RESUMEN
The objective of this study was to determine the profile (credentials, training, and type of practice) of female academic general surgeons and factors that influenced their career choice. A survey was sent to female academic surgeons identified through general surgery residency programs and American medical schools. The women had to be Board eligible/certified by the American Board of Surgery or equivalent Board and have an academic appointment in a Department of Surgery. Data were analyzed using the SPSS program. Two hundred seventy women (age range, 32-70 years) completed the survey (98.9% response rate). Fellowships were completed by 82.3 per cent (223/270), most commonly in surgical critical care. There were 134 (50.2%, 134/367) who had two or more Board certificates, most frequently (46%, 61/134) in surgical critical care. Full-time academic appointments were held by 86.7 per cent of women, most as assistant professors, clinical track; only 12.4 per cent were tenured professors. The majority of women described their practice as "general surgery" or "general surgery with emphasis on breast." The most frequent administrative title was "Director." Only three women stated that they were "chair" of the department. The top reason for choosing surgery was "gut feeling," whereas "intellectual challenge" was the reason they pursued academic surgery. When asked "Would you do it again?", 77 per cent responded in the affirmative. We conclude that female academic surgeons are well trained, with slightly more than half having two or more Board certificates; that most female academic surgeons are clinically active assistant or associate professors whose practice is "general surgery," often with an emphasis on breast disease; that true leadership positions remain elusive for women in academic general surgery; and that 77 per cent would choose the same career again.
Asunto(s)
Docentes Médicos , Médicos Mujeres/tendencias , Especialidades Quirúrgicas , Adulto , Anciano , Enfermedades de la Mama/cirugía , Selección de Profesión , Habilitación Profesional , Cuidados Críticos/estadística & datos numéricos , Educación de Postgrado en Medicina/tendencias , Docentes Médicos/normas , Docentes Médicos/estadística & datos numéricos , Becas , Femenino , Humanos , Satisfacción en el Trabajo , Mentores , Persona de Mediana Edad , Ejecutivos Médicos/estadística & datos numéricos , Médicos Mujeres/normas , Médicos Mujeres/estadística & datos numéricos , Práctica Profesional/clasificación , Especialidades Quirúrgicas/educación , Especialidades Quirúrgicas/normas , Especialidades Quirúrgicas/estadística & datos numéricos , Consejos de Especialidades , Estados UnidosAsunto(s)
Servicios Médicos de Urgencia/normas , Hígado/lesiones , Heridas no Penetrantes/diagnóstico , Heridas no Penetrantes/terapia , Heridas Penetrantes/diagnóstico , Heridas Penetrantes/terapia , Conductos Biliares/lesiones , Procedimientos Quirúrgicos Cardiovasculares/métodos , Procedimientos Quirúrgicos del Sistema Digestivo/métodos , Humanos , Técnicas de Sutura/normas , Índices de Gravedad del Trauma , Heridas no Penetrantes/clasificación , Heridas no Penetrantes/cirugía , Heridas Penetrantes/cirugíaAsunto(s)
Apendicitis/diagnóstico por imagen , Perforación Intestinal/diagnóstico por imagen , Intestinos/anomalías , Tomografía Computarizada por Rayos X/métodos , Dolor Abdominal/etiología , Enfermedad Aguda , Adulto , Apendicitis/complicaciones , Apendicitis/cirugía , Diagnóstico Diferencial , Diarrea/etiología , Humanos , Perforación Intestinal/complicaciones , Perforación Intestinal/cirugía , Seudoobstrucción Intestinal/etiología , Intestinos/cirugía , Leucocitosis/sangre , Leucocitosis/etiología , Masculino , Náusea/etiología , Examen Físico , Rotura Espontánea , Vómitos/etiologíaRESUMEN
This is a report of a 10-year experience (1989-1998) with 300 consecutive patients found to have an injury to a named abdominal vessel at the time of an exploratory laparotomy for trauma. An abdominal gunshot wound was the mechanism of injury in 78 per cent of patients, and injury to more than one named abdominal vessel was present in 42 per cent. The abdominal aorta, inferior vena cava, and external iliac artery and vein were the most commonly injured vessels. When management for the five most commonly injured arteries was grouped, exsanguination before attempts at repair occurred in 11 to 15 per cent of patients and the mean survival in the remainder was 46 per cent. When management for the five most commonly injured veins was grouped, exsanguination before attempts at repair occurred in 5 per cent of patients and the mean survival in the remainder was 64 per cent. A number of administrative and medical changes in the management of patients with abdominal trauma occurred from 1992 through 1994. Despite significantly increased Injury Severity Scores for patients treated from 1993 through 1998 as compared with those treated from 1989 through 1992 survival rates for patients with injuries to the abdominal aorta and inferior vena cava were unchanged. Survival rates for injuries to the external iliac artery and vein increased significantly. The local changes in management should be considered for prospective studies in other urban trauma centers.
