Evan Jacob Lipson, M.D.
https://www.hopkinsmedicine.org/profiles/results/directory/profile/2194148/evan-lipson
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Control of hemorrhage can initially be accomplished with digital pressure until the vessel can be exposed in anticipation of proximal and distal control with clamps or loops acne description eurax 20 gm order fast delivery. Primary repair with an end-to-end anastomosis is the preferred method of repair, if it can be done without tension. This method of repair is unlikely to be successful if the span of vessel lost is greater than 2 cm. In the vast majority of cases tension-free anastomosis cannot be achieved, and thus an interposition graft should be used with a reversed autogenous saphenous vein obtained from the contralateral leg. The majority of cases will present with clear clinical evidence of vascular injury with the presence of "hard" signs. In the absence of concomitant life-threatening injuries, the presence of one or more of these hard signs mandates immediate surgical exploration in the setting of uncomplicated penetrating trauma to the lower extremity. The use of hard signs present during physical examination as an indication for surgery has proved to be safe and reliable, with therapeutic exploration rates approaching 100%. Any further imaging is unnecessary and may result in delaying definitive repair and prolonging ischemia. Furthermore, asymptomatic vascular injuries, which are nonocclusive, have been shown to be benign and have a self-limited history 95% of the time. Because these occult injuries often spontaneously resolve and do not require repair, they do not require the expenditure of resources for detection. In addition Fryberg showed that those occult injuries that do show progression could be repaired without sequelae. B, the same patient demonstrating active bleeding, which began in the angiography suite. B, Angiogram in patient who also sustained a dislocated knee with blunt occlusion of the popliteal artery. C, Angiogram on patient who sustained a highimpact proximal tibial fracture with occluded popliteal artery. Note sharp take-off of the current tibial artery, tibioperoneal trunk, and its bifurcation giving rise to the posterior tibial and peroneal arteries (arrows). If associated injuries allow, systemic heparinization should be considered during the repair and postoperatively. This will help reduce the risk of distal thrombosis and increase the likelihood of successful revascularization.
In essence acne practice 20 gm eurax order fast delivery, ligation of the portal vein should be performed if an extensive injury is present and the patient requires a damage control operation. The surgeon must then be prepared to infuse significant amounts of fluids to reverse the transient peripheral hypovolemia secondary to splanchnic hypervolemia. More recently, Ivatury et al reported on 14 patients with injuries to the portal vein, among whom exsanguination occurred in 3, venorrhaphy was performed in 10 (of whom 6 survived), and ligation was done in 1 (who survived). Finally, Jurkovich reported on 56 injuries to the portal vein with 33 patients undergoing primary repair (42% mortality rate), 1 undergoing complex repair (died), and 10 undergoing ligation (90% mortality rate). It should be noted that complex reconstructions of the common or external iliac artery in the presence of significant enteric or fecal contamination in the pelvis remain a serious problem. Both end-to-end repairs and interposition grafts in this location have developed postoperative pseudoaneurysms and blowouts secondary to pelvic infection from the original contamination. Therefore, a surgeon should consider an extra-anatomic bypass such as a femorofemoral crossover in these situations. This would require ligation of the iliac stump with a double-running row of 4-0 or 5-0 polypropylene sutures, followed by coverage with noninjured retroperitoneum or a vascularized pedicle of omentum. Blunt trauma to the iliac arteries is less common as they are protected by the bony pelvis and lie deep in the retroperitoneum. Partial transections, avulsions, or intimal injuries with secondary thrombosis have all been reported in association with pelvic fractures. Of the 10 patients with blunt thromboses reported in the literature through 1997, most were treated with insertion of a prosthetic graft, although several underwent primary repairs. As noted earlier, the recent study of patients in the National Trauma Data Bank documented a 7. The survival rate among patients with injuries to the iliac arteries will vary with the number of associated injuries to the iliac vein, aorta, and vena cava, but ranged from 45% to 81% in older series and 45% to 55% in more recent series. Common, External, and Internal Iliac Veins Injuries to the common or external iliac vein are treated either with lateral repair using 4-0 or 5-0 polypropylene suture or with ligation. Indeed, the literature describing endovascular techniques in these potentially devastating injuries comprises mostly case reports and small case series and has been reviewed elsewhere. Endovascular therapy has a longstanding and well-established role in the management of renovascular injury and bleeding from pelvic fractures. As previously mentioned, renovascular injuries are difficult to manage operatively, especially when the renal artery is involved. As the diagnosis is often somewhat delayed and because of the relatively poor function of kidneys revascularized with open surgery, enthusiasm for attempts at open repair has waned.
