Daniel E. Furst MD Carl M. Pearson Professor of Rheumatology, Director, Rheumatology Clinical Research Center, Department of Rheumatology, University of California, Los Angeles

https://people.healthsciences.ucla.edu/institution/personnel?personnel_id=8022

Approximately 3% to 4% of such patients have a more complex injury that can only be repaired by a cardiac surgeon using cardiopulmonary bypass (Table 9-3) erectile dysfunction johnson city tn cheap top avana 80mg mastercard. Treatment in the Operating room After Cardiorrhaphy If a left anterolateral or bilateral anterolateral thoracotomy has been performed herbal erectile dysfunction pills uk generic 80mg top avana with amex, the superior and inferior transected ends of the internal mammary arteries should be clamped and ligated with 3-0 silk ties erectile dysfunction what kind of doctor buy generic top avana line. As the heart is usually edematous after a repair erectile dysfunction doctors in south africa order top avana pills in toronto, the pericardial sac is not closed if a median sternotomy and midline pericardiotomy have been used for exposure erectile dysfunction treatment covered by medicare purchase top avana 80 mg online. Closure of this lateral defect with interrupted 2-0 silk sutures would then be appropriate impotence and diabetes 2 order top avana. The pericardial sac is drained with a rightangle 36 Fr thoracostomy tube inserted through the epigastric area of the abdominal wall. If either pleural cavity has been opened, one or two 36 Fr thoracostomy tubes are placed through the 5th intercostal space between the ipsilateral anterior and middle axillary lines. On occasion, epicardial pacing wires may have to be sewn to the heart when arrhythmias continue despite cardiac repair and resuscitation. An unstable patient who is not fully responsive to continuing resuscitation and inotropes may benefit from the transfemoral insertion of an intraaortic balloon pump before transfer to the intensive care unit. Certain patients will not tolerate wire closure of the sternum after a cardiac repair, presumably due to compression of the edematous heart. A plastic silo (a genitourinary irrigation bag opened on three seams) should be sewn to the skin edges of the median sternotomy with continuous sutures of 2-0 nylon as a temporary closure maneuver. As the patient enters the diuretic phase of recovery in the subsequent 48 to 72 hours, the silo is removed; and the sternum is closed at a reoperation. MajorComplications Cardiac Failure Cardiac failure after repair of a traumatic injury may require the use of inotropic medications and/or an intraaortic balloon pump. Possible causes of cardiac failure in these cases are as follows: (1) tamponade from a coagulopathy, hemorrhage from the repair, or hemorrhage from missed injury; (2) cardiac compression from closure of the sternum; (3) posttraumatic acute myocardial infarction without injury to a coronary artery42; (4) posttraumatic acute myocardial infarction with injury to a coronary artery; and (5) undiagnosed injury to a cardiac valve, a papillary muscle, the chordae tendinae, or the atrial or ventricular septum. Cardiac compression from closure of the sternum is unusual and remains the diagnosis of exclusion. Delayed Diagnosis of Intracardiac Lesions For more than 55 years, it has been recognized that patients who survive acute repair of a wound or rupture of the atrium or ventricle may also have an internal cardiac injury. Patients with hemodynamically significant injuries, particularly those to a valve, a papillary muscle, the chordae tendinae, or the septum should have delayed repair on cardiopulmonary bypass40,44,46 (Table 9-3). When considering all patients who require cardiopulmonary bypass for repair of cardiac trauma those requiring its use in the delayed setting account for 85% to 90% of cases. Survival Survival after penetrating cardiac trauma depends on the mechanism of injury (stab versus gunshot), the number of signs of life on admission (cardiovascular and respiratory components of trauma score), the location of the thoracotomy (emergency department versus operating room), the cardiac rhythm at time of the pericardiotomy (rhythm versus asystole), the number of chambers injured, and the associated injuries. Injuries to the Great Vessels Definition/Classification the great vessels in the chest and thoracic outlet are variously defined, but most consider this category to include the large vessels originating from the aortic arch and those in what is traditionally considered zone I of the neck. In this context, the terminology may also include the ascending, transverse, and proximal descending aorta as well as the innominate (brachicephalic), common carotid and the subclavian arteries. Because of their sizes and proximal locations, the innominate and central jugular veins may also be included as great vessels of the chest. Table 9-6 provides the American Association for the Surgery of Trauma Thoracic Vascular Organ Injury Scale for vascular trauma in this region. Of patients who underwent emergent thoracotomy after penetrating thoracic injury, less than one third had great vessel injury as the cause of hemorrhage. Blunt Trauma Blunt injuries to the great vessels (exclusive of the descending thoracic aorta, which will be described in Chapter 10) are very uncommon. When they do occur, these injuries almost always involve the proximal innominate or subclavian artery. In an older series describing 43 patients with injury to the innominate artery from 1960-1992, a blunt mechanism was the cause in 17% of patients. Etiology Penetrating Trauma A gunshot wound to the chest has less than a 5% chance of injuring a thoracic great vessel. Stab wounds are also uncommon and are reported to injure a great vessel in only 2% of instances. Blunt Trauma Blunt injuries to the innominate and subclavian arteries most commonly occur in individuals wearing shoulder-harness restraints in frontal motor-vehicle crashes. The proposed mechanism for this injury is direct compression to the upper sternum into the artery itself with partial or complete avulsion off the aortic arch. This mechanism occurs as the victim slides under the shoulder harness and may cause stretching and avulsion of the innominate artery. Either mechanism may lead to disruption of the intima with or without injury to part or all of the media and adventitia. Similar mechanisms are proposed to explain blunt injury to the carotid and vertebral arteries in recent years. Disruptive injuries to cervical vertebrae contribute to select patterns of zone I vascular trauma as well. The etiology of blunt injury to either subclavian artery is slightly different and more likely related to deceleration of the vessel in relation to the first rib and the supraclavicular area fixated under the shoulder-harness restraint itself. Shoulder harness notwithstanding, a sudden posterior movement of the shoulder from blunt trauma may cause disruption of the intima and all or part of the media of this relatively fragile artery. Presentation Penetrating Trauma There are 3 different clinical scenarios with which patients with penetrating wounds to the thoracic outlet and superior mediastinum will present. Some patients will be asymptomatic with normal vital signs and with a normal chest x-ray. Secondly, some patients will be asymptomatic with a normal blood pressure but will have a contained hematoma in the suprasternal, mediastinal or supraclavicular area. The third group of patients will have proximity of penetrating wound to zone I structures with hard signs of vascular trauma such as external bleeding, expanding hematoma, or hemorrhagic shock. The