Asunto(s)
Aorta Abdominal/lesiones , Arteria Ilíaca/lesiones , Vena Ilíaca/lesiones , Vena Cava Inferior/lesiones , Heridas no Penetrantes/cirugía , Heridas Penetrantes/cirugía , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Aorta Abdominal/cirugía , Niño , Preescolar , Femenino , Georgia/epidemiología , Humanos , Arteria Ilíaca/cirugía , Vena Ilíaca/cirugía , Puntaje de Gravedad del Traumatismo , Laparotomía , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Análisis de Supervivencia , Vena Cava Inferior/cirugía , Heridas no Penetrantes/epidemiología , Heridas Penetrantes/epidemiologíaRESUMEN
BACKGROUND: Critically ill surgical patients are often difficult to assess for complications because of their altered sensorium, multiple monitoring devices, and immobility. Surgeon-performed ultrasound may enhance the physical examination of these patients and provide for an early detection of select complications. We hypothesized that a focused thoracic ultrasound examination could reliably detect a pleural effusion and the results could be used in the decision matrix for patient care. METHODS: Serial focused thoracic ultrasound examinations were performed by a surgeon and a medical student on critically ill patients. The medical student learned select facets of the physical examination and then demonstrated how ultrasound imaging could enhance these findings. Ultrasound images were recorded on hard copy and videotape, with the results available to the surgical intensive care unit and surgery teams. The images were reviewed and compared with the chest radiograph readings. RESULTS: Forty-seven patients underwent 140 ultrasound examinations. There were 85 true-negative, 46 true-positive, 9 false-negative, and zero false-positive examination results, yielding an 83.6% sensitivity, 100% specificity, and 94% accuracy. Of the 46 true-positive results, thoracentesis was performed or a thoracostomy tube was placed in 5 patients. Nine false-negative ultrasound examinations occurred in six patients, five of whom had their effusions detected on computed tomographic scans. CONCLUSION: A focused thoracic ultrasound examination reliably detects pleural effusions in critically ill patients, and the results can be used successfully in the decision matrix for patient care.
