SINTERDODIC

ESTRUCTURA INTEGRAL DE UNA COMPETENCIA
Estudiantes de 8º semestre de Medicina
Asignatura: Cirugía


1. ACCION.
�?� Habilidades:
o Elaborar historias clínicas completas de las patologías mas frecuentes de tratamiento médico- quirúrgico.
o Solicitar e interpretar adecuadamente las pruebas de laboratorio, imágenes diagnósticas.
o Establecer un diagnóstico y manejo adecuado de acuerdo al nivel de complejidad donde se desempeña.
o Establecer una conducta terapéutica (toma de decisiones) con coherencia al concepto del binomio salud-enfermedad, teniendo en cuenta la concepción de salud del paciente y de su entorno.

�?� Destrezas:
o Para la ananmnesis, exploración física e impresiones diagnósticas.

2. OBJETO.
�?� Conocimientos: De la estructura y funcionamiento normal y patológico del ser humano desde los principios de las ciencias básicas, clínicas , sociales comunitarias y del comportamiento.
�?� Técnicas: Semiológicas
�?� Instrumentos: Los cinco sentidos apoyados por instrumentos como el estetoscopio, tensiómetro, termómetro, equipo para órganos de los sentidos, equipos de bio-protección.

3. CONTEXTO.
�?� Situación:
o Consulta externa
o Áreas de hospitalización
o Áreas de Urgencias

�?� Condiciones: En todos los niveles de atención en salud.




Elaborado por: Dr. José Mercado Herrera
Docente de Cirugía
















FORMATO PARA EVALUACION

Actividad. Historias Clínicas Fecha:

Estudiante o grupo evaluado:

Evaluador: Dr. Docente del Departamento de Cirugía

Competencia: SABER HACER: La historia clínica de pacientes con enfermedades medico- quirúrgicas.

Excelente (E) - Satisfactorio (B) - Aceptable (A) - Deficiente (D)


Competencia INDICADORES DE LOGRO Valoración cualitativa Valoración
cuantitativa
E B A D Número Letra
Ananmnesis Diligencia formato de historia
Obtiene relación médico-paciente
Efectúa interrogatorio sistemático
Examen Físico Realiza examen clínico
Realiza procedimientos diagnósticos
Impresión Clínica (Capacidad Diagnóstica) Identifica síntomas
Interpreta signos
Identifica factores de riesgo
Realiza propuesta diagnóstica
Efectúa sustentación de la propuesta
Enfoque clínico terapéutico
(Toma de decisiones) Realiza proposición de estudios diagnósticos
Sustenta propuesta de estudios diagnósticos
Anticipa posibles resultados
Interpreta resultados obtenidos
Realiza diagnóstico diferencial
Sustenta diagnóstico definitivo
Indica terapia apropiada
Identifica criterios de remisión
Indica seguimiento pertinente
EVALUACION DEFINITIVA
SUGERENCIAS ( FORTALEZAS Y DEBILIDADES)







Firma del Docente Firma del estudiante











FORMATO PARA EVALUACION

Actividad. Revisión de una enfermedad Fecha:

Estudiante o grupo evaluado:

Evaluador: Dr. Docente del Departamento de Cirugía

Competencia: SABER: Conocimiento de las principales enfermedades de tratamiento medico-quirúrgico
Excelente (E) - Satisfactorio (B) - Aceptable (A) - Deficiente (D)




Competencia INDICADORES DE LOGRO Valoración cualitativa Valoración
cuantitativa
E B A D Número Letra
Correlación básico Clínica
Define y clasifica la enfermedad
Explica el impacto epidemiológico

Explica la etiopatogenia
Explica la Fisiopatología
Identifica la historia natural
Identifica factores de riesgo
Interpreta signos
Realiza diagnóstico diferencial
Enfoque clínico terapéutico
(Toma de decisiones) Realiza proposición de estudios diagnósticos
Sustenta propuesta de estudios diagnósticos
Anticipa posibles resultados
Interpreta resultados obtenidos

Sustenta diagnóstico definitivo
Indica terapia apropiada
Identifica criterios de remisión
Indica seguimiento pertinente
EVALUACION DEFINITIVA
SUGERENCIAS ( FORTALEZAS Y DEBILIDADES)







Firma del Docente Firma del estudiante















FORMATO PARA EVALUACION

Actividad. Historias Clínicas Fecha: 1 al 15 de Septiembre de 2004

Estudiante o grupo evaluado:

Evaluador: Dr. Docente del Departamento de Cirugía

Competencia: SER: Actitudes , valores, deontología médica
Excelente (E) - Satisfactorio (B) - Aceptable (A) - Deficiente (D)

Competencia INDICADORES DE LOGRO Valoración cualitativa Valoración
cuantitativa
E B A D Número Letra
Actitudes y desempeño

Trabajo personal y en equipo Responsabilidad
Relaciones interpersonales
Sensibilidad social
Interés -auto motivación
Liderazgo y autonomía
Presentación personal
Compromiso institucional
EVALUACION DEFINITIVA
SUGERENCIAS ( FORTALEZAS Y DEBILIDADES)








Firma del Docente Firma del estudiante
























FORMATO PARA EVALUACION

Actividad. Historias Clínicas Fecha: 1 al 15 de Septiembre de 2004

Estudiante o grupo evaluado:

Evaluador: Dr. Docente del Departamento de Cirugía

Competencia: COMUNICATIVA: Habilidades comunicativas
Excelente (E) - Satisfactorio (B) - Aceptable (A) - Deficiente (D)

Competencia INDICADORES DE LOGRO Valoración cualitativa Valoración
cuantitativa
E B A D Número Letra
Habilidades comunicativas Habilidad para escuchar
Expresión oral
Expresión escrita
Pertinencia del lenguaje
Manejo de ayudas educativas
Coherencia para la comunicación con el paciente y sus familiares

EVALUACION DEFINITIVA
SUGERENCIAS ( FORTALEZAS Y DEBILIDADES)







Firma del Docente Firma del estudiante

GRUPO B

8.- ¿Cuáles son las principales indicaciones de cirugía en la HVDA?