Most such lesions require no specific treatment and resolve after weaning from the ventilator acne under eyes buy eurax 20 gm mastercard. Persistent Air Leaks and Bronchopleural Fistula Air leaks are not uncommon after chest trauma and typically resolve with tube thoracostomy. If such injury is excluded, then complete lung expansion is the cornerstone of therapy. Tracheostomy can, by decreasing the anatomic dead space, help to lower the peak airway pressures and thus at least slow the air leak. Scapular fractures are rarely associated with nonunion, but can cause chronic pain. Pain and disability are particularly associated with the degree of glenoid angulation and displacement if the fracture is treated nonoperatively. Clavicular fractures, by contrast, do carry an incidence of nonunion, though that number is somewhat in dispute. Early studies of nonoperative treatment of clavicle fractures revealed a nonunion rate as low as 0. The nonunion rate has in more recent studies been reported to be much higher, with a rate of 15% for conservative treatment of displaced middle third fractures. An analysis of 8 studies and 14 case series of midshaft clavicle fractures revealed an overall nonunion rate of 4. Other long-term sequelae of clavicular fractures include pain, cosmetic deformity, and thoracic outlet compression. For these patients, later operative fixation may successfully manage severe symptoms. Scapulothoracic dissociation, as would be expected, has significant long-term sequelae. Primary amputation of the affected limb, though a difficult decision, should be considered to avoid a defunctionalized limb when complete brachial avulsion has occurred. As the spectrum of thoracic injury is great and occurs in isolation as well as in part of multisystem trauma, providers need to understand the pathophysiology and impact of these injuries on overall patient care. Although most thoracic injuries may be managed nonoperatively, vigilance is required to detect injuries that are potentially life threatening and require urgent intervention. Complications of Bony Injuries Complications of bony injuries to the chest are most commonly related to pain. Sternal fractures in isolation or with only mild associated injury appear to have a relatively low incidence of postinjury sequelae; in one study, only 3% of patients at a 6-week follow-up had complaints requiring further intervention, including surgical intervention for a displaced fracture. Livingston D, Lavery R, Passannante M, et al: Admission or observation is not necessary after a negative abdominal computed tomographic scan in patients with suspected blunt abdominal trauma: results of a prospective, multi-institutional trial. Damschen D, Cogbill T, Siegel M: Scapulothoracic dissociation caused by blunt trauma. Di Bartolomeo S, Sanson G, Nardi G, et al: A population-based study on pneumothorax in severely traumatized patients.
Performing cardiorrhaphy for ventricular for stab wounds is usually less challenging than for gunshot wounds acne yahoo generic 20 gm eurax overnight delivery. Missile injuries often produce some degree of blast effect that causes myocardial fibers to retract. Frequently, missile injuries that have been successfully sutured and controlled enlarge, as the damaged myocardium retracts and becomes more friable. Frequently, these injuries require multiple sutures to control significant hemorrhage. In the presence of this scenario, bioprosthetic materials such as Teflon strips or pledgets are often needed to buttress the suture line. The sutures are then gently tied against the Teflon strip or pledget, which will buttress and reinforce the suture line. This maneuver must be repeated until total control of ventricular hemorrhage is achieved. The authors have recently used commercially made fibrin sealants to seal complex ventricular injuries. Use of Bioprosthetic and Autogenous Materials Trauma surgeons are familiar with the use of Teflon pledgets or strips to buttress suture lines on friable myocardial tissue. Mattox provided the first reference in the literature alluding to the use of this material. The authors strongly believe in the necessity to buttress complex suture lines and use Teflon when indicated. However, no studies have been performed to determine if the use of Teflon increases tensile strength of the repair. The use of autogenous materials such as the pericardium to bolster suture lines is also well known. A small flap is developed and excised from the pericardium to be used in a manner similar to use of Teflon pledgets. Inexperienced trauma surgeons will often suture the pericardium to a ventricular injury causing the chamber to be fixated, which leads to dysrhythmias. Injudicious or inappropriate placement of sutures during cardiorrhaphy may narrow and occlude a coronary artery or one of its branches. Therefore, it is recommended that sutures be placed underneath the bed of the coronary artery. Coronary arteries are usually divided into three segments: (1) proximal, (2) middle, and (3) distal. Injuries to the proximal segment of a coronary artery will usually require cardiopulmonary bypass for repair, although this is infrequently necessary.