Asunto(s)
Cuidados Críticos/métodos , Cirugía General/métodos , Examen Físico/métodos , Derrame Pleural/diagnóstico por imagen , Sistemas de Atención de Punto , Ultrasonografía , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Enfermedad Crítica , Árboles de Decisión , Reacciones Falso Negativas , Reacciones Falso Positivas , Femenino , Humanos , Masculino , Persona de Mediana Edad , Traumatismo Múltiple/complicaciones , Selección de Paciente , Rol del Médico , Derrame Pleural/etiología , Derrame Pleural/cirugía , Sensibilidad y Especificidad , Tomografía Computarizada por Rayos X , Ultrasonografía/instrumentación , Ultrasonografía/métodos , Ultrasonografía/normasRESUMEN
As the role of the general surgeon continues to evolve, the surgeon's use of ultrasound imaging will surely influence practice patterns, particularly for the evaluation of patients in the acute setting. With the use of real-time imaging, the surgeon receives "instantaneous" information to augment the physical examination, to narrow the differential diagnosis, or to initiate an intervention. With select ultrasound examinations, the surgeon can rapidly evaluate adult and pediatric patients with an acute abdomen, especially those patients who are hypotensive. In the hands of the surgeon, this noninvasive, bedside tool can assess more accurately the presence, depth, and extent of an abscess, confirm complete aspiration, or diagnose wound dehiscence before it is apparent on physical examination. Ultrasound imaging is so accurate for the diagnosis of pyloric stenosis that it has essentially replaced the upper gastrointestinal series in most institutions. The surgeon's use of ultrasound imaging to detect a pleural effusion has virtually supplanted the lateral decubitus radiograph. Furthermore, an ultrasound-guided thoracentesis not only facilitates the procedure but improves its safety. As surgeons become more facile with ultrasound imaging, it is anticipated that other uses will develop to further enhance its value for the assessment of patients in the acute setting.
Asunto(s)
Cirugía General , Procedimientos Quirúrgicos Operativos , Ultrasonografía , Abdomen Agudo/diagnóstico por imagen , Abdomen Agudo/etiología , Abdomen Agudo/cirugía , Algoritmos , Cirugía General/educación , Humanos , Unidades de Cuidados Intensivos , Internado y Residencia , Ultrasonografía/instrumentación , Ultrasonografía/métodos , Ultrasonografía Intervencional , Heridas y Lesiones/diagnóstico por imagen , Heridas y Lesiones/cirugíaRESUMEN
BACKGROUND: The morbidity and mortality of various open abdominal techniques remains unclear. METHODS: A retrospective review was made of all trauma or general surgery patients who underwent an open abdominal closure from January 1997 to December 2000, at a large urban acute care hospital. Data are mean +/- SD. RESULTS: From 1997 to 2000, 181 patients (aged 39.8 +/- 16.5 years) had an open abdomen for abdominal infection, planned reexploration, abdominal compartment syndrome, inability to reapproximate fascia, or as part of a "damage control" procedure. Twenty-three patients went on to develop an abdominal compartment syndrome. Gastrointestinal fistulas occurred in 26 patients, and 9 patients had a dehiscence. The overall mortality was 44.7%. Of the survivors, 52% went on to fascial closure, requiring 1 to 7 additional abdominal operations. CONCLUSIONS: The morbidity of the open abdomen varies with the particular indication. Gastrointestinal fistulas are the most common acute complication and an abdominal wall hernia, the most common chronic complication.
Asunto(s)
Abdomen/cirugía , Técnicas de Sutura , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Niño , Síndromes Compartimentales/etiología , Enfermedad Crítica , Fístula Gástrica/etiología , Hernia Ventral/etiología , Humanos , Fístula Intestinal/etiología , Persona de Mediana Edad , Complicaciones Posoperatorias , Reoperación , Estudios Retrospectivos , Dehiscencia de la Herida OperatoriaAsunto(s)
Traumatismos de las Arterias Carótidas/cirugía , Esófago/lesiones , Traumatismo Múltiple/cirugía , Músculos del Cuello/trasplante , Colgajos Quirúrgicos , Tráquea/lesiones , Heridas por Arma de Fuego/cirugía , Adulto , Fístula Esofágica/prevención & control , Humanos , Masculino , Músculos del Cuello/irrigación sanguínea , Técnicas de Sutura , Resultado del TratamientoRESUMEN