aortogram demonstrated a through-and-through wound (arrow) of the descending thoracic aorta. However, measurement of blood pressure using either a stethoscope or the continuous wave Doppler machine has a great enough sensitivity for the thorough clinician to identify this injury. The mark of a shoulder-harness restraint at the lateral aspect of the lower neck may be present as a physical examination finding. If the victim was not wearing a restraint and there was no air-bag deployment, sternal contusions indicate risk for blunt injury of the descending thoracic aorta. Patients with avulsion of the innominate artery from the aortic arch will present with hypotension, with diminished or absent pulses at the right arm, and with a large hematoma in the superior mediastinum on a chest x-ray. Other less-severe injuries include an intimal tear of the innominate or subclavian artery without thrombosis. Depending on the extent of the arterial-wall injury and the flow-limiting nature of the intimal abnormality there may be a finding of disparate blood pressures in the arms. Therefore, it is external markers of mediastinal injury, asymmetric arm pressures, and/or an abnormal chest x-ray that should prompt additional, moredetailed diagnostic studies. As will be discussed in Chapter 10, widening of the superior mediastinum on chest x-ray is a marker for blunt injury to the descending thoracic aorta. As noted, the patient with blood pressure discrepancies between arms should be suspected of having a subclavian or axillary artery injury. Delayed film demonstrates reconstitution of the left axillary artery in this patient with an intermittently normal left radial pulse. Regardless of chest x-ray findings, no additional diagnostic studies are indicated in the third group of patients with profound hypotension. Patients with a systolic blood pressure less than 70 mm Hg or with a recent cardiac arrest should have preliminary operative management in the emergency department as described in previous sections. Blunt Trauma Diagnosis of blunt common carotid artery injury proceeds in much the same manner as with patients who have a penetrating injury. Initial chest x-ray is useful as a general screening test to assess for the presence of hemothorax and/or a widened mediastinum indicative of hematoma. As indicated earlier, patients with blunt proximal common carotid artery injury often have a clinical presenting sign of contusion or a physical finding of discrepant upper extremity blood pressure measurements. If no pleural connection is present, insertion of a finger or pack into the stab-wound or gunshotwound site may control hemorrhage temporarily until the patient can be transferred to the operating room. In cases of proximal (zone I of the neck) common carotid artery injury, the patient may also manifest a widened superior aspect of the mediastinum on the initial chest x-ray. Patients in the hypotensive group will require judicious resuscitation in the emergency department before further imaging studies. Judicious and even hypotensive resuscitation in patients with penetrating vascular trauma may avoid restarting bleeding that had stopped or may avoid exacerbating ongoing bleeding. The purpose of additional imaging studies in this scenario is to verify and localize the aortic or arterial injury and to help determine the best management approach. In the past, the diagnostic study that was most commonly used was transfemoral digital subtraction aortography by interventional radiology. The only change that may be needed from the previously described approach is to place the thoracic incision or incisions above the male nipple if there is an obvious wound, a pulsating hematoma, or external bleeding in proximity to the subclavian vessels. While it is more difficult to spread the ribs at this level, it does allow for rapid insertion of a finger or pack to control intrapleural hemorrhage from an injury to a subclavian vessel. After the bilateral anterolateral thoracotomy is performed, bimanual dissection is performed to separate the upper chest flap and sternum from the underlying thymus and pericardium. Finochietto retractors are placed bilaterally, and a finger or clamp is used to control hemorrhage. The same incision is used when the initial chest x-ray documents a hematoma in the superior mediastinum. Median sternotomy provides excellent exposure to the innominate artery and veins, the first portion of the right subclavian artery, and the proximal right common carotid artery. Although relatively posterior along the aortic arch and therefore challenging to manipulate through this approach, the proximal left common carotid artery should be approached via a median sternotomy. Injury to the second portion of either subclavian artery (posterior to the scalenus anticus muscle) is approached via a supraclavicular incision. Exposure of the injured subclavian artery (or vein) may be improved by an ipsilateral infraclavicular incision and by isolation of the proximal most axillary artery (or vein). Before claviculotomy or resection of the clavicle is performed, circumferential stripping of the periosteum is performed to separate away the often tightly adherent subclavian vein. At the completion of the vascular repair, the claviculotomy may be repaired by drilling holes in an anteroposterior direction in the ends. With this maneuver, a sternal wire is curved into the letter "U," and is placed posteroanterior; and the two ends are twisted to align or approximate the divided ends of the bone. Another technique of repair is use of a dynamic compression plate across the anterior aspect of the fracture. When a segment of clavicle has been removed, inserting a sternal wire across each "fracture" site is the quickest repair. Repair of the divided clavicle is should be performed in patients who are hemodynamically well. This is especially important because most patients with this injury pattern are young and active. The disadvantages of this incision include multiple sharp bony ends that catch the gloves of the surgical team and significant postoperative pain for the patient. The use of Dacron or Teflon pledgets as previously described may also assist in repairing arterial injuries in this location. Repair of Penetrating Wound of the Innominate Artery After performing a pericardiotomy, the crossover left innominate vein is rapidly mobilized and elevated superiorly or inferiorly with a Silastic vessel loop. This vein may be ligated if necessary because it has been injured or is obstructing exposure of the injured artery. Finger control on a perforation of the artery is maintained until proximal and distal vascular clamps. A wound near the distal bifurcation of the innominate artery may be difficult to visualize through a standard median sternotomy. In these cases, the median sternotomy may be extended cephalad with a longitudinal cervical incision or laterally with a supraclavicular incision. These extensions of the median sternotomy will allow for distal control of the common carotid and right subclavian arteries, respectively. Dissection around the proximal right subclavian artery should be done with care as the right recurrent laryngeal nerve loops around this vessel within 1. Exposure of the first portion of right subclavian artery may require a median sternotomy and right supraclavicular incision. Exposure of the junction of the first and second portions of the left subclavian artery may require a high left anterolateral thoracotomy, a partial upper median sternotomy, and a left supraclavicular incision-the so called "book thoracotomy. An infraclavicular incision may also need to be performed adjacent to the proximal