9.- Cómo debe ser el enfoque de manejo de un paciente con HVDA?

10.- Defina qué es la HVDB y cuáles son las principales causas?

11.- Cuáles son las principales indicaciones quirúrgicas de HVDB?

12 ¿Cómo debe ser el enfoque de manejo de la HVDB?

13.- ¿En qué consiste las angiodisplasiasas del colon?

14.- ¿Qué velocidad de sangrado se requiere para que a) una arteriografía selectiva sea positiv? b) una gammagrafía con eritrocitos marcados sea positiva?

Preguntas problémicas



GRUPO A

1.- ¿Qué es hematemesis, melena, y hematoquesia?

2.- ¿ Cómo se define una HVDA ?

3.- ¿Qué porcentaje de pacientes con hemorragia de vías digestivas se intervienen quirúrgicamente?

4.- ¿ Cuáles son las principales causas de HVDA y cuáles las mas frecuentes en nuestro medio?

5.- ¿Que es hemobilia, cómo se produce y cuál es su tratamiento?

6.- ¿Cuáles métodos no quirúrgicos conoce para el control del sangrado de várices esofágicas?

7.-¿ Cómo debe ser el tratamiento quirúrgico de la ulcera péptica sangrante?

DBvendor=ProQuest Information and Learning Company
DBname=ProQuest
Text-encoding=ASCII

VENDOR - ProQuest Information and Learning Company
DATABASE - ProQuest
AUTHOR - Harris DG; Rossouw GJ; Pretorius J; Van Wyk J; Janson JT
TITLE - Delayed pericardial effusion following stab wounds to the chest.
JOURNAL - Eur J Cardiothorac Surg
DATE - 2003 Apr
ISSN - 1010-7940
VOLUME - 23(4) , p. 473-6
ABSTRACT - INTRODUCTION: Delayed pericardial effusion following penetrating cardiac trauma has not been commonly reported, and the exact incidence remains unknown. It was more common before 1960, when pericardiocentesis was still a popular treatment for stable patients presenting with a stab wound to the heart. MATERIAL AND METHODS: During an 8-year period, 24 patients were diagnosed with delayed pericardial effusions following a recent stab wound over the chest. Nine patients had been initially treated at our trauma unit, and the remaining 15 patients were referred by a peripheral clinic. RESULTS: Diagnosis was confirmed by cardiac ultrasound or echocardiogram. Sixteen patients were adequately treated by subxiphoid drainage. Sternotomy was performed in five patients, left thoracotomy in two and right thoracotomy in one patient. No actively bleeding injuries were found. Three patients had active infection in the pericardial space. Fever, pleural effusions and ascites were common associated findings. Additional procedures performed included laparotomy for acute abdominal pain in two patients (both negative), and simultaneous drainage of a pleural empyema. Two patients with staphylococcal pericardial infections required subsequent pericardiectomy. SUMMARY: The diagnosis of a penetrating cardiac patient may be missed in a stable patient, and patients may present with delayed pericardial effusions and tamponade. Post pericardiotomy syndrome may be the most common cause of delayed pericardial effusion, followed by sepsis. Subxiphoid pericardial window is an adequate form of treatment. Recent literature reveals that occult cardiac injury is not uncommon, thus a case should be made to actively investigate all patients with precordial stab wounds with cardiac ultrasound or echocardiogram.
ER -

VENDOR - ProQuest Information and Learning Company
DATABASE - ProQuest
AUTHOR - Wei T; Zeng C; Wang C; Chen L; Wang L
TITLE - Acute myocardial infarction and congestive heart failure following a blunt chest trauma.
JOURNAL - Heart Vessels
DATE - 2002 Dec
ISSN - 0910-8327
VOLUME - 17(2) , p. 77-9
ABSTRACT - A 42-year-old man experienced chest discomfort after being struck by a low-speed flying object. Two weeks after the accident, the patient complained of severe shortness of breath accompanied by ankle edema. Chest X-ray indicated acute pulmonary edema and left ventricular enlargement. There were Q waves and flat T waves in the precordial ECG leads. Echocardiography revealed dyskinesis in the interventricular septum, hypokinesis in the anterior left ventricular wall, and severe impairment of left ventricular function. A coronary angiogram showed 90% stenosis of the proximal left descending coronary artery. Subsequent medical therapy with diuretics and enalapril led to significant improvement in ventricular function and the patient's symptoms. We conclude that a mild blunt chest trauma can cause myocardial infarction and severe congestive heart failure. Careful investigations into myocardial ischemia or infarction and a close follow-up should be conducted in all patients presenting with a blunt chest trauma.
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VENDOR - ProQuest Information and Learning Company
DATABASE - ProQuest
AUTHOR - Pons F; Jancovici R; Bonnet PM; Chapuis O; de Kerangal X; Lang-Lazdunski L
TITLE - The role of videothoracoscopy in management of precordial thoracic penetrating injuries.
JOURNAL - Eur J Cardiothorac Surg
DATE - 2002 Jul
ISSN - 1010-7940
VOLUME - 22(1) , p. 7-12
ABSTRACT - OBJECTIVES: To report on the value of diagnostic videothoracoscopy in patients with possible penetrating cardiac wounds. METHODS: Thirteen patients admitted over a 4 year period with hemodynamic stability and a penetrating injury in cardiac proximity had exploratory videothoracoscopy. All data related to those patients were retrospectively reviewed. RESULTS: Eighty-five percent of patients had videothoracoscopy within 8 h of trauma. In most cases (eight of 13), operations were performed on patients in the supine position with the chest slightly rotated. Nine patients had a left hemothorax, five had pulmonary lacerations and five had a bleeding parietal vessel. Pericardial exploration was achieved either by direct vision (nine patients), or by the performance of a pericardial window (four patients). Acute hemopericardium related to a cardiac wound was diagnosed in two patients. Procedures included evacuation of clotted hemothorax (six patients), stapling of pulmonary laceration (four patients), and electrocoagulation of bleeding parietal vessel (four patients). Four patients required conversion to thoracotomy: two for repair of a cardiac wound, one for adequate exposure of the pericardium and one for ligation of a bleeding intercostal artery. The mean operative time was 37+/-23 min. Two patients experienced postoperative complications (coagulopathy, subcutaneous emphysema) and the in-hospital mortality was 0%. The mean hospital stay was 10+/-4 days. CONCLUSIONS: In the hands of an experienced surgeon, videothoracoscopy may represent a valid alternative to subxiphoid pericardial window in patients with hemodynamic stability and a suspected cardiac wound. Videothoracoscopy can rule out a cardiac injury and allows for the performance of associated procedures such as diaphragm assessment/repair, evacuation of clotted hemothorax, hemostasis of parietal vessels or pulmonary laceration and removal of projectiles.
ER -