OBJECTIVE: To evaluate admission systolic blood pressure (SBP) in the emergency center (EC) as a means by which patients with transmediastinal gunshot wounds (TM-GSWs) can be triaged to the operating room versus further diagnostic evaluation. METHODS: A prospective case series presenting concurrent data collected for 68 consecutive patients with TM-GSWs admitted to one urban trauma center over a 4.5-year period. For purposes of analysis, patients were assigned to the following groups based on SBP in the EC: group I, SBP > 100 mm Hg; group II, SBP from 60 to 100 mm Hg; group III, SBP < 60 mm Hg. RESULTS: The management and outcomes of 68 patients with a mean age of 29 years were evaluated. For patients in group I (n = 20), TM-GSW was diagnosed by findings on x-ray film for 15 patients (75%), at physical examination for 4 patients (20%), and at operation for 1 patient (5%). Indications for immediate operation were found in five patients (25%), whereas further diagnostic evaluation prompted operation for three additional patients. Only one patient developed persistent hypotension from neurogenic shock. There were two deaths from late complications. In patients in group II (n = 16), TM-GSW was diagnosed by findings on x-ray film for 9 patients (56%), at physical examination for 5 patients (31%), and at operation for 2 patients (13%). Six patients with persistent hypotension had indications for immediate operation, whereas further diagnostic evaluation in the remaining patients, who became hemodynamically normal during resuscitation, prompted operation in an additional two patients. There were two intraoperative deaths. For the patients in group III (n = 32), six patients with signs of life underwent immediate operation with one intraoperative death, seventeen patients required EC thoracotomy with 100% mortality, and nine patients were pronounced dead in the EC without an attempt at operation. CONCLUSION: The diagnosis of TM-GSW for patients in groups I and II is confirmed by finding at physical examination and on chest x-ray films in 90% of cases. In the absence of obvious bleeding, patients with TM-GSWs and SBP > 100 mm Hg may safely undergo further diagnostic evaluation. Sixty percent of such patients did not require an operation. All patients with TM-GSWs and SBP < 60 mm Hg (group III) require immediate operation. For patients with TM-GSWs, SBP from 60 to 100 mm Hg (group II), and without obvious bleeding, it is the response to resuscitation and the results of further diagnostic evaluation that determine the need for operation. Fifty percent of such patients did not require operation.
Asunto(s)
Mediastino/lesiones , Heridas por Arma de Fuego/diagnóstico por imagen , Adulto , Presión Sanguínea/fisiología , Femenino , Humanos , Hipotensión/diagnóstico por imagen , Hipotensión/mortalidad , Hipotensión/cirugía , Masculino , Mediastino/diagnóstico por imagen , Mediastino/cirugía , Estudios Prospectivos , Radiografía , Tasa de Supervivencia , Toracotomía , Centros Traumatológicos , Triaje , Heridas por Arma de Fuego/mortalidad , Heridas por Arma de Fuego/cirugíaRESUMEN
HYPOTHESIS: Factors associated with fetal death in injured pregnant patients are related to increasing injury severity and abnormal maternal physiologic profile. DESIGN: A multi-institutional retrospective study of 13 level I and level II trauma centers from 1992 to 1996. MAIN OUTCOME MEASURE: Fetal survival. RESULTS: Of 27,715 female admissions, there were 372 injured pregnant patients (1.3%); 84% had blunt injuries and 16% had penetrating injuries. There were 14 maternal deaths (3.8%) and 35 fetal deaths (9.4%). The population suffering fetal death had higher injury severity scores (P<.001), lower Glascow Coma Scale scores (P<.001), and lower admitting maternal pH (P = .002). Most women who lost their fetus arrived in shock (P = .005) or had a fetal heart rate of less than 110 beats/min at some time during their hospitalization (P<.001). An Injury Severity Score greater than 25 was associated with a 50% incidence of fetal death. Placental abruption was the most frequent complication, occurring in 3.5% of patients and associated with 54% mortality. Cardiotrophic monitoring to detect potentially threatening fetal heart rates was performed on only 61% of pregnant women in their third trimester. Of these patients, 7 had abnormalities on cardiotrophic monitoring and underwent successful cesarean delivery. CONCLUSIONS: Fetal death was more likely with greater severity of injury. Cardiotrophic monitoring is underused in injured pregnant patients in their third trimester even after admission to major trauma centers. Increased use of cardiotrophic monitoring may decrease the mortality caused by placental abruption.
