Selective management of embolized intracardiac missiles.

Intracardiac projectiles are occasionally found in stable patients who have sustained penetrating trauma. These missiles may arise from embolization from a peripheral injury site. We describe 3 patients with embolized intracardiac projectiles. The diagnosis was suggested by the presence of a foreign body within the cardiac silhouette on chest roentgenograms and was confirmed using fluoroscopy, echocardiography, or computed tomography. The management of embolized intracardiac missiles should be individualized to each patient. All of our patients had fixed intracavitary right-sided missiles and were successfully managed expectantly.

The perils of bungee jumping.

Bungee jumping is a relatively new recreational sport. Most emergency physicians and trauma surgeons have limited experience with its associated injuries. We report the case of a bungee cord attachment apparatus malfunctioning, resulting in a free fall of the jumper of approximately 240 feet. The presence of an air cushion on the ground prevented significant injury. Knowledge of the potential injuries of this new sport is crucial for effective management.

Congenital colonic varices in the adult. Report of a case.

PURPOSE: This study was conducted to report a rare cause of colonic bleeding. METHODS: Case report. CONCLUSION: Surgical resection of congenital colonic varices is associated with a low incidence of morbidity and mortality, and a favorable long-term prognosis can be expected when there is no evidence of hepatocellular disease (portal hypertension).

Computed tomography in the diagnosis of blunt thoracic injury.

BACKGROUND: Computed tomography (CT) is an important diagnostic modality in the evaluation of blunt head and abdominal injuries, but it has not been routinely used to evaluate blunt chest trauma. METHODS: One hundred seventy stable patients with blunt thoracic trauma were evaluated with chest x-ray (CXR), and subsequently by CT. RESULTS: Of a total of 131 fractures, 53% were identified on initial CXR, 39% on CT, and 26% were not seen on either study. Twenty-one pneumothoraces were seen on CT but not on CXR. Chest tubes were placed in 8 patients and 12 patients were observed without incident. One hemothorax identified by CT scan alone required treatment. Four of 6 diaphragmatic injuries were seen on CT and 2 on CXR. Parenchymal abnormalities were apparent in 189 lung fields on CT and in 66 lung fields on CXR. Most represented atelectasis and did not require treatment. Altogether, CT scanning resulted in changes in management for 11 patients (6%). CONCLUSIONS: Although CXR is less sensitive in detecting parenchymal and pleural injuries than CT, the majority of the injuries identified by CT alone are minor and require no treatment. CXR remains the primary modality for diagnostic evaluation of blunt thoracic trauma.

Patterns and prognosis of Clostridium difficile colitis.

UNLABELLED: The incidence of Clostridium difficile colitis has increased during recent years, presumably because of liberal use of broad-spectrum antibiotic regimens. METHODS: A retrospective review to determine patterns of C. difficile colitis development, morbidity, and treatment results was undertaken. During an 18-month period, 90 patients were diagnosed with C. difficile colitis by fecal toxin assays. Patient demographics, symptoms, previously administered antibiotic regimens, diagnostic evaluations, treatment modalities, morbidity, and mortality were identified, entered into a computer data base, and analyzed. RESULTS: The mean age was 58 years; males outnumbered females 1.2:1. Among 90 patients, 41 (46 percent) developed C. difficile colitis after surgical procedures. Eighty (89 percent) patients received antibiotic therapy before developing C. difficile colitis: 35 (44 percent) for documented infections and 45 (56 percent) as empiric or prophylactic therapy. Cephalosporins, penicillins, quinolones, vancomycin, and aminoglycosides were the most frequently administered antibiotic classes prior to C. difficile colitis diagnosis. Ten (11 percent) patients developed C. difficile colitis without previous antibiotic therapy. Eighty-two (91 percent) patients presented with diarrhea, while eight (9 percent) had fever only. Primary C. difficile colitis treatment for both groups included vancomycin (66 percent), metronidazole (24 percent), or both drugs (10 percent). Ten (11 percent) patients received no treatment. No patient developed toxic colitis or megacolon. Colonoscopy was performed in four (4 percent) patients; pseudomembranes were identified in one (25 percent) patient. There was one C. difficile colitis recurrence after treatment, but no C. difficile colitis-associated morbidity. Mortality (14 patients, 16 percent) was not related to C. difficile colitis, but to underlying illness. No difference in patient age, sex, previous antibiotic administration, serum albumin, total days hospitalized, duration of C. difficile colitis antibiotic therapy, C. difficile colitis treatment regimens, or mortality was identified between nonsurgical and surgical patients. The white blood cell count was significantly lower in the nonsurgical group however. Clostridium difficile colitis developed most commonly after antibiotic administration with symptoms of diarrhea, but did occur without previous antibiotic administration or diarrhea. CONCLUSION: Despite the clinical setting, C. difficile colitis had no associated morbidity and treatment was highly effective. Mortality was related to underlying medical illness, not C. difficile colitis.

Protective effect of 2-chloroadenosine on lung ischemia reperfusion injury.