VENDOR - ProQuest Information and Learning Company
DATABASE - ProQuest
AUTHOR - Klouche K; Bisera J; Kamohara T; Povoas H; Tang W; Weil MH
TITLE - A selective alpha(2)-adrenergic agonist for cardiac resuscitation.
JOURNAL - J Lab Clin Med
DATE - 2002 Jul
ISSN - 0022-2143
VOLUME - 140(1) , p. 27-34
ABSTRACT - The effects of selective alpha(2)-adrenergic agonist alpha-methylnorepinephrine on the initial success of resuscitation and postresuscitation myocardial function were compared with nonselective alpha- and beta-adrenergic epinephrine in a swine model of cardiac arrest. Epinephrine, the primary pharmacological intervention in the treatment of cardiac arrest, improves immediate outcome. However, epinephrine increases the severity of myocardial dysfunction after cardiac resuscitation. Both inotropic and chronotropic actions provoke disproportionate increases in myocardial oxygen consumption by the ischemic heart, prompting this study, in which we hypothesized that a selective alpha(2)-adrenergic agonist, alpha-methylnorepinephrine (alpha-MNE), would moderate these adverse effects of epinephrine and minimize postresuscitation myocardial dysfunction. After 7 minutes of untreated ventricular fibrillation (VF) in 14 anesthetized male domestic pigs, precordial compression at a fixed rate of 80 compressions/min was begun, along with mechanical ventilation. Either alpha-MNE (100 microg/kg) or epinephrine (20 microg/kg) was administered as a bolus after 2 minutes of precordial compression. After an additional 4 minutes of precordial compression, defibrillation was attempted. Left ventricular systolic and diastolic function was quantitated with the use of transesophageal echo-Doppler imaging. Comparable increases in coronary perfusion pressure to 15 mm Hg were observed after the administration of both drugs. All animals were successfully resuscitated; epinephrine and alpha-MNE were equally quick in restoring spontaneous circulation after 7 minutes of untreated VF. Ejection fraction was reduced by 35% and 14% by epinephrine and alpha-MNE, respectively, after resuscitation. Epinephrine and alpha-MNE increased postresuscitation heart rate by 38% and 15%, respectively. Accordingly, significantly less postresuscitation impairment followed the administration of alpha-MNE. alpha-MNE, a selective alpha-adrenergic agonist, was as effective as epinephrine in restoring spontaneous circulation after 7 minutes of untreated VF in a porcine model for CPR and demonstrated lesser postresuscitation myocardial injury.
ER -

VENDOR - ProQuest Information and Learning Company
DATABASE - ProQuest
AUTHOR - Carrillo EH; Boaz PW; Ali AT; Guinn BJ
TITLE - Transthoracic ultrasonography is an alternative to subxyphoid ultrasonography for the diagnosis of hemopericardium in penetrating precordial trauma.
JOURNAL - Am J Surg
DATE - 2000 Jan
ISSN - 0002-9610
VOLUME - 179(1) , p. 34-6
ABSTRACT - BACKGROUND: Surgeon-performed ultrasonography is increasingly becoming part of the initial evaluation of patients after blunt or penetrating trauma. Currently, most institutions obtain a subxyphoid or subcostal view of the heart and pericardial space, and a three-view ultrasonogram of the abdomen to detect blood in the pericardial sac or in three dependent abdominal areas. METHODS: A left parastemal standard transverse transthoracic view is described in addition to the aforementioned views. This facilitates the visualization of the pericardial sac when a subxyphoid or subcostal view cannot be obtained because of anatomical reasons (narrow subxyphoid space) or local factors (pain, fractures, subcutaneous emphysema, or chest wall contusion). RESULTS: The transthoracic view can be useful in patients where the subxyphoid view is difficult to obtain through the conventional approach. In most patients an excellent view of the pericardial sac and ventricles can be obtained and, therefore, expedites the diagnosis and treatment of patients with hemopericardium. CONCLUSION: Surgeon-performed ultrasonography has become the diagnostic test of choice for patients suspected of having hemopericardium and cardiac tamponade. Transthoracic ultrasonography is an excellent alternative for those patients where a subxyphoid or subcostal view to visualize the pericardial sac and heart cannot be obtained owing to local or anatomical factors.
ER -