Asunto(s)
Muerte Fetal/epidemiología , Muerte Fetal/etiología , Complicaciones del Embarazo/epidemiología , Heridas y Lesiones/epidemiología , Femenino , Humanos , Puntaje de Gravedad del Traumatismo , Embarazo , Estudios RetrospectivosRESUMEN
The use of ultrasound for the investigation of urgent diagnostic dilemmas is by no means new. Although it has been widely used for almost 40 years, during the past two decades ultrasound has achieved a primary role in the investigation of emergent conditions, notably in the trauma setting. This is further underscored by the American College of Surgeons (ACS) training initiatives. In addition to the basic ultrasound course sponsored by the ACS at the Clinical Congress meetings, the ACS will offer a specialty module course, "Ultrasound in the Acute Setting," that covers ultrasound as used in trauma, critical care, and acute general surgical problems. This initiative underscores the surgeons' interest in having ultrasound as an integral part of their trauma practice. Having the ability to perform and interpret the ultrasound examination gives the surgeon the advantage of obtaining immediate information about the patient. Considering the pace of the trauma setting, ultrasound is an ideal modality for assessment of these patients. It should be the initial diagnostic test for the evaluation of patients with precordial wounds and blunt truncal injuries because it is rapid and accurate, and it augments the surgeon's diagnostic capabilities.
Asunto(s)
Traumatismos Abdominales/diagnóstico por imagen , Traumatismos Abdominales/cirugía , Urgencias Médicas , Grupo de Atención al Paciente , Ultrasonografía/instrumentación , Hemoperitoneo/diagnóstico por imagen , Hemoperitoneo/cirugía , Humanos , Sensibilidad y Especificidad , TransductoresRESUMEN
This is a report of a 22-year experience with penetrating cardiac trauma at a single urban Level I trauma center. We conducted a retrospective chart review supplemented by computerized patient log. Comparisons of mortality between Period 1 (1975-1985; 113 patients) and Period 2 (1986-1996; 79 patients) were by chi2 or Fisher's exact tests. Statistical significance was defined as P < or = 0.05. From 1975 to 1996, 192 patients (mean age, 32 years; 88% male) with penetrating cardiac stab wounds (68%) or gunshot wounds (32%) were treated. The most common initial clinical presentation was cardiac tamponade, and most patients (54%) were hypotensive (systolic blood pressure 30-90 mm Hg). The most common initial intervention in the emergency center was tube thoracostomy. The use of pericardiocentesis as a diagnostic and therapeutic modality in the emergency center virtually disappeared in Period 2, as compared with Period 1. Since 1994, surgeon-performed cardiac ultrasound has been performed and has correctly diagnosed hemopericardium in 12 patients (100% survival). The overall mortality for all patients during the 22-year study interval was 25 per cent and was not significantly different between Period 1 (27%) and Period 2 (22%). The mortality associated with gunshot wounds was increased compared with that of stab wounds. Similarly, mortality for patients who arrested in the emergency center was increased compared with those patients who did not arrest. We conclude: 1) cardiac tamponade is the most common presentation in patients with cardiac wounds; 2) pericardiocentesis in the emergency center has essentially disappeared; 3) surgeon-performed ultrasound of the pericardium should improve survival of future patients who are normotensive or mildly hypotensive; 4) over the last 11 years, there has been a substantial decrease in mortality in patients with stab wounds and a statistically significant decrease in arrested patients; and 5) overall mortality for penetrating cardiac trauma has not changed during the 22-year interval.