portion of the lateral 1/3 of the clavicle, as well. Connecting the supra- and infraclavicular incisions and dividing the clavicle, if necessary, will allow for distal control of the first portion of the axillary artery. This maneuver allows for perfusion of the right upper extremity via backflow through the right common carotid artery from the circle of Willis in the brain. If a short segmental resection of the innominate artery is necessary for a through-and-through gunshot wound, an endto-end and often pledgeted, anastomosis is performed with 5-0 polypropylene suture. As previously noted, temporary vascular shunts are not usually inserted during end-to-end anastomoses or insertion of interposition grafts because there is almost always adequate cerebral crossover flow in young patients. As the end-to-end anastomosis or suture line on the distal graft is completed, proximal and distal flushings of air are necessary before the final sutures are tied. The proximal clamp and a clamp on the right common carotid artery are then reapplied as backflow from the right subclavian artery completes the evacuation of air. Antegrade flow is first established into the right subclavian artery by removing the clamp on the innominate artery. Flow into the right common carotid artery is established 10 seconds later by removing the clamp on this vessel. Depending on the location of an interposition graft, the proximal suture line may lie on top of the trachea.

Experience in multiple wars of the 20th century resulted in ligation standing as an accepted practice to address injuries to the cava erectile dysfunction pills pictures discount 80mg top avana visa. Broering et al have proposed changing the nature of the ischemia to a cold-ischemia protocol erectile dysfunction video buy cheap top avana 80 mg on line. By infusing the liver with cold preservation solution erectile dysfunction over the counter order top avana 80 mg line, ischemia time may be prolonged erectile dysfunction with normal testosterone levels order top avana 80 mg with amex, allowing better opportunity for repair erectile dysfunction pills at walgreens purchase on line top avana. As a group erectile dysfunction doctor visit cheap 80 mg top avana, patients undergoing ligation had a 41% early mortality rate and a 59% overall mortality rate. While patients in the repair group fared better with an early and overall mortality rate of 21%, the patients in the ligation group were significantly more ill. Suprarenal caval ligation is even more poorly tolerated with a high mortality rate, unless the patient happens to have existing generous collaterals with the azygos and lumbar venous systems. Hesitation to ligate the major abdominal veins stems not only from mortality concerns but from the potential sequelae of ligation. Some groups advocate for prophylactic fasciotomy in patients undergoing ligation of the vena cava. A low index of suspicion should result in rapid fasciotomy should there be evidence of rising compartment pressures. Though some narrowing may be expected and accepted following venorrhaphy, attempts to primarily close injuries that are greater than 50% circumference of the cava may result in excessive restriction of luminal size, subsequent thrombus formation, and even complete thrombosis. In the infrarenal portion of the cava, adequate mobilization may allow visualization of the posterior aspect of the vessel with direct repair by gentle rotation of the vena cava. When possible, knots should be kept extraluminal to remove a nidus of thrombus formation. More proximally, rotation of the vessel is usually not possible due to the tethering effect of the renal veins and the liver. Transected vessels may be amenable to an end-to-end anastomosis, although it is rare that such a patient would be stable enough to tolerate more than ligation. End-to-end anastomosis is more difficult in the vena cava compared to an extremity vein. Due to the tethering of the visceral and lumbar tributaries, mobilization of the vena cava to increase length is difficult. If loss of length prevents an end-to-end anastomosis, interposition grafting is a consideration. The internal jugular or external iliac veins are large-caliber donor options that may be used for caval interposition. A significant amount of time is required for vessel acquisition and reconstruction with these techniques, and this must be considered when deciding whether the patient is stable for such repair. ThePortalVein Injury to the portal vein is uncommon, documented in one series at 0. There is also a high frequency of major associated injuries, especially in the region of the portal triad. Of patients with portal triad injuries who died in the operating room, 85% had at least a portal vein injury. Contained within the hepatoduodenal ligament, the closely associated hepatic artery and bile ducts are frequently injured at the same time. Despite a high flow rate, approaching 1 L/min, pressures are low at approximately 10 mm Hg or less. A wide Kocher maneuver, with leftward reflection of the duodenum and pancreatic head allows near complete exposure of the portal vein and associated structures. The common bile duct may be isolated and retracted leftward as well to provide additional access to the anterior surface of the vein. Division of the pancreatic neck may be necessary to access more distal portions of the portal vein. A Pringle maneuver (an atraumatic clamp, vessel loop, umbilical tape, or manual pressure is used to occlude the portal structures) is often needed to control hemorrhage while the portal structures are being mobilized. This may be the only way to reasonably control the inflow-both splenic flow from the celiac axis and superior mesenteric flow. In less-dire circumstances, the Pringle maneuver is generally the most useful method of controlling hemorrhage from suprapancreatic portal vein injuries. Even in more limited injuries, the occlusive tape or clamp prevents visualization of the injury site. Indiscriminate clamping should be avoided to prevent injury to delicate structures in the region. Once the injury is visualized, it can be gently grasped with Judd-Allis clamps and mobilized to allow suture closure or passage of vascular tapes. Simple repairs should be performed using 5-0 or 6-0 monofilament suture in an interrupted fashion. If the portal vein has been divided, an end-to-end anastomosis may be accomplished if there is minimal tension between the two ends. Behind the pancreas, small medial tributaries entering the portal vein may be ligated and divided to achieve additional length. Additionally, if it has not already been done to achieve control, partial division of the pancreas and ligation of small medial tributaries may provide satisfactory mobilization to make anastomosis possible. Reverse saphenous vein interposition grafting is feasible, but few patients are stable enough to permit this approach. From a review of 18 patients presenting to the hospital with portal venous injuries between 1958 and 1980, survival was limited to 13% when ligation was used as a last-ditch salvage option. The reported high mortality rates likely are partially related to failure of appreciation of the tremendous fluid requirements. However, many reports of high mortality following portal vein ligation were made before our appreciation of abdominal compartment syndrome and the benefits of temporary abdominal closure. Contemporary fluid and wound management will likely improve outcomes with portal vein ligation. Low mesenteric flow combined with shock may lead to venous thrombosis, bowel ischemia, and necrosis. Additionally, portal vein thrombosis and portal hypertension