VENDOR - ProQuest Information and Learning Company
DATABASE - ProQuest
AUTHOR - Harris DG; Rossouw GJ; Van Rooyen T; Pretorius J; Papagiannopoulos KA
TITLE - Current evaluation of cardiac stab wounds.
JOURNAL - Ann Thorac Surg
DATE - 1999 Dec
ISSN - 0003-4975
VOLUME - 68(6) , p. 2119-22
ABSTRACT - BACKGROUND: Patients with penetrating cardiac injuries may be stable or only mildly shocked, especially if the laceration has sealed off and the patient has been aggressively resuscitated. Clinical signs, chest roentgenograms, pericardiocentesis, and subxiphoid window are not always helpful in establishing the diagnosis. We reflect on the current evaluation based on 128 patients. METHODS: There were four groups of patients, ranging from lifeless (group I) to stable (group IV). Patients in groups I and II were prepared immediately for operation. Those in groups III and IV were often investigated further (chest roentgenogram and cardiac ultrasound). RESULTS: Mortality was 8%. Significant findings were a precordial stab, central venous pressure of more than 15 cm of water, one or more clinical signs of tamponade, and initial shock. Cardiac ultrasound was performed in 5 patients in group II (15%), 14 patients in group III (48%), and 37 patients in group IV (86%). There were no false positives, and 6 false negatives (11%). Thirty-one patients (24%) had clotted lacerations. There were no negative sternotomies. CONCLUSIONS: Efficient fluid resuscitation and rapid confirmation of diagnosis with cardiac ultrasound should decrease mortality. Stable patients with a precordial wound should undergo cardiac ultrasound or echocardiogram. Diagnosis may be reliably confirmed in these patients whose clinical signs often fluctuate (or rapidly deteriorate).
ER -

VENDOR - ProQuest Information and Learning Company
DATABASE - ProQuest
AUTHOR - Rozycki GS; Newman PG
TITLE - Surgeon-performed ultrasound for the assessment of abdominal injuries.
JOURNAL - Adv Surg
DATE - 1999
ISSN - 0065-3411
VOLUME - 33() , p. 243-59
ABSTRACT - 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.
ER -

VENDOR - ProQuest Information and Learning Company
DATABASE - ProQuest
AUTHOR - Guan DW; Li DX; Kondo T; Jia JT; Ohshima T
TITLE - Morphological findings of 'cardiac concussion' due to experimental blunt impact to the precordial region.
JOURNAL - Forensic Sci Int
DATE - 1999 Mar 29
ISSN - 0379-0738
VOLUME - 100(3) , p. 211-20
ABSTRACT - The dog's precordial region at the sternum was impacted with a mechanical elastic-cord propelled impactor at the velocity of 8.0 m/s. The left and right intraventricular pressures and electrocardiogram (ECG) were monitored continuously for 60 min after the impact. The micro- and ultra-structure of myocardium were examined. Localization of myocardial myoglobin (Mb), creatine kinase BB (CK-BB) and creatine kinase MM (CK-MM) as well as plasma membrane permeability were studied by immunohistochemical and lanthanum probe techniques. Upon the impact, abrupt over-pressures within both ventricles were recorded with transient depression of the left ventricular systolic pressure. In all the dogs, some rhythm- and conduction-disorders were noted, which lasted transiently and resumed to normal sinus rhythm. At autopsy, no gross injuries of the heart were detected, and microscopic examination showed no visible myocardial lesions. However, immunohistochemically, focal patchy loss of myocardial Mb, CK-BB and CK-MM was identified with scattered deposition of these substances between myocardial fibers elsewhere. Such changes as relaxed myofibrils with widened I band, contracted myofibrils and broken cristae of the mitochondria were observed in myocardial ultrastructure. Lanthanum particles deposited inside the mitochondria. These results indicate that increase in cardiac cell membrane permeability and ultrastructural damage in myocardium may be involved even in cardiac concussion.
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VENDOR - ProQuest Information and Learning Company
DATABASE - ProQuest
AUTHOR - Rozycki GS; Schmidt JA; Han DC; Harviel JD; Figueredo V; Hammerman D; Davis F; Hoyt DB; Knudson MM; Ochsner MG; Feliciano DV
TITLE - The role of ultrasound in patients with possible penetrating cardiac wounds: a prospective multicenter study.
JOURNAL - J Trauma
DATE - 1999 Apr
ISSN - 0022-5282
VOLUME - 46(4) , p. 543-51; discussion 551-2
ABSTRACT - 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.
ER -