Asunto(s)
Lesiones Cardíacas/epidemiología , Población Urbana/estadística & datos numéricos , Heridas Penetrantes/epidemiología , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Distribución de Chi-Cuadrado , Niño , Urgencias Médicas , Femenino , Georgia/epidemiología , Lesiones Cardíacas/diagnóstico por imagen , Lesiones Cardíacas/cirugía , Humanos , Masculino , Persona de Mediana Edad , Morbilidad/tendencias , Mortalidad/tendencias , Estudios Retrospectivos , Centros Traumatológicos/estadística & datos numéricos , Ultrasonografía , Heridas Penetrantes/diagnóstico por imagen , Heridas Penetrantes/cirugíaRESUMEN
BACKGROUND: The Focused Assessment for the Sonographic Examination of the Trauma patient (FAST) sequentially surveys for the presence or absence of blood in dependent abdominal regions including the right upper quadrant, left upper quadrant, and the pelvis. But it does not readily identify intraparenchymal or retroperitoneal injuries, and a CT scan of the abdomen may be needed to reduce the incidence of missed injuries. We hypothesized that select patients who are considered high risk for occult injuries should undergo a CT scan of the abdomen when the FAST is negative so that occult injuries can be detected. STUDY DESIGN: An algorithm was prospectively tested for the evaluation of select injured patients over a 3 1/2-year period. Entrance criteria included adult patients with a blunt mechanism of trauma, a negative FAST examination, and a spine fracture (with or without cord injury), or a pelvic fracture. Trauma team members performed the FAST on patients during the Advanced Trauma Life Support secondary survey. Data recorded included the patient's mechanism and type of injury, the results of the FAST and CT scan examinations, operative or postmortem findings or both, and patient outcomes. Patients with spine injuries were grouped according to spine level and the presence or absence of neurologic deficit. The patients with pelvic fractures were grouped according to the Young and Resnick classification. RESULTS: One hundred two of 1,490 patients (6.8%) who had FAST examinations were entered into this study. Thirty-two patients (30.5%) had spine injuries, with only one false-negative ultrasound result. Seventy patients (68.6%) had pelvic fractures with 13 false-negative ultrasound results: 11 ring (9 from motor vehicle crashes, 2 from pedestrians struck), 1 acetabular, and 1 isolated pelvic fracture. Nine patients underwent nonoperative management for solid organ injuries, and 4 patients needed surgery. CONCLUSIONS: Based on these preliminary data, we conclude that patients with pelvic ring-type fractures should have CT scans of the abdomen because of the higher yield for occult injuries.
Asunto(s)
Traumatismos Abdominales/diagnóstico , Sistemas de Atención de Punto , Fracturas de la Columna Vertebral/diagnóstico , Ultrasonografía/instrumentación , Heridas no Penetrantes/diagnóstico , Traumatismos Abdominales/cirugía , Adolescente , Adulto , Anciano , Algoritmos , Diagnóstico Diferencial , Femenino , Fracturas Óseas/diagnóstico , Fracturas Óseas/cirugía , Hemoperitoneo/diagnóstico , Hemoperitoneo/cirugía , Humanos , Masculino , Persona de Mediana Edad , Examen Neurológico , Huesos Pélvicos/lesiones , Estudios Prospectivos , Sensibilidad y Especificidad , Traumatismos de la Médula Espinal/diagnóstico , Traumatismos de la Médula Espinal/cirugía , Fracturas de la Columna Vertebral/cirugía , Tomografía Computarizada por Rayos X , Heridas no Penetrantes/cirugíaRESUMEN
OBJECTIVE: This is a report of 50 consecutive patients with juxtapyloric perforations after smoking "crack" cocaine (cocaine base) at one urban public hospital. SUMMARY BACKGROUND DATA: Although the exact causal relation between smoking crack cocaine and a subsequent juxtapyloric perforation has not been defined, surgical services in urban public hospitals now treat significant numbers of male addicts with such perforations. This report describes the patient set, presentation, and surgical management and suggests a possible role for Helicobacter pylori in contributing to these perforations. METHODS: A retrospective chart review was performed, supplemented by data from the patient log in the department of surgery. RESULTS: From 1994 to 1998, 50 consecutive patients (48 men, 2 women) with a mean age of 