Traumatic tricuspid regurgitation with cyanosis: diagnosis by transesophageal echocardiography.

This case report demonstrates the utility of transesophageal echocardiography in the rapid diagnosis of cardiac injury from blunt thoracic trauma. Initial transesophageal echocardiography identified a flail tricuspid valve leaflet and regurgitation in a patient with jugular venous distention and hemodynamic instability. Progressive hypoxemia prompted repeat transesophageal echocardiography with contrast enhancement, which revealed opening of the foramen ovale and a right-to-left interatrial shunt. Operative repair of the lesion was lifesaving.

The future of general surgery characterized by general surgical chief residents.

The future of any specialty in medicine depends in large part on the career choices of its trainees. We obtained data from General Surgery Chief Residents who finished their training in 1990 and compared their attitudes to a similar survey conducted by us in 1985. According to those responses, residents in general surgery continue to choose fellowship training at a time when they no longer perceive an oversupply of general surgeons. This has broad implications for the future of general surgery as a specialty that requires significant change in the structure of our residency programs.

Increases in type III collagen gene expression and protein synthesis in patients with inguinal hernias.

OBJECTIVE: The aim of this study was to determine if alterations in fibrillar collagen synthesis were associated with the development of inguinal hernias. SUMMARY BACKGROUND DATA: Previous work has suggested that alterations in connective tissue accumulation may play a functional role in the development of inguinal hernias. In particular, several investigators have suggested that alterations in collagen synthesis, causally related to connective disorders such as osteogenesis imperfecta, may also be responsible for the inguinal herniation that is markedly increased in such patients. This study was undertaken therefore to study collagen synthesis in patients with inguinal hernia in the absence of any other connective tissue disease. METHODS: Skin fibroblasts from 9 patients with hernias and 15 control individuals were radiolabeled with 3H-proline. Trypsin-chymotrypsin-resistant type I and III collagens were isolated and analyzed by sodium dodecyl sulfate polyacrylamide gel electrophoresis, and recovery was quantified by laser densitometry. Steady-state levels of alpha 1(I) and alpha 1(III) procollagen mRNAs were also determined by northern and slot-blot hybridization analysis. RESULTS: The alpha 1(I)/alpha 1(III) collagen ratios were shown to be 6.3 +/- 0.34 in fibroblasts from control individuals and 3.0 +/- 0.25 in fibroblasts from patients with inguinal hernias. This statistically significant difference (p < 0.0001) was caused by an increase in the secretion of alpha 1(III) procollagen from the fibroblasts of patients with hernias. A concomitant increase in the steady-state levels of alpha 1(III) procollagen mRNA was observed in total RNA isolated from the patients' fibroblasts. CONCLUSIONS: A constitutive and systemic increase in type III collagen synthesis may result in reduced collagen fibril assembly in the abdominal wall, eventually leading to the development of herniation. Although it is not yet clear what genetic factors are responsible for the elevation in type III collagen synthesis in patients with hernias, this study represents the first attempt to define individuals with an abnormality in collagen production that may be specifically related to herniation. A clearer understanding of the possible genetic factors that influence the pathophysiology of this disease will be important to improve the treatment of patients in whom inguinal hernias develop.

Nonoperative management of bilateral shattered kidneys from blunt trauma.

Bilateral shattered kidneys secondary to blunt abdominal trauma has not, to our knowledge, been reported. In the case reported herein, severe pulmonary, myocardial, and orthopedic injuries necessitated nonoperative management of this peculiar injury. The patient recovered without sequelae related to the renal injury.

The adequacy and cost effectiveness of routine resuscitation-area cervical-spine radiographs.