may occur as sequelae in this setting. The complications of portal vein ligation are sobering but are unavoidable when ligation is the only option to control hemorrhage and to provide immediate patient survival. When injuries result from blunt mechanisms, damage occurs due to shear forces exerted on the mobile mesentery, resulting in avulsion of the vessel. A direct approach at the base of the mesentery may be appropriate if Hepatic proper a. Colon mobilization and a Kocher maneuver are used to provide access, and the body of the pancreas must be divided to gain proximal control. Subsequent dissection will permit placement of tapes and clamps for proximal and distal occlusion. In cases where significant tissue loss precludes primary repair, a saphenous vein interposition graft may be required. Judgment and composure are required to recognize the need for ligation and to accomplish it quickly before loss of massive quantities of blood in futile attempts at repair. Temporary shunts should be considered for portal and superior mesenteric venous injuries in a subset of unstable patients whose injury anatomy is such that a shunt can be inserted without causing further damage. The relative low flow in the venous system in comparison to the arterial system will result in a higher rate of thrombosis of those shunts. However, this may provide additional options; and, if thrombosis occurs, the end result would be no different than with ligation. Except in cases of endovascular grafts for aortic injuries, most published experience has come in the form of case reports. The two main areas in which endovascular techniques have been employed are balloon occlusion control of hemorrhage and stent graft repair of injuries. While both interventional radiology and endovascular surgery are widely available at most trauma centers, a number of variables should be considered before a trauma surgeon opts for this management strategy. First, practitioners who are skilled in these techniques must be readily available. Secondly, a hybrid operative suite must be available and must be able to accommodate the multiple demands of the resuscitation, the operative exploration, and the fluoroscopy needed for the endovascular approach. An extensive inventory of guidewires, catheters, and grafts of various sizes is required. The anatomy of the portal and superior mesenteric veins preclude percutaneous access. Occlusion Balloons the use of occlusion balloons to control hemorrhage is one of the most appealing applications of endovascular technology. The balloon can be inserted via femoral vein access following Seldinger technique of sheath insertion. Upon entry into the abdomen, identification of the injury was rapid and blood loss was minimal, decreasing operative time overall. Upon identification, the injured vessel might be accessed at a site remote from the injury or directly through the vessel laceration. As with standard proximal occlusion, there is immediate loss of vascular return to the heart. The sequestration of blood volume may lead to hypotension and, in some cases, to circulatory arrest. VenousShunts Atriocaval Shunt First described by Schrock in 1968, this shunt functionally bypasses the site of a retrohepatic caval injury. A large diameter chest tube is introduced via a small incision in the right atrial appendage. Temporary Venous Shunts the use of temporary prosthetic shunts in the management of venous injuries has been limited. Recent military operations in Iraq and Afghanistan have again raised the profile of temporary shunts used for damage control vascular surgery, though the vast majority of this evidence is from extremity injuries. A 2009 review of 64 extremity arterial injuries in United States troops demonstrated 38% with concomitant venous injuries. These authors note that several of the patients in their study underwent venous shunting and subsequent restoration of venous continuity. The use of venous shunts for abdominal trauma may facilitate damage control surgery via improved hemorrhage control and by allowing time for patient resuscitation, operative planning, or potential transfer to a higher level of care. Most of the published data on long-term shunt patency rates comes from the civilian trauma literature. Patency was excellent in both groups, with 8 of 19 patients (42%) requiring a shunt for 12 to 24 hours and with a longest dwell time of 52 hours. While the patency rates of temporary arterial shunts are encouraging, reports of temporary venous shunting remain largely limited to small series, and limited objective data exists on patency rates in these cases. Rasmussen et al note in a 2006 review that four venous injuries were shunted in combat troops and all remained patent. Venous shunts are an acceptable choice when damage control is required, but surgeons must remain mindful that patency times are not well defined. The use of Venovenous Bypass, Circulatory Arrest, and Transplantation the profound hemorrhage from major abdominal vein injuries, combined with a young, otherwise-healthy trauma patient, may place the trauma surgeon in the position of attempting truly heroic measures. Definitely falling into the camp of uncommon measures for hemorrhage control, both venovenous bypass and circulatory arrest have intermittently been described in case reports with marginal success. To entertain these options, a trauma center must have personnel who are experienced in placing patients on bypass and who are experienced managing a pump, as well as cannula availability. Following institution of bypass, intraoperative blood loss is less; and renal function and 30-day survival are improved with venovenous bypass, though these studies have been done in liver transplant populations. Care must be taken to avoid air embolism and to be wary of the hemodynamic effects of large volume shifts associated with bypass circuits. However, the requirement for a heparinized circuit in the polytrauma patient may be prohibitive. Rather than representing a deterioration in technique or care, this likely reflects maintenance and transport of evermore severely injured patients to the hospital phase of management. Each injury must be evaluated on a case-by-case basis, as no single algorithm is adequate to predict management in these cases. Adherence to excellent vascular technique with rapid hemorrhage control and limited operative times is the key to success. The use of temporary vascular shunting and endovascular techniques provide tantalizing glimpses of the ever-evolving management options. Pearl J, Chao A, Kennedy S, et al: Traumatic injuries to the portal vein: case study. Matsumoto S, Sekine K, Yamazaki M, et al: Predictive value of a flat inferior vena cava on initial computed tomography for hemodynamic deterioration in patients with blunt torso trauma. Isolated reports of liver explantation with back-table repair and autotransplantation exist, with poor survival. If total hepatic isolation can be achieved, the liver is explanted and repaired, bloodlessly, on a back table. Potentially, a second team may address remaining vascular or other visceral injuries in vivo. The transplant option is not feasible in any but the most extraordinary of circumstances due to lack of ready organ availability and associated patient injuries. Splanchnic hypertension with portal and superior mesenteric venous narrowing or occlusion may occur. Postoperative screening with duplex ultrasonography is warranted to monitor the cava following repair, especially in patients with lower extremity edema or other symptoms. In symptomatic or high-risk patients, consideration may be given to a caval filter or extended anticoagulation.