VENDOR - ProQuest Information and Learning Company
DATABASE - ProQuest
AUTHOR - Michalodimitrakis EN; Tsatsakis AM
TITLE - Vehicular accidents and cardiac concussion. A traumatic connection.
JOURNAL - Am J Forensic Med Pathol
DATE - 1997 Sep
ISSN - 0195-7910
VOLUME - 18(3) , p. 282-4
ABSTRACT - Concussion of the heart (commotio cordis) occurs in traffic accidents in which blunt force impact over the precordial area occurs, even in the absence of multiple blunt force injuries. The functional dynamics of the heart, with ventricular arrythmias and conduction disturbances, serve as the pathophysiological basis of this condition. As a cause of death in vehicular accidents, it is less common than other causes. However, it should be considered in the differential diagnosis, especially in cases with minor or no apparent injuries.
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VENDOR - ProQuest Information and Learning Company
DATABASE - ProQuest
AUTHOR - Porter JM; Ivatury RR
TITLE - Unwillingness to lie supine? a sign of pericardial tamponade.
JOURNAL - Am Surg
DATE - 1997 Apr
ISSN - 0003-1348
VOLUME - 63(4) , p. 365-6
ABSTRACT - The stable patient with an occult cardiac injury can represent a diagnostic dilemma. The trauma surgeon must maintain a high index of suspicion for cardiac injury with precordial penetrating trauma. Herein are reported two cases of stable patients with penetrating precordial trauma who refused to lie supine because of difficulty breathing, preferring to sit upright, who eventually had positive pericardial windows and sternotomies for repair of cardiac injuries. The presence of this clinical finding, unwillingness to lie supine, should make the trauma surgeon highly suspicious of a cardiac injury and to proceed quickly to echocardiography or, preferably, to subxiphoid pericardial window to rule out cardiac injury.
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VENDOR - ProQuest Information and Learning Company
DATABASE - ProQuest
AUTHOR - Grewal H; Rohman M; Simon RJ; Divakar M; Ivatury RR
TITLE - Evaluation of subxiphoid pericardial window used in the detection of occult cardiac injury.
JOURNAL - Injury
DATE - 1995 Jun
ISSN - 0020-1383
VOLUME - 26(5) , p. 305-10
ABSTRACT - We critically evaluated several diagnostic modalities (clinical criteria, subxiphoid pericardial window (SPW) and laparoscopy) used in the detection of occult cardiac injury in haemodynamically stable patients at high risk of cardiac injury. Over 5 years, 122 patients were admitted to a Level I trauma centre with such an injury. They sustained 69 stab wounds, and 53 gunshot wounds. Sites of penetration were: precordial (81), right chest (25), lateral chest (13), thoracoabdominal (40) and abdominal (19). Vital signs in the emergency room were (mean +/- SD): systolic BP, 111 +/- 23.2 mmHg; HR, 106 +/- 18.7; GCS, 13.6 +/- 1.3; and CVP, 17 +/- 7.8 cmH2O. SPW was performed in all patients and was positive for haemopericardium in 26 patients, 24 (92 per cent) of whom had a cardiac injury at operation. Two patients had pericardial lacerations without cardiac injury. In addition, 14 patients with lower precordial and thoracoabdominal wounds underwent laparoscopy. At laparoscopy, the pericardium was evaluated by transdiaphragmatic inspection in 10 patients. The presence (two) or absence (eight) of blood within the pericardium was accurately predicted and verified by SPW. Univariate and multiple logistic regression analysis of clinical data failed to reveal any significant predictor of cardiac injury. SPW remains the standard means of diagnosing occult cardiac injury in high-risk patients. Since the incidence of occult cardiac injury in haemodynamically stable patients is 20 per cent, SPW should be used liberally. Laparoscopy may have a role in evaluating the pericardium in the subgroup of patients with lower chest wounds, and it facilitates inspection of intra-abdominal viscera and diaphragm at the same time.
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VENDOR - ProQuest Information and Learning Company
DATABASE - ProQuest
AUTHOR - Nearing BD; Verrier RL; Oesterle SN
TITLE - Quantification of ischaemia induced vulnerability by precordial T wave alternans analysis in dog and human.
JOURNAL - Cardiovasc Res
DATE - 1994 Sep
ISSN - 0008-6363
VOLUME - 28(9) , p. 1440-9
ABSTRACT - OBJECTIVE: The aim was to examine the regional specificity of T wave alternans and the value of precordial ECG monitoring for non-invasive tracking of cardiac vulnerability during acute coronary artery occlusion and reperfusion in animals and humans. METHODS: The left ventricular ECG was monitored during two acute occlusions of the left anterior descending coronary artery and subsequent reperfusion in each of 61 chloralose anaesthetised dogs, and over 150,000 beats were analysed. In subgroups of these animals, lead II and precordial lead V5 were monitored or epicardial electrograms were recorded. In seven patients, lead II and precordial leads V1-6 were monitored during angioplasty. T wave alternans magnitude was quantified by complex demodulation. The same recording equipment and analytical methods were used in the clinical and experimental studies. RESULTS: A close temporal correspondence and linear correlation was found between T wave alternans magnitude--but not ST segment depression or ventricular premature beat incidence--and the incidence of spontaneous ventricular tachycardia and fibrillation during acute coronary artery occlusion and reperfusion. Epicardial electrograms showed alternans to be regionally specific, occurring in the ischaemic but not in the normal zones, and to predict spontaneous ventricular fibrillation and ventricular tachycardia (sensitivity = 79%, specificity = 86%). A significant linear relationship (r2 = 0.86, p < 0.01) between alternans magnitude detected in V5 and the left ventricular intracavitary lead indicates that the precordial leads could be used to assess cardiac vulnerability from the body surface. Lead V5 showed greater resolution than lead II. In humans, the precordial leads overlying the ischaemic zone were superior to lead II or Frank leads for alternans detection during both the occlusion and the reperfusion phases. In both animals and humans, alternation invariably occurred during the first half of the T wave, coinciding with the vulnerable period of the cardiac cycle and suggesting an important electrophysiological link to cardiac vulnerability. CONCLUSIONS: Alternans is regionally specific and is linearly projected to the precordium. Quantification of its magnitude in the precordial ECG may provide a non-invasive means for tracking cardiac vulnerability during acute myocardial ischaemia and reperfusion in both animals and humans.
ER -