In medical prophylactic strategy acne 26 year old female 20 gm eurax with mastercard, emphasis is placed on the use of bulletproof vests, helmets, and means for detecting and dismantling nonconventional explosives during the operations. However, these measures are not easy to implement in the tropical jungle where the armed conflict takes place in Colombia. The first important favorable result of this medical strategy was reflected in the morale and patriotism of the soldiers who feel backed by a highly qualified medical rescue team that can ensure immediate care and offer the highest probability of survival. Between January 2005 and December 2010, 8631 Colombian soldiers were wounded in action, and there were 2462 deaths in the field of military operations (28. In 2005, there were 531 deaths (35%) and this figure dropped to 425 (17%) in 2010 (Table 2). Training of the military personnel in first aid and resuscitation, together with the application of management guidelines for controlling acute bleeding and the use of prophylaxis for infection have been critical in improving the probability of survival of wounded soldiers. These results reflect the high degree of expertise in providing care to trauma patients with a multidisciplinary approach, without forgetting the process of physical, psychological, and social rehabilitation as a fundamental pillar of comprehensive patient care (Table 3). Infection is the main cause of nonacute hospital morbidity and fatality of patients wounded in action, except for the immediate sequelae of exsanguination. The following are clinical examples of refined damage control techniques in military trauma care: 1. Patient with penetrating thoracoabdominal gunshot wound that injured the jejunum, colon, spleen, diaphragm, left lung, and the thoracic aorta. Patient injured by a grenade fragment in the right lower limb causing femoral fracture and popliteal-femoral artery lesion. An additional example of multidisciplinary management using modern technologies is that of a patient wounded in action by an assault rifle grenade causing multiple severe injuries to the liver, right kidney, jejunum, colon, stomach, lung, and abdominal wall. The strategy for developing the medical care plan for patients wounded in action must consider all possible variables to include in the Haddon matrix analysis. Every medical care plan for trauma and critically ill patients, and in particular in military medicine, must be based on strong continuing academic training and education of each and every one of the team members. Although some aspects of that role have raised controversy, the rapid and effective transport of severely injured patients leaves little room for doubt. And although prehospital care has absolutely improved trauma outcomes since the early days of advanced life support in the field, some practices have been less positive than others. Although there was no scientific evidence to support that statement, it was intuitively obvious to most that the essence of the statement was true. But the blanket acceptance of that concept has not been without cost and risk, and more recent science has brought that concept into question. Much of our current trauma system structure is based upon the golden hour concept, with patients transported to trauma centers as rapidly as possible, even if that includes helicopter and lightsand-siren ground ambulance transport.
