries, and how this would be affected by implementing the pelvic injury treatment guidelines recently published by the Faculty of Pre-Hospital Care.Study designAll blunt trauma patients attended in a 5-month period were included in the study. The presence or absence of pelvic girdle injury on computed tomography (CT) or, if unavailable, pelvic X-ray was used as a primary outcome measure. A retrospective database and case note review was conducted to identify patients who had pelvic binder applied in the study period. For the purposes of the study, pelvic ring and acetabular fractures were grouped together as patients with suspected pelvic girdle injury that should be fitted with a pelvic binder in the pre-hospital setting. The sensitivity and specificity, relating to the presence of pelvic girdle injury in patients with pelvic binders, was calculated in order to determine pre-hospital diagnostic accuracy.Results785 patients were attended during the study period. 170 met the study inclusion criteria. 26 (15.3%) sustained a pelvic girdle injury. 45 (26.5%) had a pelvic binder applied. There were eight missed fractures (31%), of which the majority (six) sustained less severe injuries that were managed non-operatively. Two patients required operative fixation. Radiological images and/or reports were available on 169 (99.4%) patients. As a test of the presence of pelvic fracture, pelvic binder application had a sensitivity of 0.69 (95% CI 0.50–0.85) and a specificity of 0.81 (95% CI 0.74–0.87).ConclusionsEven with a careful clinical assessment and a low threshold for binder application, this study highlights the problems of distracting injury when trying to diagnose and manage pelvic fractures. By implementing the pelvic treatment guidelines published by the Faculty of Pre-hospital Care, the missed injury rate could be reduced from 31% to 8%. 相似文献
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Al-Mulhim AS Nasser MA Abdullah MM Ali AM Kaman L 《Journal of laparoendoscopic & advanced surgical techniques. Part A》2008,18(4):599-602
BACKGROUND: Currently, emergency laparoscopic surgery for acute abdominal conditions has become the favored surgical approach; therefore, we investigated the diagnostic accuracy and therapeutic efficacy of laparoscopy in acute abdominal pain in Saudi Arabian patients. PATIENTS AND METHODS: In this prospective study, 176 patients with acute abdominal pain (113 patients with pain localized to the right iliac region [group A] and 63 patients with generalized abdominal pain [group B] underwent emergency laparoscopy between January 2002 and December 2006. We evaluated the initial clinical diagnosis, the laparoscopic diagnosis, and the outcome in these two groups of patients. RESULTS: In group A, a definitive diagnosis was established at laparoscopy in 89% of patients, and it was therapeutic in 81.4% of the patients, and in 9 patients (8%) a conversion to laparotomy was necessary a to manage their condition. In group B, the diagnosis was accurate in 87% of patients, and it was therapeutic in 79.4% of the patients, and in 5 patients (8%) a conversion to laparotomy was necessary. There was no mortality. CONCLUSIONS: The emergency laparoscopy is a diagnostic and therapeutic option in the majority of acute abdominal pain conditions. 相似文献
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P T McDonald N M Rich G J Collins C A Andersen L Kozloff 《American journal of surgery》1978,135(5):651-655
Diagnostic and therapeutic laparoscopy are safe procedures that only rarely cause significant morbidity. However, major abdominal arterial and venous injury may occur, requiring prompt recognition and laparotomy. Direct compression will control major hemorrhage until resuscitation is complete. Vascular repair utilizing principles of proximal and distal control, good exposure, appropriate anticoagulation, and lateral suture technic should result in restoration of normal blood flow without significant sequelae. 相似文献
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Moretti B Notarnicola A Moretti L Setti S De Terlizzi F Pesce V Patella V 《BMC musculoskeletal disorders》2012,13(1):88
ABSTRACT: BACKGROUND: Total knee arthroplasty (TKA) is often associated with a severe local inflammatory reaction which, unless controlled, leads to persistent pain up to one year after surgery. Standard and accelerated rehabilitation protocols are currently being implemented after TKA, but no consensus exists regarding the long-term effects. Biophysical stimulation with pulsed electromagnetic fields (PEMFs) has been demonstrated to exert an anti-inflammatory effect, to promote early functional recovery and to maintain a positive long-term effect in patients undergoing joint arthroscopy. The aim of this study was to evaluate whether PEMFs can be used to limit the pain and enhance patient recovery after TKA. METHODS: A prospective, randomized, controlled study in 30 patients undergoing TKA was conducted. Patients were randomized into experimental PEMFs or a control group. Patients in the experimental group were instructed to use I-ONE stimulator 4hours/day for 60days. Postoperatively, all patients received the same rehabilitation program. Treatment outcome was assessed using the Knee Society Score, SF-36 Health-Survey and VAS. Patients were evaluated pre-operatively and one, two, six and 12 months after TKA. Joint swelling and Non Steroidal Anti Inflammatory Drug (NSAID) consumption were recorded. Comparisons between the two groups were carried out using a two-tail heteroschedastic Student's t-test. Analysis of variance for each individual subject during the study was performed using ANOVA for multiple comparisons, applied on each group, and a Dunnet post hoc test. A p value<0.05 was considered statistically significant. RESULTS: Pre-operatively, no differences were observed between groups in terms of age, sex, weight, height, Knee-Score, VAS, SF-36 and joint swelling, with the exception of the Functional Score. The Knee-Score, SF-36 and VAS demonstrated significantly positive outcomes in the I-ONE stimulated group compared with the controls at follow-ups. In the I-ONE group, NSAID use was reduced and joint swelling resolution was more rapid than in controls. The effect of I-ONE therapy was maintained after use of the device was discontinued. CONCLUSIONS: The results of the study show early functional recovery in the I-ONE group. I-ONE therapy should be considered after TKA to prevent the inflammatory reaction elicited by surgery, for pain relief and to speed functional recovery. 相似文献
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BACKGROUND: Peritoneal seeding or liver metastases found at laparotomy usually preclude curative treatment in patients with gastric adenocarcinoma. Such exploratory laparotomies may be avoided by diagnostic laparoscopy. However, routine diagnostic laparoscopy does not benefit those patients who proceed to laparotomy after negative laparoscopy. The aim of this study was to evaluate prospectively the selective use of laparoscopy in uncertain situations. METHODS: One hundred and twenty consecutive patients with primary gastric adenocarcinoma were studied prospectively. Diagnostic laparoscopy was performed in patients with clinical T4 tumours or suspected metastases, unless laparotomy was required for symptomatic disease. RESULTS: Ninety-six of 120 patients were selected for immediate laparotomy with curative intent (n = 81) or for palliation (n = 15). In two of the 81 patients gastrectomy was abandoned because of unexpected peritoneal carcinomatosis. Fifteen patients underwent diagnostic laparoscopy, which identified intra-abdominal metastases in six; the other nine patients proceeded to laparotomy, which revealed peritoneal metastases not detected at laparoscopy in four patients. The remaining nine patients had overt metastases and were referred for systemic chemotherapy without abdominal exploration. CONCLUSION: Diagnostic laparoscopy in selected patients effectively limits the number of unnecessary invasive staging procedures. Routine use of diagnostic laparoscopy in all patients with gastric adenocarcinoma is not warranted. 相似文献