The resolution of B-mode ultrasound is related to the transducer frequency and the depth of the imaged structure diabetic erectile dysfunction pump purchase top avana in india. Resolution decreases with the use of lower-frequency transducers b12 injections erectile dysfunction effective 80 mg top avana, which are used for the examination of deeper structures erectile dysfunction urinary tract infection purchase top avana online pills. When superficial anatomic features are evaluated with high-frequency transducers erectile dysfunction louisville ky order genuine top avana line, details of vessel walls can be seen erectile dysfunction doctor toronto order top avana online pills, including atherosclerotic plaque erectile dysfunction protocol foods to eat generic top avana 80 mg otc, dissection or intimal flap. Conversely, use of B-mode ultrasound as a stand-alone modality may be insensitive for detection of vascular injury when deeper vessels are evaluated. In these instances the only abnormal finding may be a hematoma in proximity to the vascular injury. Patient discomfort (or the agitation or the presence of wounds), external fixators, or dressings may limit ultrasound examinations for trauma. Duplex scanning, with the addition of Doppler flow detection to the B-mode image, increases the utility of diagnostic vascular ultrasound. Flow information from a specific point of interest is displayed by the pulsed Doppler flow velocity waveform. Color flow duplex scanning displays areas with flow in color overlying the B-mode image of anatomy. Color flow imaging assigns colored (rather than gray scale) pixels in regions where moving tissue. The color flow display provides information about the location of the flow, its direction, and its velocity. With experience, users can learn to recognize characteristic signatures of abnormal flow, including higher pitch with elevated velocities; abrupt blunted signal proximal to an occlusion; course sound with spectral broadening from tur- bulence; or continuous low-resistance, diastolic flow associated with an arteriovenous fistula. Use and interpretation of vascular ultrasound is integral to the training of surgeons. Vascular ultrasound may be useful for trauma care, even if vascular specialty expertise is not available. Most radiologists have training in general ultrasound, and many general and trauma surgeons have skills with the use of point-of-care ultrasound. Measurements of vessel size (detection of aneurysms), detection of arterial or venous flow, assessment for deep-vein patency, mapping of superficial veins, and other simple evaluations can be learned without extensive formal training. A very practical aspect of ultrasound in this setting is its ability to be repeated over time to confirm initial impressions or show trends. Duplex ultrasound scanning is indicated to detect or characterize vascular injuries of the neck and extremities, especially where vessels are relatively superficial. Dissection, stenosis, thrombosis, and arteriovenous fistula can all be demonstrated using this imaging modality. Because duplex is safe, inexpensive, and noninvasive, it is especially useful to confirm a normal physical examination in patients who have injury mechanisms that are associated with a risk of vascular injury, such as penetrating trauma, posterior knee dislocation, hyperextension, and supracondylar fracture. In most cases, the presence of an extremity vascular injury can be excluded with a combination of physical examination and noninvasive pressure measurement. Using continuouswave Doppler, the cuff occlusion technique measures the systolic blood pressure in the injured limb, which can be compared to the pressure in the uninjured contralateral limb. When minor vascular injuries are diagnosed, most may be managed nonoperatively with expectation of spontaneous healing. Injuries with low risk of late complications include intimal injuries (intimal flap) that are associated with <50% stenosis. The noninvasive nature of duplex allows for serial examination to confirm a benign injury outcome. Severely injured patients are at risk for venous thrombosis and pulmonary embolism. Duplex scanning is the diagnostic test of choice for the detection of venous thrombosis of the extremities. Simple point-of-care testing should be aimed at probe compression to verify that the popliteal and common femoral vein collapse under manually applied pressure. As has been noted, the noninvasive and available nature of ultrasound means that this imaging modality can be repeated over time for surveillance or follow-up examination as needed. Duplex can identify defects that may lead to early thrombosis or late complications including abnormalities of the intima at the site of vascular clamp placement. Duplex can also detect flow-limiting stenosis at the anastomosis of a vascular repair or the presence of intraluminal thrombus. However, fasting before abdominal duplex may reduce the amount of bowel gas that obscures the view of deeply positioned abdominal, retroperitoneal, and pelvic vessels. Ultrasound can be used as a screening tool, to detect injuries or vascular complications that are not evident from clinical assessment. Examples of screening examinations include evaluation of limbs with "soft" or no signs of vascular injury that sustained mechanisms of trauma known to predispose to vessel injury. Ultrasound can be used as a diagnostic tool, either alone or in combination with other testing modalities. Arterial disruption, intimal dissection or flap, thrombosis and arteriovenous fistula can be definitively diagnosed using ultrasound, especially in the extremities. As has been noted, duplex may complement other diagnostic tests or maneuvers such as Doppler pressure measurements in the initial screening of an injured extremity. In many cases, if the initial examination is normal and there is no hard sign of vascular injury, a more thorough evaluation with duplex can follow on an elective basis. The utility of ultrasound as a tool to guide invasive procedures should not be overlooked. This modality has become increasingly the standard to guide percutaneous arterial or venous access and to help with localizing a vascular lesion during operative surgical management. Intraoperative ultrasound imaging demonstrates patency of the aorta at the level of the inferior mesenteric artery. B, the seat belt injury to the terminal aorta resulted in an extensive intimal tear, which is seen in this intraoperative transverse B-mode image. B, ct shows that the pseudoaneurysm is separate from the anterior tibial artery, arising from a branch vessel injury. Finally, ultrasound can be used for assessment of outcomes, either during a procedure (when corrective action can be taken if a technical defect is found) or later, if surveillance is indicated. As air has high acoustic impedance, a water-based gel is used for acoustic coupling between the transducer and the skin for routine applications; but blood or saline irrigation provides suitable coupling during intraoperative use. A transducer that is appropriate for the depth and the location to be evaluated is selected. Transducer elements can be mounted in a curved or linear array to create a sector or boxlike image. Probes designed specifically for intraoperative use may have a T-shaped