VENDOR - ProQuest Information and Learning Company
DATABASE - ProQuest
AUTHOR - Hearns PA
TITLE - Differentiating ischemia, injury, infarction: expanding the 12-lead electrocardiogram.
JOURNAL - Dimens Crit Care Nurs
DATE - 1994 Jul-Aug
ISSN - 0730-4625
VOLUME - 13(4) , p. 172-8; quiz 179-83
ABSTRACT - In 50% of cases of myocardial infarction, the 12-lead electrocardiogram (ECG) is not diagnostic of the infarction. Critical care nurses, aware of subtle ECG changes coupled with patient complaint of chest pain, may improve recognition of myocardial infarction. Expanding the 12-lead ECG to include right ventricular precordial leads and posterior chest leads facilitates recognition of right ventricular infarction and posterior wall infarction not recognized on the standard 12-lead ECG.
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VENDOR - ProQuest Information and Learning Company
DATABASE - ProQuest
AUTHOR - Aaland MO; Sherman R; Bryan FC 3rd
TITLE - Two-dimensional echocardiogram in hemodynamically stable victims of penetrating precordial trauma.
JOURNAL - Am Surg
DATE - 1994 Jun
ISSN - 0003-1348
VOLUME - 60(6) , p. 412-5
ABSTRACT - Hemodynamically stable patients with penetrating precordial trauma present a diagnostic dilemma. Previous reports utilizing subxiphoid pericardial windows as the diagnostic measure demonstrated negative rates ranging from 75-82%. In an effort to decrease the high rate of negative invasive procedures, the following study was undertaken. Protocol: All hemodynamically stable victims with penetrating precordial trauma were evaluated using emergent echocardiogram over a one year period at Grady Memorial Hospital. If the echocardiogram was negative for the presence of pericardial fluid, the patient was observed for 24 hours. If pericardial fluid was detected, the patient underwent a subxiphoid pericardial window. Patients requiring immediate surgery for other reasons, i.e. peritonitis, underwent a pericardial window during the procedure without preoperative echocardiogram. Results: Fifty-three patients were entered into the study. The injuries sustained included 40 stab wounds, 11 gunshot wounds and 2 shotgun injuries. Two echocardiograms (8%) demonstrated > 20cc of fluid and were followed by pericardial windows. The remaining 51 patients did well without the need for pericardial window. Nine additional hemodynamically stable patients underwent pericardial windows without preoperative echocardiograms. Only one of these was positive with a cardiac injury proven at sternotomy. Conclusion: Echocardiogram is a sensitive noninvasive method of evaluating hemodynamically stable victims of penetrating chest wounds in proximity to the heart.
ER -

VENDOR - ProQuest Information and Learning Company
DATABASE - ProQuest
AUTHOR - Klinkenberg TJ; Lacquet LK; Kaan GL
TITLE - Delayed sequelae of penetrating chest trauma: a plea for early sternotomy.
JOURNAL - J Cardiovasc Surg (Torino)
DATE - 1994 Apr
ISSN - 0021-9509
VOLUME - 35(2) , p. 173-5
ABSTRACT - Penetrating wounds of the anterior chest wall are often associated with cardiac tamponade. Eighty to ninety percent of stab wounds to the heart result in acute tamponade, whereas delayed cardiac tamponade or hemothorax are rare, but hurtful for the patient. Of the cases reviewed, fifty percent of the patients who underwent sternotomy required repair of cardiac injuries. The presented case report adds further justification for early sternotomy in case of precordial penetrating chest injury in the danger zone.
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VENDOR - ProQuest Information and Learning Company
DATABASE - ProQuest
AUTHOR - Freshman SP; Weber CJ; Wisner DH
TITLE - 2-D echocardiography: emergent use in the evaluation of penetrating precordial trauma.
JOURNAL - J Trauma
DATE - 1991 Jul
ISSN - 0022-5282
VOLUME - 31(7) , p. 902-5; discussion 905-6
ABSTRACT - Diagnosis of cardiac injury in stable patients suffering penetrating precordial trauma has relied on observation, subxiphoid window, or exploratory thoracotomy. Previous reports have stressed the need for an alternative noninvasive diagnostic test. Although the use of echocardiography (ECHO) in this patient population has been suggested, to our knowledge no report thus far has presented extensive experience with this technique. We present our experience over 3 years with 36 patients in whom emergent ECHO was used as part of their initial work-up. Injuries included single stab wounds (17), multiple stab wounds (14), and gunshot wounds (5). Four patients (11%) had jugular venous distention, and 12 (33%) were tachycardic. None had a systolic blood pressure below 90 mm Hg. Four ECHOs (11%) were positive for pericardial effusion. No valvular abnormalities were detected. Three of the effusions were small and these patients were triaged to monitored beds and observed. All three effusions resolved on serial echocardiography. The fourth patient underwent an uneventful operative repair of a left ventricular laceration. Although the yield is low, emergent 2-D ECHO is a valuable tool in the triage of stable penetrating trauma patients when cardiac injury is suspected. Patients without effusion can be discharged or triaged to a ward bed. Small effusions can be observed in a monitored setting with serial examinations, while large effusions should be treated surgically. Echocardiography is less expensive than ICU admission and less invasive than either subxiphoid window or thoracotomy. There are no known complications associated with the procedure and it is recommended for emergent use when available.
ER -