Portable resuscitation-area cervical-spine radiographs (PCS) frequently constitute a routine part of the emergency evaluation of patients suffering from blunt trauma. Their adequacy and cost were evaluated by reviewing the records of 92 consecutive trauma patients. Forty-seven of 74 patients (63.5%) had adequate PCS in that all seven cervical vertebrae were visualized. In 27 patients (36.5), all seven cervical vertebrae were not adequately visualized. Inadequate studies were most likely to occur in patients with abnormal vital signs on admission (56%) (P less than .01) and in those subsequently requiring general anesthesia (34.5%). Fifteen patients were intubated without difficulty by maintaining neck immobilization because of uncertainty regarding cervical-spine injuries. The annual cost of inadequate cervical-spine studies was estimated to be $31,000.00. Although the four cervical-spine injuries were diagnosed by the portable technique, routine PCS were frequently inadequate in visualizing all seven cervical vertebrae. Major decisions concerning intubation and surgery frequently had to be made before adequate radiographic evaluation could be completed. It is suggested that time and money are lost by routinely doing a single lateral portable cervical radiograph. It is more appropriate to obtain complete radiographic studies after life-threatening injuries are addressed while patients are treated using the standard techniques of neck immobilization.

A simplified approach to techniques of splenic salvage.

Splenic salvage or partial splenectomy may be simplified by following these basic steps. The spleen is completely mobilized from all of its attachments so that it is tethered only by its blood supply. Appropriate hilar and short gastric vessels are ligated, and devitalized splenic tissue is débrided. Parenchymal bleeding is controlled by compression using horizontal mattress sutures placed through pledgets of folded sheets of oxidized cellulose.

The suicidal jailhouse hanging.

Jailhouse suicide is commonly attempted by hanging. Two prisoners recently have been treated in our trauma service after unsuccessful attempts at suicidal hanging. Both of our patients demonstrated problems related to hypoxic encephalopathy, fluid and electrolyte disturbances, and mental status change, all as a result of this injury. These patients' hospital course illustrates some of the salient features in the management of this unusual patient population.

Early diagnosis and treatment of blunt diaphragmatic injury.

Diaphragmatic rupture following blunt torso trauma is an infrequent injury often posing a considerable diagnostic challenge. Between June 1984 and July 1986, nine patients sustaining rupture of the diaphragm due to blunt trauma were treated. All were injured in high-speed motor-vehicle accidents. Six patients arrived in shock (SBP less than or equal to 95 mm Hg). All patients had multiple associated injuries; mean ISS = 41.5. Eight patients (89%) had associated intra-abdominal injuries, the spleen being injured most frequently (63%). Associated thoracic injuries occurred in six patients (67%). The admission CXR was abnormal in eight patients (89%) but diagnostic of diaphragmatic rupture in only four. DPL was positive in four of five patients (80%) and falsely negative in one. Seven ruptures were left-sided, one right-sided and one involved the central tendon. All injuries were diagnosed shortly after admission and successfully repaired via a transabdominal approach. One patient died as a result of a massive subdural hematoma. Blunt diaphragmatic rupture is an indication of a high-energy insult and is usually associated with other major organ system injuries. An aggressive approach to the management of the multiply injured patient can result in early recognition and successful treatment of this injury.

Ruptured aneurysm of the internal iliac artery.

Our case and others reported in the literature illustrate that isolated aneurysms of the internal iliac artery are uncommon lesions with a highly lethal potential. The classic signs of ruptured abdominal aneurysm--pain, palpable mass, and shock--are usually altered with rupture of these aneurysms because of their deep location in the pelvis. Rectal examination will aid diagnosis. Surgical management of IIA aneurysms 4 cm or larger is indicated at the time of diagnosis, since rupture is usually fatal.

Peritoneal lavage in patients with normal mentation and hematuria after blunt trauma.

The need for diagnostic peritoneal lavage in the confused or obtunded patient with trauma is universally accepted. The use of peritoneal lavage in patients without neurologic impairment is controversial. The usefulness of diagnostic peritoneal lavage in patients with blunt trauma, hematuria and normal mentation was studied. In this subgroup, exploratory laparotomy was required in 44.6 per cent of the patients. Operation was four times more common for nonurogenital than urogenital injuries. Peritoneal lavage was 92 per cent accurate in predicting the need for laparotomy. Omission of peritoneal lavage resulted in either missed injury or serious diagnostic delay in 12 per cent of the patients. Patients presenting with hematuria after blunt trauma need evaluation for associated nonurogenital injury and would be well served by diagnostic peritoneal lavage.