or hockey-stick design to facilitate use in the operative field. Transducers are typically designed to operate over a range of frequencies (broadband) for greater versatility and better imaging. Because air in the lungs and viscera interferes with ultrasound transmission, ultrasound imaging to evaluate for truncal vascular injury is limited. Subcostal and parasternal windows allow for evaluation of the heart and pericardial sac, but the thoracic aorta cannot be visualized with a transthoracic approach. Direct vascular examination of intraabdominal vessels is seldom performed in the early phases of trauma evaluation and management. When ultrasound is used for procedural guidance or intraoperative assessment, the transducer is sheathed in a sterile sleeve. Acoustic coupling gel needs to be in the sleeve, with no air gap or bubbles between the transducer face and the sleeve. Vascular access is facilitated with routine ultrasound use for venous and arterial sites. During this process, an 18- or 21-gauge needle can be observed or directed into the vessel lumen with ultrasound. Needles with a stippled surface may be more echogenic and easier to visualize with ultrasound. Ultrasound imaging can also confirm intraluminal positioning of catheters and guidewires. There are some ultrasound imaging applications that require specialized capabilities. Tissue heating is negligible with diagnostic ultrasound applications, and there is essentially no risk of injury in typical clinical applications. The primary risks associated with the use of diagnostic ultrasound are the risks of interpretation errors. However, recently some have recommended more targeted use to avoid unnecessary health-care costs and radiation-exposure risks. Also of practical importance, there are many pieces of medical equipment that may not be compatible with use in the presence of a strong magnetic field. Additionally, other noninvasive imaging modalities may suffice to make the correct diagnosis of vascular injury and may allow for appropriate management. Most patients with truncal vascular injuries have associated spine or spinal cord injury or injury to the viscera or solid organs. B, metallic fragments create ct streak artifacts that degrade imaging and interfere with postprocessing. C, Digital subtraction arteriography is useful after shotgun or blast injuries with multiple fragments because there is a risk of significant injury to major arteries or branches. D, Arrows highlight locations of several pseudoaneurysms that appear as outpouchings from the artery. However, on an individual basis, radiation-associated risks are low and usually not major considerations in the context of a potentially life- or limb-threatening vascular injury. The most practical way to keep radiation exposures as low as reasonably achievable in trauma care is to perform only those studies needed for patient management. Technology advances (detector design, image-processing systems) have decreased radiation dose and other procedure-specific changes (adjustments in tube current [mA], tube potential [kVp], gantry rotation time, helical pitch) can further limit exposure. Metal can create streak artifacts by causing the detectors to operate in a nonlinear response region, and even small fragments can create a star-pattern artifact. Patient body habitus also affects image quality with more image distortion occurring in larger patients. Inaccurate geometry, inaccurate alignment of the x-ray tube with the detectors, or incorrect data can produce artifacts and blurring that limit spatial resolution. Detector calibration errors and balance can also occur detracting from image quality. Artifacts caused by equipment malfunction can be eliminated by repair or preventive maintenance. Beam attenuation is proportional to the average attenuation coefficient in each volume element (voxel). Resolution may be degraded when tissues with different absorption densities are in the same voxel. Partial-volume effects are minimized by the use of thin sections or "cuts" and by the selection of a section that lies in the center of the object of interest for attenuation measurements. Beam-hardening artifacts result from preferential absorption of low-energy photons from the x-ray beam. Finally, as experienced clinicians are aware, transporting critically ill or injured patients to an imaging suite is associated with risks. The imaging delay is typically estimated, but most systems will time the arterial phase acquisition with bolus tracking, starting when the contrast arrives at a preselected region of interest. Some postprocessing may be done automatically, but technologists, radiologists, and other clinicians are able to manipulate the dataset to yield the views and projections of specific diagnostic interest. The use of dual energy levels (kVp) during imaging can facilitate removal of bone from images or can help distinguish calcium from contrast-enhanced blood. The selection of the thickness of the imaging slice through the imaged volume can be selected (though it cannot be thinner than the collimation width used for imaging). Thin-slice reconstructions have better edge definition, better highcontrast resolution, and fewer partial-volume artifacts at the cost of greater noise and poorer low-contrast resolution. In fact, some information may be lost as vessels without sufficient contrast may not be displayed. Smaller imaging increments (with overlap of adjacent slice acquisition) provide for better 3-D rendering. Evaluation and management of penetrating lower extremity arterial trauma: an Eastern Association for the Surgery of Trauma practice management guideline. Niola R, Pinto A, Sparano A, et al: Arterial bleeding in pelvic trauma: priorities in angiographic embolization. Katsanos K, Sabharwal T, Carrell T, et al: Peripheral endografts for the treatment of traumatic arterial injuries. Johansen K, Lynch K, Paun M, et al: Non-invasive vascular tests reliably exclude occult arterial trauma in injured extremities. Al-Shakhrah I, Al-Obaidi T: Common artifacts in computerized tomography: a review. Early and effective management of this injury including control of the bleeding and replacement of blood volume are imperative for survival. The wise surgeon understands that recent advances in the field make proper resuscitation every bit as important as any operative maneuver to expose and control a blood vessel or intricately reconstruct a vascular injury. Without knowing and adhering to this modern approach to resuscitation, the patient will be dead or needlessly compromised. Hypovolemia from inadequately controlled hemorrhage has been identified as a leading cause of avoidable death in both the prehospital and in-hospital civilian settings. A landmark analysis of cause of death during a decade of war in Afghanistan and Iraq reported that noncompressible bleeding in the torso. In effect, such individuals died from uncontrolled bleeding and unmitigated hemorrhagic shock. The importance of coagulopathy following vascular trauma and hemorrhage has become more apparent and has influenced a profound change in military medical strategy of when blood products are first administered, the ratio in which they are administered, how coagulopathy is dynamically monitored, and how product replacement is tailored to the need.