37 had epigastric pain and signs of peritonitis a median of 2 to 4 hours (but up to 48 hours) after smoking crack cocaine. A history of chronic smoking of crack as well as chronic alcohol abuse was noted in all patients; four had a prior history of presumed ulcer disease in the upper gastrointestinal tract. Free air was present on an upright abdominal x-ray in 84% of patients, and all underwent operative management. A 3- to 5-mm juxtapyloric perforation, usually in the prepyloric area, was found in all patients. Omental patch closure was used in 49 patients and falciform ligament closure in 1. Two patients underwent parietal cell vagotomy as well. In the later period of the review, antral mucosal biopsies were performed through the juxtapyloric perforation in five patients. Urease testing was positive for infection with H. pyonri in four, and these patients were prescribed appropriate antimicrobial drugs. CONCLUSIONS: Juxtapyloric perforations after the smoking of crack cocaine occur in a largely male population of drug addicts who are 8 to 10 years younger than the patient group that historically has perforations in the pyloroduodenal area. These perforations are usually 3 to 5 mm in diameter, and an antral mucosal biopsy for subsequent urease testing should be performed if the location and size of the ulcer allow this to be done safely. Omental patch closure is appropriate therapy for patients without a history of prior ulcer disease; antimicrobial therapy and omeprazole are prescribed when H. pylori is present.
Asunto(s)
Cocaína Crack/efectos adversos , Helicobacter pylori/aislamiento & purificación , Píloro/lesiones , Píloro/microbiología , Adulto , Femenino , Humanos , Masculino , Persona de Mediana Edad , Píloro/cirugía , Estudios RetrospectivosRESUMEN
BACKGROUND: Ultrasound is quickly becoming part of the trauma surgeon's practice, but its role in the patient with a penetrating truncal injury is not well defined. The purpose of this study was to evaluate the accuracy of emergency ultrasound as it was introduced into five Level I trauma centers for the diagnosis of acute hemopericardium. METHODS: Surgeons or cardiologists (four centers) and technicians (one center) performed pericardial ultrasound examinations on patients with penetrating truncal wounds. By protocol, patients with positive examinations underwent immediate operation. Vital signs, base deficit, time from examination to operation, operative findings, treatment, and outcome were recorded. RESULTS: Pericardial ultrasound examinations were performed in 261 patients. There were 225 (86.2%) true-negative, 29 (11.1%) true-positive, 0 false-negative, and 7 (2.7%) false-positive examinations, resulting in sensitivity of 100%, specificity of 96.9%, and accuracy of 97.3%. The mean time from ultrasound to operation was 12.1+/-5 minutes. CONCLUSION: Ultrasound should be the initial modality for the evaluation of patients with penetrating precordial wounds because it is accurate and rapid.
Asunto(s)
Lesiones Cardíacas/diagnóstico por imagen , Derrame Pericárdico/diagnóstico por imagen , Heridas Penetrantes/diagnóstico por imagen , Enfermedad Aguda , Adolescente , Adulto , Anciano , Algoritmos , Niño , Urgencias Médicas , Femenino , Lesiones Cardíacas/clasificación , Humanos , Puntaje de Gravedad del Traumatismo , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Estudios Prospectivos , Centros Traumatológicos , Ultrasonografía , Estados Unidos , Heridas Penetrantes/clasificaciónRESUMEN
In all its forms and applications, sonography plays a significant role in the management of injured patients, from the emergency department to beyond hospital discharge. The use of new and existing sonographic technology will increase because sonographic imaging and measurements are generally less invasive; are inexpensive; use no ionizing radiation; and are portable, repeatable, and, in many instances, as accurate as the so-called "contemporary gold standards." The training and credentialing of physicians in sonography is in evolution and will be an increasingly important issue with more widespread use and broader applications. The future of sonography in trauma care in the next millennium is bright, and surgeons and surgical residents are encouraged to gain proficiency and learn about this new surgical frontier as it evolves.
