The safety of emergency neuromuscular blockade and orotracheal intubation in the acutely injured trauma patient.

BACKGROUND: This study was done to determine the safety and success of orotracheal intubation with planned neuromuscular blockade in patients who are severely injured. The study was performed at Carle Foundation Hospital, designated Level I trauma center located in east central Illinois. STUDY DESIGN: A retrospective review of the trauma registry and medical records of all patients requiring emergency airway control from September 1, 1987 to September 30, 1991 was performed. Two hundred twenty-nine patients who were critically injured were reviewed, the mean injury severity score was 29 (range of 3 to 75), the mean revised trauma score was 9 (range of 3 to 12), the mean Glasgow Coma Scale was 9 (range of 3 to 15), and the mean age was 31 years (range of one to 94 years). RESULTS: Indications for intubation included hemodynamic instability or altered level of consciousness (66.4 percent), or both, combative or uncooperative behavior (33.2 percent), and need to secure airway for transport (0.4 percent). Two hundred twenty-three (97.4 percent) patients were successfully intubated. Six (2.6 percent) patients required cricothyroidotomy and one (0.4 percent) patient was aspirated during intubation. Eight (3.5 percent) patients had cervical spine injuries but had no complications from orotracheal intubation. In the combative group, 32 (42 percent) patients had significant head injuries and 17 (22 percent) had other potentially life-threatening injuries. CONCLUSIONS: Orotracheal intubation with planned neuromuscular blockade and in-line cervical traction is a safe, effective method for airway control in patients who are severely injured. This technique is also indicated to expedite therapy in combative, uncooperative patients because of the high incidence of significant life-threatening injuries to the brain and other organs.

Outcomes following injury in a predominantly rural-population-based trauma center.

OBJECTIVE: To determine the incidence, severity, and outcomes of injury in patients treated in a rural-based level I trauma center and to compare the outcomes with a nationally indexed patient population--the Major Trauma Outcome Study. DESIGN: Retrospective evaluation of trauma registry data. SETTING: State of Illinois designated level I trauma center located in Urbana. PATIENTS: A total of 2246 trauma patients admitted from August 1989 through August 1992, with a mortality cohort of 158 patients. There were 1735 patients (77%) with Injury Severity Scores less than or equal to 19 and 511 patients (23%) with more severe injuries (Injury Severity Scores > or = 20). MAIN OUTCOME MEASURES: Mortality rates using the TRISS method, the Major Trauma Outcome Study, and final patient dispositions. RESULTS: The overall mortality rate, excluding those patients who were pronounced dead on arrival, was 125/2213 (5.6%). Eighty-six (69%) of these 125 patients had neurological Abbreviated Injury Scores of 3 or greater, with neurotrauma being a major contributor to their deaths. The m-statistic was 0.99 and the z-statistic was -3.30 for the entire group. The observed probability of survival met or exceeded the expected probability of survival when compared with the Major Trauma Outcome Study in all categories. CONCLUSION: Acceptable mortality rates compared with the Major Trauma Outcome Study can be achieved in a rural-community-based level I trauma center despite relatively small numbers of critically injured patients. Such outcomes may assist in justifying resource allocation for trauma centers in rural areas.

Role of Ca 125 as tumor marker in ovarian carcinoma.

Thirty-three healthy women (group 1), 20 patients with a history of ovarian carcinoma but no manifest disease at the time of the study (group 2), and 45 patients with surgically demonstrable ovarian cancer (group 3) were studied to establish guidelines for the use of the ovarian cancer antigen Ca 125 in monitoring the course of ovarian carcinoma. Ninety-nine percent of all Ca 125 titers of patients in groups 1 and 2 were less than or equal to 25 U/mL. By contrast, 96% of patients with manifest ovarian cancer had Ca 125 levels greater than 25 U/mL. Ca 125 values rising from the normal range to greater than 25 U/mL predicted recurrent disease in all of ten patients, provided benign causes (four cases) for titer elevations such as bowel obstruction could be ruled out. Seven of ten patients with recurrent cancer had elevated antigen levels two to five months before the diagnosis could be made clinically. In patients with Ca 125 values greater than 25 U/mL, titer changes of greater than or equal to 50% compared with reference values predicted tumor response or progression in 41 of 43 patients (95%) with antigen positive tumors. Antigen levels less than or equal to 25 U/mL did not exclude the presence of tumor at second look operation in six of 13 patients (46%). It is concluded that the Ca 125 is useful for the detection of persistent and recurrent disease, and for the evaluation of treatment responses.(ABSTRACT TRUNCATED AT 250 WORDS)

Combination antiemetic therapy in cisplatin-induced nausea and vomiting.

Twenty-seven consecutive patients with advanced gynecologic malignancies undergoing chemotherapy with cisplatin in combination with other agents were studied in a prospective, randomized fashion to compare the antiemetic efficacy of a combination regimen with high-dose metoclopramide. The combination regimen consisted of prochlorperazine, dexamethasone, and pentobarbital. Patients treated with the combination regimen had significantly less vomitus (P less than 0.01, Student's t test) and fewer vomiting episodes (P less than 0.001, test for homogeneity) than patients treated with metoclopramide. In addition, the sedative and sleep-inducing effect of the barbiturate made the experience of vomiting more tolerable, even in those instances where the combination regimen was not superior to metoclopramide in the control of vomiting.