The region between the vagina and the anus is the clinical perineum (per i-ne um; area between the thighs) erectile dysfunction treatment natural in india purchase top avana 80 mg line. To prevent such tearing erectile dysfunction doctor tampa buy cheap top avana 80mg line, an incision called an episiotomy (e-piz-e-ot o-me) is sometimes made in the clinical perineum erectile dysfunction treatment by food discount top avana online. Traditionally erectile dysfunction treatments herbal purchase top avana 80 mg with mastercard, this clean erectile dysfunction from diabetes buy discount top avana 80mg online, straight incision has been thought to result in less injury erectile dysfunction world statistics order discount top avana on line, less trouble in healing, and less pain. However, many studies report less injury and pain when no episiotomy is performed. Externally, each of the breasts of both males and females has a raised nipple surrounded by a circular, pigmented area called the areola (a-re o-la). In prepubescent children, the general structure of the male and female breasts is similar, and both males and females possess a rudimentary duct system. The female breasts begin to enlarge during puberty, under the influence of estrogen and progesterone. Some males also experience a minor and temporary enlargement of the breasts at puberty. Occasionally, the breasts of a male can become permanently enlarged, a condition called gynecomastia (gi ne-ko-mas te-a). Causes of gynecomastia include hormonal imbalances and the abuse of anabolic steroids. The duct of each lobe is formed as several smaller ducts, which originate from lobules, converge. In the milk-producing, or lactating, mammary gland, the ends of these small ducts expand to form secretory sacs called alveoli. Myoepithelial cells surround the alveoli and contract to expel milk from the alveoli (figure 19. The breasts are supported by suspensory ligaments that extend from the fascia over the pectoralis major muscles to the skin over the breasts (figure 19. When the smooth muscle contracts in response to stimuli, such as touch, cold, and sexual arousal, the nipple becomes erect. Describe the changes that occur in females during puberty and the changes in the ovary and uterus that occur during the menstrual cycle. As in the male, female reproduction is controlled by hormonal and nervous system mechanisms. During puberty, the vagina, uterus, uterine tubes, and external genitalia begin to enlarge. Adipose tissue is deposited in the breasts and around the hips, causing them to enlarge and assume an adult form. The changes associated with puberty primarily result from the increasing rate of estrogen and progesterone secretion by the ovaries. At puberty, the cyclical adult pattern of hormone secretion is gradually established. Estrogen and progesterone from the ovaries have a strong negative-feedback effect on the hypothalamus and pituitary. Estrogen and progesterone have less of a negative-feedback effect on the hypothalamus and pituitary, and a sustained increase in estrogen concentration has a positive-feedback effect. The normal cyclical pattern of reproductive hormone secretion that occurs during the menstrual cycle becomes established. Menses (men sez; month) is a period of mild hemorrhage, during which part of the endometrium is sloughed and expelled from the uterus. Typically, the menstrual cycle is about 28 days long, although it can be as short as 18 days or as long as 40 days (figure 19. The menstrual cycle results from the cyclical changes that occur in the endometrium of the uterus. The first day of menstrual bleeding (menses), when the endometrium sloughs off, is considered day 1 of the menstrual cycle. Sloughing of the endometrium is inhibited by progesterone but Reproductive stimulated by estrogen. Menses typically lasts 4 or 5 days and can be accompanied by strong uterine contractions, called menstrual cramps, that are extremely uncomfortable in some women. Menstrual cramps are the result of forceful myometrial contractions that occur before and during menstruation. As the endometrium of the uterus sloughs off, it becomes inflamed, and prostaglandins are produced as part of the inflammation. Many women can alleviate painful cramps by taking medications, such as aspirin-like drugs, that inhibit prostaglandin biosynthesis just before the onset of menstruation. These medications, however, are not effective in treating all painful menstruation, especially when the cause of the pain, such as that experienced by women who have tumors of the myometrium, is not due to the inflammatory response. Ovulation occurs on about day 14 of the menstrual cycle, although the timing of ovulation varies from individual to individual and can vary within an individual from one menstrual cycle to the next. To avoid or optimize contraception, it is critical to predict ovulation; however, there is no single reliable method that can predict its exact timing. The simplest method of predicting ovulation is looking for a drop in basal body temperature preceding ovulation, but it is the least reliable method. Between the end of menses and ovulation is the proliferative phase, which refers to proliferation of the endometrium. During the proliferative phase, the secondary follicles in the ovary mature; as they do so, they secrete increasing amounts of estrogen. Estrogen acts on the uterus and causes the epithelial cells of the endometrium to divide rapidly. Following ovulation, the corpus luteum begins to secrete progesterone and smaller amounts of estrogen. Progesterone acts on the uterus, causing the cells of the endometrium to become larger and to secrete a small amount of fluid. Between ovulation and the next menses is the secretory phase of the menstrual cycle, called this because of the small amount of fluid secreted by the cells of the endometrium. During the secretory phase, the lining of the uterus reaches its greatest degree of development. If fertilization occurs, the zygote undergoes several cell divisions to produce a collection of cells called the blastocyst (blastosist). The blastocyst passes through the uterine tube and arrives in the uterus by 7 or 8 days after ovulation. The endometrium is prepared to receive the blastocyst, which becomes implanted in the endometrium, where it continues to develop. If the secondary oocyte is not fertilized, the endometrium sloughs away as a result of declining blood progesterone levels. By day 28, the declining progesterone causes the endometrium to slough away to begin menses and the next menstrual cycle. However, maternal mortality rates for