Asunto(s)
Heridas y Lesiones/diagnóstico por imagen , Costos y Análisis de Costo , Habilitación Profesional , Educación Médica , Servicio de Urgencia en Hospital , Diseño de Equipo , Predicción , Cirugía General/educación , Humanos , Ciencia del Laboratorio Clínico , Alta del Paciente , Radiología/educación , Ultrasonografía Intervencional , Heridas y Lesiones/terapiaRESUMEN
With the exception of the use of ECG to screen patients for blunt cardiac injury, recent advances in the diagnosis of thoracic trauma involve new technology. Use of surgeon-performed pericardial and pleural ultrasound for the detection of tamponade or hemothorax, TEE or spiral CT to diagnose rupture of the thoracic aorta, and thoracoscopy to evaluate a hemothorax or the integrity of the left hemidiaphragm are all standard techniques in modern trauma centers. In terms of treatment, emergency center thoracotomy is performed more selectively and with the adjunct of staple closure for cardiac wounds. Pulmonotomy is used selectively to control deep lobar hemorrhage and to avoid the need for an emergent lobectomy. Finally, nonoperative management of an intimal tear of the thoracic aorta or delayed operative management of a full-thickness tear in the patient with multiple injuries, using beta-blocker-induced relative hypotension, is rapidly becoming the standard of care throughout the United States.
Asunto(s)
Traumatismos Torácicos/diagnóstico , Disección Aórtica/cirugía , Disección Aórtica/terapia , Aneurisma de la Aorta Torácica/diagnóstico , Rotura de la Aorta/diagnóstico , Taponamiento Cardíaco/diagnóstico por imagen , Ecocardiografía Transesofágica , Lesiones Cardíacas/diagnóstico , Hemorragia/cirugía , Hemotórax/diagnóstico por imagen , Humanos , Enfermedades Pulmonares/cirugía , Neumonectomía , Grapado Quirúrgico , Traumatismos Torácicos/cirugía , Traumatismos Torácicos/terapia , Toracoscopía , Tomografía Computarizada por Rayos X , Heridas no Penetrantes/diagnósticoRESUMEN
BACKGROUND: The focused assessment for the sonographic examination of the trauma patient (FAST) is a rapid diagnostic test that sequentially surveys for hemopericardium and then the right upper quadrant (RUQ), left upper quadrant (LUQ), and pelvis for hemoperitoneum in patients with potential truncal injuries. The sequence of the abdominal part of the examination, however, has yet to be validated. The objectives of this multicenter study were as follows: (1) to determine where hemoperitoneum is most frequently identified on positive FAST examinations; and (2) to determine if a relationship exists between that areas and the organs injured. METHODS: Ultrasound registries from four Level I trauma centers identified patients who had true-positive FAST examinations. Demographic data, areas positive on the FAST, and organs injured were recorded; injuries were classified as multiple, single solid organ (liver or spleen), isolated hollow viscus, or retroperitoneal. Relationships between positive locations on the FAST examinations and the associations of organs injured to areas positive were assessed using McNamara's chi2 test; a p value < 0.05 was considered statistically significant. RESULTS: The RUQ was the most common site where hemoperitoneum was detected, and this was statistically significant compared with either the LUQ or the pelvis. Also, statistically significant correlations (p < 0.001) were observed between positive RUQ areas on the FAST and multiple injuries, single solid organ (liver or spleen) injury, and retroperitoneal injuries. CONCLUSION: Blood is most often found on the FAST in the RUQ area in patients with multiple intraperitoneal injuries or isolated injury to the liver, spleen, or retroperitoneum, but not when there is injury to a hollow viscus.