Reperfusion following ischemia yields an inflammatory response characterized by polymorphonuclear leukocyte (PMN) influx, inflammatory mediator release, microvascular permeability alteration, and protein-enriched fluid transudation. Evidence has accumulated suggesting that low-dose adenosine may "down-regulate" the PMN response. This study evaluated the effects of an adenosine analogue, 2-chloroadenosine (2CA), on ischemia-reperfusion (IR) injury in rabbit lungs. In these experiments the left pulmonary hilum was skeletonized, obliterating the bronchial circulation, and the left pulmonary artery and vein were occluded for 1 min for the sham ischemia (SI-V) group or for 1 hr for the ischemia (I-V) and 2CA-treated (I-A) groups. The left lung was inflated with nitrogen during the ischemic period. Saline (SI-V and I-V groups) or 2CA (I-A group) infusions were begun prior to and during the reperfusion period. After 4 hr of reperfusion and restored ventilation, selective left lung physiologic measurements and bronchoalveolar lavage (BAL) were performed. Groups (N = 8/group) were compared using analysis of variance. The I-A group demonstrated a significantly lower mean pulmonary artery pressure and higher cardiac output than the I-V group. Pulmonary vascular resistance was significantly elevated in group I-V compared to group I-A. A significantly greater alveolar WBC influx and protein transudation (BAL/plasma albumin) occurred in the ischemic group compared to the 2CA-treated animals and sham controls. Decreased PaO2 and increased venous admixture were noted in the ischemic group, but did not reach significance when compared to the 2CA group.(ABSTRACT TRUNCATED AT 250 WORDS)

Conservative versus surgical management of chylothorax.

Chylothorax is a potentially life-threatening disorder that has profound respiratory, nutritional, and immunologic consequences. Treatment for this problem is controversial, and the results have been variable. From 1985 to 1990, 29 patients (16 males, 13 females; mean age: 20.1 years; range: 5 days to 76.8 years) were diagnosed as having chylothorax (18 right, 6 left, 5 bilateral). Etiologies included surgical trauma (26) and nonsurgical trauma (3). Initial conservative treatment consisted of tube thoracostomy drainage (mean duration: 13.3 days; range: 1 to 62 days; mean total volume: 4,030 mL) and dietary modification (low-fat diet, total parenteral nutrition). This resulted in resolution of the chylothorax in 23 patients (79% success), although 2 patients died of unrelated causes while hospitalized (myocardial infarction and cardiopulmonary arrest). Five adult patients and one infant (21%) required ligation of the thoracic duct, with resolution of the chylothorax in all six (100% success). Despite successful duct closure, one infant died of respiratory failure unrelated to the operation, and one adult died as the result of a cerebrovascular accident 6 weeks postoperatively, yielding an operative mortality of 33% and an overall mortality of 14% (4 of 29). Our experience demonstrates that initial treatment of chylothorax with thoracostomy drainage and dietary modification is successful in the majority of patients and is not associated with high morbidity or mortality rates. Surgical intervention for chylothoraces that fail to respond to initial conservative measures will be required in a minority of patients but appears to be associated with a higher risk of complications.

Surgical spectrum of aortic stenosis in children: a thirty-year experience with 257 children.

Aortic stenosis accounts for 5 to 6% of infants and children seen for surgical repair of congenital heart disease. The clinical presentation and reported results of operation for aortic stenosis are highly variable. This retrospective review was undertaken to assess our operative mortality and the degree of gradient reduction afforded by each of several surgical techniques used to treat aortic stenosis in children over a 30-year period. Two hundred fifty-seven patients ranging in age from 1 day to 19 years were operated on between 1957 and 1986. The indication for operation included asymptomatic patients with gradients greater than 50 mm Hg to patients in profound cardiogenic shock. The operative mortality for children older than 6 months was 4%, whereas neonates seen with critical aortic stenosis had a 60% mortality. The late mortality was 2%. Eighty percent of surviving patients to date have undergone cardiac catheterization after repair. This shows an overall reduction of 57 mm Hg in the left ventricular-aortic gradient. Patients with supravalvular aortic stenosis and discrete subvalvular aortic stenosis as well as patients undergoing aortic valve replacement showed a reduction in or elimination of associated aortic insufficiency, whereas patients undergoing aortic valvotomy or neonates having valvotomy had a significant increase in demonstrable aortic insufficiency. The incidence of third-degree heart block or cerebral emboli following operation for aortic stenosis was less than 1%. However, the incidence of late bacterial endocarditis following repair was nearly 5%; six of eleven cases occurred in the group with discrete subvalvular aortic stenosis. Twenty-nine (13%) of the 223 long-term survivors have undergone a subsequent procedure for relief of residual or recurrent obstruction; 12 have had insertion of an aortic valve prosthesis, 12 have had insertion of an apicoaortic conduit, and 6 have required repeat aortic valvotomy. These data demonstrate the low operative mortality and excellent hemodynamic benefit of surgical relief of single-level aortic stenosis in children older than neonates. Conduits placed for complex obstructions or operative procedures in neonates have acceptable hemodynamic benefits, but operative mortality remains high.