VENDOR - ProQuest Information and Learning Company
DATABASE - ProQuest
AUTHOR - Baxter BT; Pomerantz M; Moore FA; Moore EE
TITLE - Intraoperative cardiac sampling following penetrating wounds: a technique for early detection of traumatic intracardiac shunts--case report.
JOURNAL - J Trauma
DATE - 1989 Dec
ISSN - 0022-5282
VOLUME - 29(12) , p. 1719-20
ABSTRACT - Intracardiac shunts complicating penetrating heart wounds may be unrecognized during the early postoperative period due to the insensitivity of noninvasive diagnostic tests. This case demonstrates the value of intraoperative cardiac sampling for oxygen saturation to identify an otherwise occult aorta-right ventricular fistula secondary to a precordial stab wound, ultimately progressing to a 1.9:1 shunt requiring operative repair.
ER -

VENDOR - ProQuest Information and Learning Company
DATABASE - ProQuest
AUTHOR - Kerr TM; Grosh J; Gelman J; Buckman RF Jr; Sood R
TITLE - Prospective trial of the six hour rule in stab wounds of the chest.
JOURNAL - Surg Gynecol Obstet
DATE - 1989 Sep
ISSN - 0039-6087
VOLUME - 169(3) , p. 223-5
ABSTRACT - Stab wounds of the chest may be associated with a spectrum of injuries ranging from the lethal to the insignificant. The management of asymptomatic patients with stab wounds of the chest is controversial. The results of previous reports have asserted that asymptomatic patients with stab wounds of the chest do not have delayed complications develop if roentgenograms of the chest taken six hours after the injury are normal. This "rule" has not been validated. A three year, prospective study of patients with stab wounds of the chest was done. Patients were excluded from the study if they had symptoms on arrival, evidence of physiologic derangement caused by intrathoracic injury, wounds near the subclavian vessels or precordial wounds. Patients with lower thoracic stab wounds were evaluated by diagnostic peritoneal lavage. If findings from lavage were negative, the patients were included in the study. One hundred and five patients met the criteria for inclusion in the study group. All of the patients were hospitalized and examined serially. All had roentgenograms of the chest performed at admission, at six hours and at 24 hours. Four patients had a pneumothorax or hemothorax develop between the time of admission and six hours of hospitalization. In the remaining 101 patients, none had a pneumothorax or hemothorax between six and 24 hours. No patient asymptomatic on admission had a tension pneumothorax develop later. No patient had delayed evidence of abdominal injury. An asymptomatic patient with a stab wound of the chest that is not precordial, not in proximity to the subclavian artery and not suspected of diaphragmatic penetration should be serially examined and have a follow-up roentgenogram of the chest at six hours. If the patient remains asymptomatic and the six hour film is normal, delayed complications are rarely, if ever, encountered and the patient does not require further studies or hospitalization. The six hour rule for stab wounds of the chest is valid.
ER -

VENDOR - ProQuest Information and Learning Company
DATABASE - ProQuest
AUTHOR - Yuasa H; Otsuka T; Makino T; Yasuda K; Koseki K; Mashiko K; Yamamoto Y; Henmi H
TITLE - [Clinical study on stab wounds of chest--factors that may influence their mortality]
JOURNAL - Nippon Kyobu Geka Gakkai Zasshi
DATE - 1989 Aug
ISSN - 0369-4739
VOLUME - 37(8) , p. 1532-6
ABSTRACT - Stab wounds of the chest occupy an important position in penetrating thoracic injuries in Japan. A retrospective review of 117 patients with stab wounds of the chest admitted to our hospital over the past 12 years (from 1975 to 1987) revealed some factors that might influence their mortality. Seven patients died from trans-diaphragmatic injuries of intra-abdominal organs. The management of intra-abdominal injuries was very important in thoracic stab wounds. Many of the patients with stab wounds of the precordial chest (danger zone) had cardiac or major vascular injuries, and the mortality rate of them was high. The mortality rate of the patients with stab wounds of the right lateral thorax was high, because many of them had trans-diaphragmatic liver injuries. We thought that right lateral thorax as well as precordial chest is the danger zone in thoracic stab wounds. Survival rate in the patients whose circulatory condition had been unstable when they admitted was very low. Five DOA (dead on arrival) patients with stab wounds of the chest required emergency room thoracotomy (ERT). One of them survived. Survival rate in the DOA patients with stab wounds of the chest was higher than that in the DOA patients with blunt thoracic injuries. ERT for cardiac insufficiency following stab wounds of the chest was thought an effective procedure for surviving. Survival rate of the patients with cardiac stab wounds was 63.6 per cent.
ER -

VENDOR - ProQuest Information and Learning Company
DATABASE - ProQuest
AUTHOR - Mooney R; Laks MM; French S; Mena I; Bessen HA; Niemann JT
TITLE - Conventional and right precordial ECGs, creatine kinase, and radionuclide angiography in post-traumatic ventricular dysfunction.
JOURNAL - Ann Emerg Med
DATE - 1988 Sep
ISSN - 0196-0644
VOLUME - 17(9) , p. 890-4
ABSTRACT - Right ventricular infarction due to ischemic heart disease can be diagnosed by a right precordial electrogram or by first-pass radionuclide angiography (FPRNA). Prior FPRNA studies have shown that cardiac dysfunction after blunt chest trauma (myocardial contusion) is most often due to right ventricular dysfunction. We hypothesized that right ventricular dysfunction due to ischemic heart disease and myocardial contusion should produce similar ECG changes due to myocyte disruption. The purpose of our study was to evaluate the diagnostic value of the right precordial electrogram in suspected cardiac contusion. Thirty-five patients with suspected myocardial contusion based on mechanism of injury/clinical findings and no history of clinical heart disease were enrolled prospectively. All patients had conventional ECG, right precordial electrogram, and FPRNA studies. Twenty patients had normal cardiac scans (group 1); percentage of myocardial creatine kinase (CK-MB) was measured in 12 of these patients and was less than 5% in 11. Fifteen patients had abnormal cardiac scans (wall motion abnormality and/or decreased right ventricular ejection fraction) (mean, 34% +/- 7% [SD]; normal, greater than 40%) (group 2); percentage of CK-MB was measured in 13 of 15 patients and was less than 5% in all 13. Conventional ECGs and right precordial electrograms in all patients were analyzed for differences in heart rate, PR interval, QRS duration, corrected QT interval, and the axis of the frontal and horizontal plane QRS complex and ST segment. There were no significant differences between group 1 and group 2 patients. No patient with myocardial contusion diagnosed by FPRNA had elevated ST segments in V4R through V6R or a percentage CK-MB of more than 5%.(ABSTRACT TRUNCATED AT 250 WORDS)
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TRAUMA DE ABDOMEN
GUIA DE MANEJO