abdominal pregnancies are significantly higher than for fallopian tube ectopic pregnancies. An ectopic pregnancy results if implantation occurs anywhere other than in the uterine cavity. Implantation in the uterine tube is eventually fatal to the fetus and can cause the tube to rupture. Menses (day 1 to day 4 or 5 of the menstrual cycle) Proliferative Phase (from day 4 or 5 until ovulation on about day 14) pituitary gland ovary uterus the rate of FsH and lH secretion is only slightly elevated during most of the proliferative phase; FsH and lH secretions increase near the end of the proliferative phase in response to increasing estrogen secretion from the ovaries. Developing follicles secrete increasing amounts of estrogen, especially near the end of the proliferative phase; increasing FsH and lH cause additional estrogen secretion from the ovaries near the end of the proliferative phase. Ovulation (about day 14) pituitary gland ovary uterus the rate of FsH and lH secretion increases rapidly just before ovulation in response to increasing estrogen levels. Secretory Phase (from about day 14 to day 28) pituitary gland ovary estrogen and progesterone reach levels high enough to inhibit FsH and lH secretion from the pituitary gland. Reproductive reproductive system 551 Older women experience gradual changes in response to the reduced amount of estrogen and progesterone produced by the ovaries (table 19. For example, during the climacteric, some women experience sudden episodes of uncomfortable sweating (hot flashes), fatigue, anxiety, temporary decrease in libido, and occasionally emotional disturbances. Ovulation results from hormonal stimuli and is not dependent on the female sex act. During the procedure, the physician observed several lesions characteristic of endometriosis and removed them with a laser instrument that vaporizes them. Female sexual Behavior and the Female sex act Sexual drive in females, like sexual drive in males, is dependent on hormones. Testosterone-like hormones, and possibly estrogen, affect brain cells (especially in the area of the hypothalamus) and influence sexual behavior. The sensory and motor neural pathways involved in controlling female sexual responses are similar to those found in the male. During sexual excitement, erectile tissue within the clitoris and around the vaginal opening becomes engorged with blood. The mucous glands within the vestibule, especially the greater vestibular glands, secrete small amounts of mucus. Larger amounts of mucuslike fluid are also extruded into the vagina through its wall. These secretions provide lubrication to allow easy entry and movement of the penis in the vagina during intercourse. The vaginal and uterine smooth muscle, as well as the surrounding skeletal muscles, contract rhythmically, and muscle tension increases throughout much of the body. After the sex act, there is a period of resolution, which is characterized by an overall sense of satisfaction and relaxation. Females are sometimes receptive to further immediate stimulation, however, and can experience successive orgasms. Gradual increase in irregular menstruations is followed by no menstruation; the endometrium finally atrophies, and the uterus becomes smaller. Hot flashes and increased sweating are correlated with vasodilation of cutaneous blood vessels; the hot flashes are related to decreased estrogen levels. Fertility begins to decline about 10 years before the onset of menopause; by age 50, almost all the oocytes and follicles have degenerated. But most of these methods also have disadvantages, and the use of some of them is controversial. When placed over the erect penis, a condom is a barrier device because it collects the semen instead of allowing it to be released into the vagina. Diaphragms are 94% effective, whereas cervical cap effectiveness ranges from 71% in a woman who has previously been pregnant to 86% in a woman who has never been pregnant. Both types of iuDs thicken cervical mucus, which bars sperm from entering the uterus. However, the risk of heart attack or stroke increases in female users of oral contraceptives who smoke or who have a history of hypertension or coagulation disorders. For most females, the pill is effective and has a minimum frequency of complications, until at least age 35. Morning-after pills, similar in composition to birth control pills, are available. For example, premature degeneration of the corpus luteum causes progesterone levels to decline and menses to occur. If the corpus luteum degenerates before the placenta begins to secrete progesterone, the endometrium and the developing embryonic mass will degenerate and be eliminated from the uterus. Predict 5 When discussing her condition with her mother, Molly discovered that her mother had experienced frequent menses that were irregular and prolonged when she was in her late 40s. Sexual activity is often maintained in men and women as they age, but the frequency of sexual intercourse usually decreases gradually. A major consequence of prostatic enlargement is blockage of the prostatic urethra. Although benign prostatic enlargement is not preventable, treatments are available to reverse its negative effects. The frequency of prostate cancer also increases as men age and is a significant cause of death in men. However, less than 15% of men age 60 or under experience abnormal erectile dysfunction. Keeping physically healthy can minimize some factors leading to abnormal erectile dysfunction, and medical treatments are available. By age 50, the amount of estrogen and progesterone produced by the ovaries has decreased. The vaginal wall becomes thinner and less elastic, and there is less lubricant in the vagina, resulting in an increased tendency for vaginal yeast infections. The incidence of breast cancer is greatest between 45 and 65 years of age and is greater for women who have a family history of breast cancer. The single most important measure to guard against death from breast cancer is early detection through breast self-exams and yearly mammograms after age 40. The incidences of uterine cancer, ovarian cancer, and cervical cancer all increase between 50 and 65 years of age. Annual medical checkups, including Pap smears for cervical cancer, are important in order to detect cancer at early stages, when it can be easily treated. During this process, each primary spermatocyte eventually gives rise to four equalsized mature sperm cells. The bulbourethral glands and the urethral mucous glands produce mucus that neutralizes the acidic pH of the urethra.

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