Emergency craniotomy in a rural Level III trauma center.

Patients with closed head injury and expanding epidural (EDH) or subdural (SDH) hematoma require urgent craniotomy for decompression and control of hemorrhage. In remote areas where neurosurgeons are not available, trauma surgeons may occasionally need to intervene to avert progressive neurologic injury and death. In 1990, a young man with rapidly deteriorating neurologic signs underwent emergency burr hole decompression of a combined EDH/SDH at our hospital, with complete recovery. In anticipation of future need, five surgeons at our rural, American College of Surgeons-verified Level III trauma center participated in a neurosurgeon-directed course in emergency craniotomy. Since January 1, 1991, 792 patients have been entered into the trauma registry, including 60 with closed head injury and Glasgow Coma Scale (GCS) score of 13 or less. All but seven were transferred to a regional Level II trauma center, which is a minimum flight time of 1 hour each way. All patients with EDH (5) and 2 of 14 with SDH were deemed too unstable for transport and underwent burr hole decompression followed by immediate transfer. All craniotomies were approved by the consulting neurosurgeon and were done for computed tomography-confirmed lesions combined with neurologic deterioration as demonstrated by (1) GCS score of 8 or less, (2) lateralizing signs (dilated pupil, hemiparesis), or (3) development of combined bradycardia and hypertension. One patient with a GCS score of 3 on arrival died. Seven survivors (mean follow-up, 3.9 years; range, 1-6.5 years), including the index case, function independently, although one survivor has moderate cognitive and motor impairment. We conclude that early craniotomy for expanding epidural and subdural hematomas by properly trained surgeons may save lives and reduce morbidity in properly selected cases when timely access to a neurosurgeon is not possible.

Constrained total elbow arthroplasty.

In 1972, the senior author designed a condylar-sparing constrained hinge elbow prosthesis with a high-density polyethylene bushing. The condylar-sparing design allows both intercondylar and intramedullary fixation of the humeral component with methylmethacrylate cement. Reattachment of the muscles and collateral ligaments to the preserved condyles provides further stability. The clinical experience spans more than 16 years in 42 elbows with a relatively low loosening rate of 7%. The implant was removed and not replaced in three elbows: one for late infection, one for posttraumatic comminuted fracture of the distal humerus, and one for loosening of a humeral component. A series of 27 patients (31 elbows) with 24-204 months of follow-up study (average, 77 months) had excellent pain relief and an average range of motion of 129 degrees flexion, -44 degrees extension, 69 degrees pronation, and 61 degrees supination.

An evaluation of the efficacy of postoperative blood salvage after total joint arthroplasty. A prospective randomized trial.

The efficacy of a postoperative blood salvage system was assessed in 239 consecutive patients undergoing total knee or total hip arthroplasty. Patients were randomly allocated to either a control group using a standard drainage system or to the study group using the Solcotrans blood salvage canister. The median amount of homologous blood required after operation by the study group was reduced by 74% from the amount required by the control group (mean, 67 ml vs 256 ml, respectively; P less than .0001). Thirteen percent (13%) of the study group required postoperative homologous blood transfusions, as compared to 39% of the control group (P less than .0001). Additionally, patients in the study group had higher hemoglobin levels beginning on the first postoperative day. This study indicates that a postoperative blood salvage system safely and effectively reduces the amount of homologous blood required and sustains higher hemoglobin levels after operation.

The emergency care network of a ski marathon.

In this paper we report the system of emergency care that was used in a large-scale cross-country ski marathon. We describe the typical terrain encountered, personnel required, physical facilities, communication system, injury protocol, and types and numbers of injuries seen. We have found that many injuries can occur in a cross-country ski race, given specific race conditions. A complete and efficient emergency care network is essential to the success of any athletic event similar to the one we report. These races are rapidly growing in number and size, yet we could not find any previous reports in the literature pertaining to the medical care necessary. We hope to provide a model for emergency care that can be applied to many different athletic events involving large numbers of participants and covering great distances.