Many have attempted to define an oxygen consumption/delivery end point itself skin care 9 year old purchase eurax 20 gm with visa, but with no clear results. However, Gattinoni in a multicenter randomized controlled trial, and Heyland in a metaanalysis, showed no such benefit. Furthermore, a prospective, randomized controlled trial by Velmahos comparing conventional versus supranormal end points demonstrated that despite all efforts, only 70% of patients were able to reach these end points. They concluded that regardless of the resuscitation strategy, the ability of the patient to achieve "optimal hemodynamic values" significantly affected outcome. Looking at O2 delivery alone, McKinley et al found that there was no difference in outcome between groups resuscitated to an O2 delivery goal of 600 mL/minute/m2 versus 500 mL/minute/m2. Resuscitation to supranormal end points has been associated with numerous complications. Improvements in blood pressure and cardiac performance by vasoactive drugs can be negated by reduced tissue perfusion, and can often result in tissue ischemia. Hayes et al found in medical and surgical critically ill patients that the use of dobutamine to augment O2 delivery may actually increase mortality risk. Overresuscitation with crystalloid solutions can lead to the development of compartment syndromes, coagulopathy, hyperchloremic acidosis, and other iatrogenic complications, such as congestive heart failure, in patients with cardiac disease. Thoracic electrical bioimpedance measures the resistance of the chest to low-voltage currents. It is inversely related to thoracic fluid content, thereby allowing calculation of cardiac output. Several studies have demonstrated that this method correlates well with thermodilution measurements of cardiac output. However, a metaanalysis demonstrated clinical utility in trend analysis but not accuracy for diagnostic interpretation. There can also be significant imprecision with tachycardia or with pathologic fluid collections such as pleural effusions. Transesophageal echocardiography can assess preload and peak velocity measurements, as well as continuous cardiac output monitoring, and has been validated with thermodilution techniques. In animal models of hemorrhagic shock, it has accurately reflected the magnitude of change on cardiac output. Though technically feasible, interventions based on these data have yet to demonstrate direct clinical benefit. Furthermore, the underlying physiologic mechanisms behind the mathematical observations are poorly understood. Accumulation of lactate occurs under anaerobic conditions, and therefore, is a marker of inadequate microcirculatory oxygen delivery. Although elevated levels indicate a worsening degree of shock, there is no clear cutoff value to determine "satisfactory" resuscitation and adequate oxygen delivery to the tissues. Manikas et al found that initial and peak lactate levels, along with duration of hyperlactatemia, correlated with the development of multiple organ dysfunction syndrome after trauma.
Diseases
Bleeding after operative management of hepatic injuries is usually not subtle as evidenced by hemodynamic instability that can also be accompanied by brisk bleeding from operatively placed intraperitoneal drains acne wont go away generic eurax 20 gm buy online. However, a more subtle presentation is the hemodynamically stable patient with a partially distended abdomen accompanied by a decreasing hematocrit. In the past, reoperation to control bleeding from within the injured liver was promptly undertaken after correction of acidosis, hypothermia, and coagulation defects. In the hemodynamically unstable postoperative patient, reexploration is warranted. The same techniques apply, namely manual compression of the liver with concomitant intraoperative resuscitation, the Pringle maneuver, and finger fracture, if necessary, through the repaired area. If there is a concern that extensive hepatotomy may sever major vascular structures or hepatic bile ducts, persistent bleeding may be controlled by extralobar hepatic arterial ligation or balloon tamponade with Penrose and red rubber catheters. If a diligent search has failed to reveal a mechanical source of bleeding, a transfusionrelated coagulopathy is the most likely culprit. Under these circumstances, packing of the injured liver should be undertaken rapidly, following the guidelines for packing removal as described earlier. Findings from recent military data have revolutionized transfusion practices and contribute to a higher likelihood of prevention of coagulopathy and thus cessation and prevention of hemorrhage. More frequent platelet administration is also warranted, although the ideal ratio has not yet been identified. These changes in transfusion practices have had a marked impact upon controlling coagulation defects and managing hemorrhage from hepatic injuries, although the specific effects of this new approach in transfusion practices on outcomes in higher grade hepatic injuries has yet to be delineated. Patients undergoing resuscitation for significant hepatic injuries should have their bladder pressures measured as a matter of routine protocol. Late Complications: Biliary and Infectious Looking at all the studies to date; biliary and infectious complications run neck in neck, with rates averaging 3% to 6% for both, depending on the series. Biliary complications developed at a mean of 12 days after injury with a range of 2 to 38 days. Infectious complications on average developed on postinjury day 15 with a range of 1 to 90 days. Bile Collections/Biliary Fistula Nonoperative management of blunt hepatic injuries can be associated with the development of a collection of bile (biloma) or the formation of a biliary fistula. Even a biliary fistula (>50 mL/ day over 14 days) that is adequately drained usually closes spontaneously. Fifty-four percent of the injuries were secondary to blunt abdominal trauma; the remainder were due to a penetrating mechanism. Thoracobiliary fistula is a rare complication of penetrating thoracoabdominal trauma.
