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Renal Parenchymal Injuries Secondary to Blunt Abdominal Trauma in Childhood: A 10-Year Review
624
TRAUMA
required in 6 and 16, respectively. A total of 27 patients died but in only 7 was the renal injury believed to the principal cause of death. 3 figures, 5 tables, 18 references
Abstracter's comment. A total of 22 nephrectomies in 37 renal explorations bears out the concern that the acutely injured kidney often will wind up "in the bucket" if Gerota's fascia is opened. T. D. A.
Renal Parenchymal Injuries Secondary to Blunt Abdominal Trauma in Childhood: A 10-Year Review L. L. MORRIS, Departments of Surgery and Urology, Adelaide Children's Hospital, North Adelaide, Australia
S. AHMED AND
Brit. J. Urol., 54: 470-477 (Oct.) 1982 Renal parenchymal injuries secondary to blunt abdominal trauma in childhood are common. In the management of these injuries the primary aim is to save life but every effort also must be made to prevent complications and to preserve functioning renal parenchyma. For this reason it is essential to recognize the type of injury and to predict the possible therapeutic outcome. The authors review 66 cases of renal parenchymal injuries secondary to blunt abdominal trauma in children. Patient age ranged from 2 to 5 years in 4 subjects, 5 to 10 years in 39 and 10 to 12 years in 23. The injuries were classified radiologically as renal contusions, lacerations and transections. The clinical and radiological features of these injuries are presented in a series of radiographs and line drawings. A clear discussion of therapeutic modalities used with late results and complications is included. All of the clinical features of injury were more acute in patients with renal laceration and transection. Complications were more common in patients with renal transections and led to partial or total renal loss in a significant number of cases. Renal contusions and most lacerations should be managed nonoperatively but renal transections generally should be managed by operative intervention. W. W. H. 6 figures, 5 tables, 11 references
The Initial Evaluation of the Multiple Trauma Patient G. W. SHAFTAN, Department of Surgery of the State University of New York, Downstate Medical Center, Brooklyn, New York World J. Surg., 7: 19-25 (Jan.) 1983 Evaluation of the multiple trauma patient must be directed first to survival. In the patient with an irreparable injury, such as massive brain destruction and hemicorporectomy, or those with documented cardiac standstill for > 10 minutes no attempt should be made at resuscitation. Except for such rare situations a maximum effort at restoration of life is demanded, and the primary evaluation and resuscitation of such patients are based upon diagnosis and therapy of the failures of oxygen transport. The sequence clearly is ventilation, and circulatory and pulmonary failure. Secondary assessment and emergency treatment are related to intracranial, intrathoracic, intra-abdominal and extremity injuries. These 2 phases overlap. Thus, ventilation needs to be achieved without further compromise of spinal cord function, while the control of external bleeding aids circulatory function.
Additionally, effective cardiopulmonary resuscitation frequently improves cerebral function. Thus, although discussed separately in this paper, evaluation and resuscitation are complex endeavors that involve all of the injuries and organs on a varying time scale, in which the failures of oxygen transport are of primary importance because of the interval that leads to death. Effective resuscitation demands a detailed knowledge of cardiopulmonary physiology and an aggressive approach by the physician so that the various possible mechanisms may be evaluated and treatment instituted rapidly. In general, the patient should have good cardiopulmonary resuscitation before being transferred to the radiology department. Chest tubes might have to be placed after emergency room physical evaluation only. The various pump failures are recognized by the inadequate circulatory response to blood volume support, which usually is accompanied by an increasing right atrial pressure. Intra-abdominal and intrathoracic bleeding generally are diagnosed by chest or peritoneal lavage tubes without x-ray examination. Despite technical advances, assessment of the multiple injured patient still depends primarily on routine physical examination using ;;:;1 of the classical quartet of physical examination techniques, namely 1) inspection, 2) palpation, 3) percussion and 4) auscultation. A high index of suspicion, the systematic examination after immediate survival assessment and treatment, a written documentation of findings and sequential recording of numerous parameters of physiological changes usually permit accurate diagnosis, better treatment, reduced morbidity and lessened mortality for these patients. E.D. W.
Traumatic Shock in Polytrauma: Circulatory Parameters, Biochemistry, and Resuscitation K. F. W. MESSMER, Department of Experimental Surgery, Surgical Center, University of Heidelburg, Heidelburg, West Germany World J. Surg., 7: 26-30 (Jan.) 1983 Traumatic shock in patients with multiple injuries originates from afferent nociceptive impulses from the traumatized tissue and from inadequate nutritional perfusion elicited by hypovolemia. Therefore, the traumatic shock in these patients represents essentially hypovolemic shock in association with the effects and sequelae of tissue damage. The primary factor rendering the patient at peril of multi-organ failure is the persistence of impairment of the microcirculation. Resuscitation must take place efficiently to prevent shock, if possible, or to treat shock when manifest. The author emphasizes that patient evaluation include sequential assessment of the heart rate and arterial pressure, and when necessary and feasible, possibly invasive hemodynamic methods, such as a central venous catheter, immediate thoracocentesis with drainage and intubation with controlled respiration. Additionally, the use of pulmonary arterial and pulmonary capillary wedge pressures with the Swan-Ganz balloon catheter and cardiac output are reviewed. To establish the body core-periphery temperature gradient as an index of peripheral perfusion, central body temperature and skin temperature must be recorded under standard conditions. Because multiple trauma involves all mechanisms and systems for maintaining homeostasis it is desirable to obtain baseline values of the key biochemical parameters of these various systems.