INTRODUCCION


Los traumatismos abdominales constituyen una importante carga en los servicios de urgencia y quirúrgicos, por tal motivo, y teniendo en cuenta que las conductas en el manejo del trauma abdominal varían de acuerdo al mecanismo que lo produce, al área afectada del abdomen y al estado hemodinámico del paciente a su ingreso al servicio de urgencia, decidimos en nuestra institución E.S.E. HOSPITAl UNIVERSITARIO DE BARRANQUILLA, elaborar la guía de manejo para el trauma abdominal, adaptándola a los recurso tecnológicos con los que contamos hoy en día en nuestro hospital y tener un protocolo mas coherente con nuestra infraestructura y medios diagnósticos al alcance en estos momentos.
Su contenido tiene amplia base en el proyecto ISS-ASCOFAME sobre trauma de abdomen y la guía práctica basada en evidencias, y la revisión de la bibliografía reciente sobre el tema, de una forma didáctica y práctica para que normatizemos de una manera racional y coordinada la atención del paciente con trauma de abdomen y utilizemos apropiadamente los recursos con los que cuenta en el momento nuestra Institución.
Esta guía es presentada a los cirujanos, residentes del Servicio de Cirugía General para su revisión, modificaciones si son necesarias y aprobación posterior por la Subgerencia Científica de Hospital Universitario de Barranquilla , para su normatización como protocolo de manejo del Trauma Abdominal en nuestra Institución.
DR. JOSE MERCADO HERRERA
Cirujano General


CONTENIDO

�?� AREAS TOPOGRAFICAS DEL ABDOMEN
�?� MECANISMOS DEL TRAUMA ABDOMINAL
�?� CLASIFICACION DEL PACIENTE Y DECISIONES
�?� MANEJO SELECTIVO DEL TRAUMA DE ABDOMEN
�?� TRAUMA CERRADO DE ABDOMEN
�?� TRAUMA PENETRANTE DE ABDOMEN
�?� ALGORRITMOS DE MANEJO DEL TRAUMA DE ABDOMEN


AREAS TOPOGRAFICAS DEL ABDOMEN
Area toracoabdominal (TA): Va desde el quinto
espacio intercostal por delante, hasta el reborde costal.
Abarca los orgános abdominales, que se proyectan al
tórax, y eldiafragma. También se llama abdomen intratorácico.
Abdomen anterior (AA): Sus límites son los re-
bordes costales hacia arriba, los ligamentos inguina-
les y las crestas ilíacas hacia abajo y las líneas axila-
res anteriores lateralmente. La pared esta constituida
láminas musculares que permiten la exploración de
las heridas traumáticas. En esta área los órganos son
completamente intraabdominales, lo cual permite el
escape fácil del líquido intestinal, en caso de ocurrir
una perforación intestinal.



�?� Abdomen posterior y flancos (AP): área limitada
hacia arriba por una línea que pasa dos espacios
intercostales por debajo de las puntas escapulares
(9º espacio intercostal); hacia abajo por las crestas ilíacas
y borde superior del sacro y lateralmente por las líneas
axilares anteriores. Las estructuras ubicadas en esta área
se encuentran parcial o totalmente extraperitoneales (duo
deno, colon ascendente, descendente y recto, riñones,
uréteres, páncreas, aorta y cava), por lo que la lesión
de algunas de estas estructuras pueden ocurrir sin pene-
netración de la cavidad, la contaminación puede presen
tarse lentamente y las manifestaciones aparecer tardía-
mente. Los músculos que la limitan son fuertes y volu-
minosos, condiciones que hacen la exploración difícil e
innecesaria.
�?� Pelvis y región glútea (PG): Limitadas hacia arriba
por las crestas ilíacas, los ligamentos inguinales y el pu-
bis,limitan inferiormente con la tuberosidad isquiática,
la pelvis y los repliegues glúteos y la región glútea.Esta
última limita lateralmente con los trocánteres mayores.
La pelvis contiene órganos extra e intraperitoneales:
(asas de intestino grueso y delgado, vejiga, uréteres, rec-
to, vasos sanguíneos, nervios, útero, anexos en la mujer
próstata y vesículas seminales en el hombre). En esta re-
gión pueden ocurrir lesiones, sin que haya penetración a
la cavidad.
La región glútea constituida principalmente por los mús-
culos glúteos, y se divide por una línea horizontal que u-
ne los trocánteres mayores. Las heridas de la mitad supe-
rior tienen riesgo de producir lesión de las estructuras
contenidas en la pelvis, las de la mitad inferior pueden le-
sionar el nervio ciático o los vasos glúteos.