Signs and symptoms of gastrointestinal hemorrhage acne care buy 20 gm eurax overnight delivery, right upper quadrant pain, and jaundice (Sandblom triad) may occur 4 days to 1 month after injury. If hemobilia is the cause of the bleeding, angiography will demonstrate a hepatic artery pseudoaneurysm that can be embolized with steel coils, Gelfoam, or acrylate glue. Coils form the most permanent embolization when other methods may recannulize and present a risk of rebleeding. Surgical intervention is rarely necessary and not necessarily advisable secondary to the difficulty associated with anatomically accessing the bleeding vessel, which is often deep within the hepatic parenchyma, unless hemobilia is either associated with a large intrahepatic cavity or angiography is not available. If surgery is required, the optimal treatment is hepatic resection encompassing the large cavity and the pseudoaneurysm. Injury to the Intrahepatic Bile Ducts and Late Stricture Injuries to the intrahepatic bile ducts are rare. The long-term sequelae of spontaneous healing of the injured hepatic parenchyma surrounding both normal and disrupted intrahepatic bile ducts are presently unknown. Although disruption of secondary and tertiary biliary radicals within the liver occurs often, late intrahepatic bile duct stricture formation is an exceedingly rare occurrence. Perihepatic Sepsis/Abscess Perihepatic sepsis/abscess associated with complex hepatic injuries is a late complication and develops at a rate of 3% to 6%. Perihepatic sepsis, especially in the multiply injured patient, can lead to septic shock formation, systemic inflammatory response syndrome, and multiple organ failure, placing the patient at risk for a late death in the final classic trimodal trauma fatalities as described by Baker and Trunkey. Noninfectious factors can also initiate severe inflammatory responses that may culminate in multiple organ failure and death. Hepatic parenchymal healing appears to be virtually complete at 6 to 8 weeks after injury. In most large series of blunt hepatic injuries, associated brain injuries account for most (60% to 70%) of the deaths. Over the past 2 decades, the mortality rate of complex hepatic injuries has decreased, predominantly because of a reduction in deaths from liver hemorrhage.
This time frame appears to range from hours up to 14 years skin care reddit cheap eurax 20 gm with mastercard, but the majority seems to develop symptoms within 10 to 72 hours. Existing data affirm that if you diagnose these injuries during the asymptomatic period, you can effectively treat the patient to prevent stroke. Although optimal screening criteria have yet to be defined, current screening algorithms include patients considered at high risk based on their injury pattern. Demetriades D, Theodorou D, Cornwell E, et al: Evaluation of penetrating injuries of the neck: prospective study of 223 patients. Ginzburg E, Montalvo B, LeBlanc S, et al: the use of duplex ultrasonography in penetrating neck trauma. Sekharan J, Dennis W, Veldenz C, et al: Continued experience with physical examination alone for the evaluation and management of penetrating zone 2 neck injuries: results of 145 cases. The second proposed mechanism is hyperextension with contralateral rotation of the head. The third mechanism of injury is a direct laceration of the artery by adjacent fractures involving the sphenoid or petrous bones. With a fracture of the bony elements composing the vertebral foramen, the foramen transversarium, it is not surprising that the vertebral artery can also be injured directly. Regardless of the type of injury mechanism, there is intimal disruption of the carotid or vertebral artery. This intimal tear becomes a nidus for platelet aggregation that may lead to emboli or vessel occlusion, and subsequent stroke. Current screening algorithms include patients with signs or symptoms, as well as those considered at high risk by injury pattern (Table 1). Injury patterns not originally included that are now potential triggers for diagnostic imaging include mandible fracture, complex skull fracture, traumatic brain injury with thoracic injuries, scalp degloving, thoracic vascular injuries, and clothesline type injury/seatbelt abrasion with significant swelling, pain, or altered mental status. However, many clinicians appropriately questioned the need for subjecting patients to angiography. Angiography is labor intensive, costly, and not without risks; if not available at smaller hospitals, angiography requires emergent transfer of a patient for definitive evaluation. A very similar finding was noted by the Medical College of Virginia group; they screened 119 patients with 92 undergoing confirmatory angiography. Each of these studies recognize that injuries in the region of the skull base appear to be the most difficult to identify, underlining the importance of carefully examining this high-risk region.