TRAUMA
required in 6 and 16, respectively. A total of 27 patients died but in only 7 was the renal injury believed to the principal cause of death. 3 figures, 5 tables, 18 references
Abstracter's comment. A total of 22 nephrectomies in 37 renal explorations bears out the concern that the acutely injured kidney often will wind up "in the bucket" if Gerota's fascia is opened. T. D. A.
Renal Parenchymal Injuries Secondary to Blunt Abdominal Trauma in Childhood: A 10-Year Review L. L. MORRIS, Departments of Surgery and Urology, Adelaide Children's Hospital, North Adelaide, Australia
S. AHMED AND
Brit. J. Urol., 54: 470-477 (Oct.) 1982 Renal parenchymal injuries secondary to blunt abdominal trauma in childhood are common. In the management of these injuries the primary aim is to save life but every effort also must be made to prevent complications and to preserve functioning renal parenchyma. For this reason it is essential to recognize the type of injury and to predict the possible therapeutic outcome. The authors review 66 cases of renal parenchymal injuries secondary to blunt abdominal trauma in children. Patient age ranged from 2 to 5 years in 4 subjects, 5 to 10 years in 39 and 10 to 12 years in 23. The injuries were classified radiologically as renal contusions, lacerations and transections. The clinical and radiological features of these injuries are presented in a series of radiographs and line drawings. A clear discussion of therapeutic modalities used with late results and complications is included. All of the clinical features of injury were more acute in patients with renal laceration and transection. Complications were more common in patients with renal transections and led to partial or total renal loss in a significant number of cases. Renal contusions and most lacerations should be managed nonoperatively but renal transections generally should be managed by operative intervention. W. W. H. 6 figures, 5 tables, 11 references
The Initial Evaluation of the Multiple Trauma Patient G. W. SHAFTAN, Department of Surgery of the State University of New York, Downstate Medical Center, Brooklyn, New York World J. Surg., 7: 19-25 (Jan.) 1983 Evaluation of the multiple trauma patient must be directed first to survival. In the patient with an irreparable injury, such as massive brain destruction and hemicorporectomy, or those with documented cardiac standstill for > 10 minutes no attempt should be made at resuscitation. Except for such rare situations a maximum effort at restoration of life is demanded, and the primary evaluation and resuscitation of such patients are based upon diagnosis and therapy of the failures of oxygen transport. The sequence clearly is ventilation, and circulatory and pulmonary failure. Secondary assessment and emergency treatment are related to intracranial, intrathoracic, intra-abdominal and extremity injuries. These 2 phases overlap. Thus, ventilation needs to be achieved without further compromise of spinal cord function, while the control of external bleeding aids circulatory function.
Additionally, effective cardiopulmonary resuscitation frequently improves cerebral function. Thus, although discussed separately in this paper, evaluation and resuscitation are complex endeavors that involve all of the injuries and organs on a varying time scale, in which the failures of oxygen transport are of primary importance because of the interval that leads to death. Effective resuscitation demands a detailed knowledge of cardiopulmonary physiology and an aggressive approach by the physician so that the various possible mechanisms may be evaluated and treatment instituted rapidly. In general, the patient should have good cardiopulmonary resuscitation before being transferred to the radiology department. Chest tubes might have to be placed after emergency room physical evaluation only. The various pump failures are recognized by the inadequate circulatory response to blood volume support, which usually is accompanied by an increasing right atrial pressure. Intra-abdominal and intrathoracic bleeding generally are diagnosed by chest or peritoneal lavage tubes without x-ray examination. Despite technical advances, assessment of the multiple injured patient still depends primarily on routine physical examination using ;;:;1 of the classical quartet of physical examination techniques, namely 1) inspection, 2) palpation, 3) percussion and 4) auscultation. A high index of suspicion, the systematic examination after immediate survival assessment and treatment, a written documentation of findings and sequential recording of numerous parameters of physiological changes usually permit accurate diagnosis, better treatment, reduced morbidity and lessened mortality for these patients. E.D. W.
Traumatic Shock in Polytrauma: Circulatory Parameters, Biochemistry, and Resuscitation K. F. W. MESSMER, Department of Experimental Surgery, Surgical Center, University of Heidelburg, Heidelburg, West Germany World J. Surg., 7: 26-30 (Jan.) 1983 Traumatic shock in patients with multiple injuries originates from afferent nociceptive impulses from the traumatized tissue and from inadequate nutritional perfusion elicited by hypovolemia. Therefore, the traumatic shock in these patients represents essentially hypovolemic shock in association with the effects and sequelae of tissue damage. The primary factor rendering the patient at peril of multi-organ failure is the persistence of impairment of the microcirculation. Resuscitation must take place efficiently to prevent shock, if possible, or to treat shock when manifest. The author emphasizes that patient evaluation include sequential assessment of the heart rate and arterial pressure, and when necessary and feasible, possibly invasive hemodynamic methods, such as a central venous catheter, immediate thoracocentesis with drainage and intubation with controlled respiration. Additionally, the use of pulmonary arterial and pulmonary capillary wedge pressures with the Swan-Ganz balloon catheter and cardiac output are reviewed. To establish the body core-periphery temperature gradient as an index of peripheral perfusion, central body temperature and skin temperature must be recorded under standard conditions. Because multiple trauma involves all mechanisms and systems for maintaining homeostasis it is desirable to obtain baseline values of the key biochemical parameters of these various systems.