Ineffectiveness of scalp hypothermia in the prevention of alopecia in patients treated with doxorubicin and cisplatin combinations.

Eleven patients were studied to determine the effectiveness of scalp hypothermia in the prevention of chemotherapy-induced hair loss. Scalp hypothermia was induced by the Kold Kap. The cytotoxic regimen used consisted of either cisplatin, doxorubicin, and cyclophosphamide or cisplatin, doxorubicin, and methotrexate given at monthly intervals. All 11 patients required a wig by the end of the fifth course of chemotherapy because of severe hair loss. Ten of the 11 patients (91%) had severe hair loss by the end of the second course of chemotherapy. These results suggest that scalp hypothermia as used in this study is ineffective in preventing chemotherapy-induced alopecia in patients treated with cisplatin and doxorubicin drug combinations in doses commonly used for treatment of gynecologic malignancies.

Jaundice.

Jaundice is caused by an increase in bilirubin in the blood. This can occur before the bilirubin is conjugated by the liver, or after the bilirubin has been conjugated. If the bilirubin has not yet ben conjugated, it will not be able to pass through lipid membranes and will not be soluble in water. Therefore it will not be present in urine. Increases in conjugated bilirubin by the liver, or problems in the conjugation itself. If the increase is conjugated bilirubin, the disorder lies within the outlet channels of the hepatocyte, or there is some kind of obstruction in the biliary outlet system. Within the liver itself, the most common causes of difficulty are acute and chronic hepatitis, alcoholic cirrhosis and drug-induced liver dysfunction. Extra-hepatic obstructions are usually associated with the gall bladder, but may result from tumors of sclerosing secondary to chronic bowel disease.

The effects of gravity on delayed and transplanted delayed tubed flaps.

Altering the position (elevated or dependent) had no immediate effect on the blood supply of delayed or transplanted delayed tubed flaps. However, after 72 hours the mean survival length in the dependent tubes was less than that in the elevated tubes. (This difference was only significant in the delayed untransplanted flaps, and not so in the delayed transplanted flaps). All of the dependent tubes had a significant increase in water content (compared to the elevated tubes). This increase was greater in the transplanted delayed tubed flaps. The tissue pCO2 levels were significantly increased after 24 hours in the dependent transplanted tubes, reflecting poor circulation and ischemia in them. The rate of clearance of subcutaneously injected technetium-99m was significantly increased in the dependent transplanted tubes after 72 hours, while in the elevated tubes the clearance rate was similar to that in normal skin. The morphological appearance of the vessels in these flaps complemented the results of the functional study.

Early diagnosis of crepitant gangrene caused by Bacteroides melaninogenicus.

A rapid non-invasive test for the presence of B. melaninogenicus in the wounds of crepitant non-clostridial gangrene is described. The wounds are viewed under an ultraviolet light, and the presence of bright red fluorescene indicates the probable presence of B. melaninogenicus.

Intracolonic tensions of oxygen and carbon dioxide in germfree, conventional, and gnotobiotic rats.

The relation of intracolonic gaseous tension to fecal microflora was investigated by mass spectrometric measurements of intracolonic O2 and CO2 in unanesthetized germfree, conventional, and gnotobiotic rats; ip measurements were obtained in rats whose colons became perforated accidentally; fecal bacterial flora and cecal size were also determined. Gnotobiotes were monoassociated with Escherichia coli, Bacteroides fragilis and Staphylococcus epidermidis, and were diassociated with E. coli plus B. fragilis and with Bacillus macerans plus an aerobic diphtheroid. Mean intracolonic Po2 in conventional rats (11.1 mmHg) was significantly lower than in germfree rats (12.8 mmHg); mean intracolonic Pco2 in conventionals (83.4 mmHg) was greater than in germfree rats (54.6 mmHg). Differences of Po2 values among all rats were slight. However, intracolonic Pco2 values were directly related to CO2 production by the normal intestinal flora, and were thus significantly lower in both germfree and gnotobiotic rats. Intraperitoneal tensions were independent of the status of rats, and the mean ip Po2 and Pco2 (38.9 and 49.1 mmHg, respectively) agreed with values in the literature. The enlarged cecum, characteristic of germfree rats, was also present in gnotobiotic rats. Counts of each bacterial species in feces of monoassociated rats were 10(8) to 10(10)/g; counts were progressively smaller in feces of diassociated rats and conventional rats (10(8) to 10(9)/g and 10(5) to 10(8)/g, respectively). Intracolonic gaseous tensions of CO2 clearly reflected the presence of a normal flora inconventional rats, and were inversely proportional to cecal size.

Effect of dimethyl sulfoxide and hydrogen peroxide on tissue gas tensions.

Tissue gas levels were measured in experimental skin flaps in rabbits, rats, and pigs. Devascularization of the flaps led to a fall in PO2 and a rise in PCO2 levels. Application of DMSO to ischemic rabbit flaps led to a fall in PCO2, DMSO and H2O2 led to a rise in PO2, an effect that lasted up to 90 min. Neither drug had an effect on the gas levels of flaps in either rats or pigs.