Complications of the fracture and surgical repair include joint contracture skin care while pregnant 20 gm eurax order, ulnar neuropathy, heterotopic ossification, and prominent hardware. It is not uncommon for patients to undergo a delayed secondary operation to release a stiff elbow, remove heterotopic bone, or remove bothersome implants. If there are no fractures, passive motion to within 30 degrees of full extension without instability suggests a stable reduction, and mobilization of the elbow can begin within a few days when the patient is more comfortable. If the elbow is unstable after reduction, then it should be immobilized in 90 degrees of flexion for approximately 1 to 2 weeks before beginning motion. Recently, some have suggested that early active flexion exercises may be helpful in establishing a stable joint. Posterior elbow dislocation with associated fractures of the radial head and the coronoid process has been referred to as the "terrible triad of the elbow" because of the difficulties encountered in its management. Definitive treatment of these complex elbow dislocations usually involves surgery because they are highly unstable and are prone to numerous complications when inadequately treated. With operative treatment, the surgeon should attempt to restore elbow stability by: (1) reestablishing radiocapitellar contact by either repairing the radial head or replacing it with a prosthesis, (2) repairing the lateral collateral ligament, and (3) performing internal fixation of the coronoid fracture as needed. The outcome of nonoperative management of a simple elbow dislocation is usually highly successful. Poor results can occur with prolonged immobilization (usually greater than 3 weeks) and inadequate rehabilitation. Additionally, complex dislocations can also have recurrent instability, failure of fixation, and posttraumatic arthritis. Operative indications for radial head fractures include displacement greater than 3 mm, a bony block to forearm rotation, an EssexLopresti lesion. Surgery for radial head fracture may entail excision, internal fixation, or prosthetic replacement. Isolated radial head fractures without elbow instability can be safely excised without compromising elbow stability or function, especially in the elderly patient. Ring et al have shown that internal fixation is best when the number of radial head fragments is three or fewer. Coronoid Fractures the coronoid process of the ulna serves both as a buttress that prevents posterior displacement of the forearm and as the attachment site for the anterior band of the medial collateral ligament. In general, type I coronoid fractures can be managed without fixation of the fragment itself. Radial Head Fractures Radial head fractures are common injuries, accounting for one third of elbow fractures, and are frequently associated with elbow dislocations.
Tizgar, 23 years: Second, the age of the "denominator" patient population examined will clearly affect the disease incidence reported in administrative databases.
Trompok, 38 years: Many of these patients have concomitant vascular, airway, or intra-abdominal injuries that often require emergent operative intervention.
Riordian, 36 years: Pulmonary Artery and Swan-Ganz Catheter Placement A pulmonary artery catheter is usually introduced via the subclavian or internal jugular vein but the femoral vein can also be used.
Nemrok, 53 years: This Military Combat Injury Scale will enable comparisons to military and civilian legacy databases; will link test, injury, and military crew safety criteria for future military vehicle development; and will incorporate effects of multiple mechanisms of injury to enhance combat trauma outcome prediction.
Felipe, 58 years: Failure to provide sufficient analgesia in the setting of chest wall injuries has been shown to result in hypoventilation, retained secretions, increased atalectasis and lobar collapse, pneumonia, and respiratory failure.
Goose, 57 years: Basic Technique of Flexible Fiberoptic Bronchoscopy Almost all bronchoscopies for trauma patients, whether performed in the acute setting soon after trauma or later for pulmonary complications, are performed on patients who have endotracheal tubes in place and are mechanically ventilated.
Vak, 60 years: Contrast medium is instilled in small volumes (20 to 30 mL), ideally under fluoroscopy.
Ben, 33 years: As the injury progresses to the subacute phase, necrosis of the lining mucosa, and hemorrhagic tracheobronchitis are prominent.
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