Embolization therapy as an alternative to thoracotomy in vascular injuries of the chest wall.

Hemothorax and persistent thoracic bleeding is frequently an indication for thoracotomy after trauma. Unfortunately, the source of the hemorrhage is often not identified. Presently, selective arteriography and transcatheter embolization (SATE) offers a good and safe alternative to localize and control hemorrhage from arterial injuries in selected patients. The records of eight patients who underwent SATE were reviewed. There were six blunt and two penetrating chest injuries. Four patients had significant preexisting medical comorbidities. Three patients with blunt injuries had undergone exploratory thoracotomy, but continued to bleed postoperatively. In three patients, angiography was indicated for associated thoracic and pelvic injuries, and five patients had SATE specifically due to thoracic hemorrhage. In all patients, SATE was effective to diagnose and control the hemorrhage. There were no complications related to the SATE procedure. Two patients died secondary to severe cerebral injuries. Given hemodynamic stability, SATE can be considered in patients who have already had a thoracotomy, have significant associated medical conditions, or those in need of other angiographic studies. Careful technique and a readiness to abandon SATE in unstable patients or when a suitable catheter position cannot be achieved are important technical points.

Cutaneous burns caused by sulfuric acid drain cleaner.

BACKGROUND: Highly concentrated solutions of sulfuric acid are available to unclog drains. We have noted a substantial number of both accidental and intentional cutaneous burns caused by these agents. METHODS: A retrospective review was conducted of children and adults who sustained sulfuric acid burns over a 13-year period ending in May 1996. Reports of injuries related to drain cleaners filed with the United States Consumer Product Safety Commission between 1991 and 1995 were also reviewed. RESULTS: Twenty-one patients (13 children, 8 adults) sustained cutaneous burns caused by concentrated sulfuric acid solutions. In 8 instances, the burn was accidental, whereas in 13 cases, sulfuric acid was used as a weapon. Median total body surface area burned was 5% (range, 1-25%). Approximately 50% of burns involved the face and neck. Skin grafting was required in 14 patients (66%). It is estimated that nationwide approximately 3,000 injuries per year are related to drain cleaners and that one-third of these involve cutaneous burns. CONCLUSION: Highly concentrated sulfuric acid drain cleaner can produce full-thickness cutaneous burns that require skin grafting in the majority of cases. Proper use of these agents and sequestering them from children may reduce accidental contact; however, their abuse as agents of assault remains a source of significant morbidity.

Effects of dichloroacetate on mechanical recovery and oxidation of physiologic substrates after ischemia and reperfusion in the isolated heart.

The effects of dichloroacetate (DCA) on fatty acid oxidation and flux through pyruvate dehydrogenase (PDH) were studied in ischemic, reperfused myocardium supplied with glucose, long-chain fatty acids, lactate, pyruvate, and acetoacetate. The oxidation rates of all substrates were determined by combined 13C nuclear magnetic resonance (NMR) spectroscopy and oxygen-consumption measurements, and PDH flux was assessed by lactate plus pyruvate oxidation. In nonischemic control hearts, DCA increased PDH flux more than eightfold (from 0.68 +/- 0.28 to 5.81 +/- 1.16 micromol/min/g dry weight; n = 8 each group; p < 0.05) and significantly inhibited the oxidation of acetoacetate and fatty acids. DCA also improved mechanical recovery after 30 min of ischemia plus 30 min of reperfusion but did not significantly increase PDH flux measured at the end of the reperfusion period (1.35 +/- 0.42 micromol/min/g dry weight) compared with untreated ischemic hearts (0.87 +/- 0.28 micromol/min/g dry weight; n = 8 each group; p = NS). Although DCA had a modest effect on functional recovery in the reperfused myocardium, this beneficial effect was not associated with either marked stimulation of PDH flux or inhibition of fatty acid oxidation.

Effects of glutamate and aspartate on myocardial substrate oxidation during potassium arrest.

OBJECTIVES: A recent report (J Clin Invest 1993;92:831-9) found no effect of glutamate plus aspartate on metabolic pathways in the heart, but the experimental conditions did not model clinical cardioplegia. The purpose of this study was to determine the effects of glutamate and aspartate on metabolic pathways feeding the citric acid cycle during cardioplegic arrest in the presence of physiologic substrates. METHODS: Isolated rat hearts were supplied with fatty acids, lactate, pyruvate, glucose, and acetoacetate in physiologic concentrations. These substrates were enriched with 13C, which allowed a complete analysis of substrate oxidation by 13C-nuclear magnetic resonance spectroscopy in one experiment. Three groups of hearts were studied: arrest with potassium cardioplegic solution, arrest with cardioplegic solution supplemented with glutamate and aspartate (both in concentrations of 13 mmol/L), and a control group without cardioplegic arrest. RESULTS: In potassium-arrested hearts, the contributions of fatty acids and lactate to acetyl coenzyme A were reduced, and acetoacetate was the preferred substrate for oxidation in the citric acid cycle. The addition of aspartate and glutamate in the presence of cardioplegic arrest did not further alter patterns of substrate utilization substantially, although acetoacetate use was somewhat lower than with simple cardioplegic arrest. When [U-13C]glutamate (13 mmol/L) and [U-13C]aspartate (13 mmol/L) were supplied as the only compounds labeled with 13C, little enrichment in citric acid cycle intermediates could be detected. CONCLUSIONS: Glutamate and aspartate when added to potassium cardioplegic solutions have relatively minor effects on citric acid cycle metabolism.

Alcohol, drug intoxication, or both at the time of burn injury as a predictor of complications and mortality in hospitalized patients with burns.

The objective of this study was to characterize the association between drug and alcohol intoxication at the time of injury and subsequent complications and mortality in hospitalized patients with burns. A computerized burn database was used to analyze data on 3047 consecutive adult (21 to 75 years) hospitalized patients with burns admitted between January 1982 and August 1994. Data for intoxicated (by history, blood alcohol content, or positive drug screen) and nonintoxicated patients were compared. The same analysis was also conducted on 429 consecutive adolescent patients with burns (ages 14 to 20 years) admitted during the same time period. The incidence of intoxication at the time of burn was 6.9%. No significant differences in age, sex, race, or burn size were noted. Intoxicated patients had a higher incidence of associated injuries. Skin graft loss, cellulitis, donor site conversion, hypotension, and pneumonia were more common in the intoxicated group. They also had more intensive care unit admissions, ventilator days, operations, transfusions, and total hospital days. Intoxicated patients had a lower mortality (7.1%) than patients in the control group (10.9%). Intoxication at the time of burn injury is an important predictor of complications in adult patients with burns.