A singular case of murder-suicide committed with a homemade firearm.

The authors illustrate a peculiar case of murder-suicide committed with a homemade firearm loaded with 12-gauge cartridges (buckshot). The structure and function of this handcrafted firearm were simple but effective: an iron tube did duty as a barrel in this primitive firearm. The cartridges (modified by winding sticky tape around the external surface of the base) were inserted down one end of the tube (serving as the breech). A second iron tube with a larger diameter (so as to be able to run over each of the preloaded barrels) and with a jutting, cone-shaped metal wedge soldered to the base, was used as a rudimental firing pin. After loading the "barrel" with the modified cartridge, the gunman would ram the "firing pin" tube violently down to fire the shot. Autopsy of the woman's body showed the presence of 3 gunshot wounds caused by buckshot, while the man had a single buckshot wound in the head. Subsequent ballistic investigations enabled reconstruction of the event (typical of murder-suicide) and the functioning of the firearm, demonstrating its lethal nature, remarkably easy handling, and simplicity of production.

Epidural space as a Starling resistor and elevation of inflow resistance in a diseased epidural space.

BACKGROUND AND OBJECTIVES: The origin and the presence of negative pressure in the epidural space as well as the relationship of the extent of epidural anesthesia to epidural pressure has long been a subject of controversy. To further elucidate epidural pressure and its time course, the pressure at the needle tip was continuously measured as it traversed the interspinous ligament and the ligamentum flavum. METHODS: In a group of 22 patients, fluid was infused under gravity, and in a second group of 25 patients, boluses of fluid were administered at controlled infusion rates and under gravity. The volume-pressure-flow relationship was thus measured in one of two ways, either with a manual syringe and pressure transducer or with a pressure-monitoring-computer-controlled volumetric infusion pump. RESULTS: Natural pressure, (i.e., pressure in the epidural space before instrumentation is applied) could be approached when the space was first entered before fluid was infused (initial pressure); or after fluid had been infused (residual pressure). Epidural pressure could be extrapolated from the upsweep of the volume-pressure-flow relationship by projecting it back to just before the first injection. The extrapolated pressure lay between the initial and residual pressures. Medicinal solution placed in the barrel of the syringe did not infuse under gravity until the syringe barrel was lifted to a certain height, at which flow began and continued at a perceptible rate, with very little or no further increase in height required to maintain flow. The pressure at which flow began was the critical opening pressure, a characteristic of a Starling resistor. Furthermore, resistance to inflow of fluid was related to the presence or absence of natural or surgical disease in the epidural space. Resistance was significantly higher in the diseased than in the surgical group, at 114 (range, 22-226) mm Hg/L/h versus 46 (range, 8-86) mm Hg/L/h. Three phases were seen in the pressure-time recordings. CONCLUSIONS: Volume-pressure-flow relationships in the epidural space can be explained by a model in which epidural and subarachnoid pressures are inextricably related with the Starling pressure, dependent on the subarachnoid pressure. This model suggests reasons why spread of anesthetics might be difficult to predict.

Anatomy of the lumbar sympathetic chain.

BACKGROUND AND OBJECTIVES: To acquire an accurate knowledge of the relationship of the sympathetic chain to the vertebral column. METHODS: In dissections on 65 cadavers the authors located the sympathetic chain and its ganglia in three dimensions with respect to the vertebral column: cephalad-caudad in the sagittal plane; ventrally and laterally in the horizontal (axial) plane. The relationship of the sympathetic chain to the psoas muscle and that of the psoas muscle to the vertebral column was also established. Transparent markers were placed at each disk space and colored markers at each grossly recognizable ganglion. Photographs and measurements were then made. RESULTS: In the sagittal plane, the lumbar ganglia were most often present opposite the middle of the body of the third vertebra and at the disks above and below. In the horizontal plane, the ganglia lay from 0 to 0.5 cm posterior to the anterior border of the third lumbar vertebra and 1.8 to 3.0 cm laterally from the center of the third lumbar vertebra. The sympathetic chain always lay anterior to the psoas muscle. CONCLUSIONS: Although the location of the ganglia is quite variable, the best approach for sympathetic block is to advance the needle paravertebrally through the fascia of the psoas muscle slightly cephalad to the midpoint of the body of L3.

Radiofrequency lumbar sympatholysis. The evolution of a technique for managing sympathetically maintained pain.

BACKGROUND AND OBJECTIVES: To develop lumbar radiofrequency sympatholysis for the relief of pain in patients with neuropathic pain who had previously responded to sympathectomy or sympathetic blocks. METHODS: The technique described by Sluijter was modified to attempt to obtain long lasting pain relief in each patient. No one technique was universally applicable. The variations in technique are illustrated by the case reports. The basic technique that evolved is as follows: a 20-gauge 15-cm insulated needle with a 5-mm active tip was inserted in the direction of an x-ray beam (C arm). The initial target was slightly cephalad to the middle of the L3 vertebra. Contrast medium was injected to confirm the location of the needle. The temperature of the tip of the needle was controlled at 80 degrees C for 90 seconds. RESULTS: Thirty-eight procedures were performed on 20 patients. Reproduction of the pain for which the sympatholysis was undertaken, induced dysesthesia, spread of dye, rapidity of temperature rise in the legs, and increase in pulse volume of the toes were useful guides to proper placement of the needle. Five patients continue to be pain free 5 months to 3 years after the last radiofrequency sympatholysis. Fifteen had temporary relief or no relief at all. The procedure was temporarily complicated by an excessively hot, swollen foot, and postsympathectomy neuralgia in a few cases. CONCLUSIONS: A single technique of radiofrequency sympatholysis does not appear to be applicable to all patients with reflex sympathetic dystrophy or sympathetically maintained pain. Despite early successful sympathetic block with radiofrequency, as confirmed by a warm foot, long lasting pain relief was difficult to obtain. The author concludes that individualized patient management is necessary when considering radiofrequency sympatholysis in the treatment of patients with sympathetically maintained pain.

Clinical classification as a predictor of therapeutic outcome after cervical epidural steroid injection.

A retrospective analysis was done on 100 patients who had received cervical epidural steroid injections for neck pain and cervical radiculopathy to identify the predictors of outcome after such treatment. Potential predictors of outcome were assessed individually and then simultaneously with a multiple-regression model. Patients with radicular symptoms and signs had the best pain relief in contradistinction to those with axial (neck) pain. A clinical classification model predicting the outcome and an algorithm for the use of such injections in the treatment of cervical radiculopathy were developed.

Additional advantages of a two-person technique for epidural needle placement and medication infusion.

Eight years' experience with the two-person technique has revealed further advantages. A glass syringe and extension tubing filled with saline are connected to the epidural needle. A small bubble of air remains in the syringe but not in the tubing. One person concentrates on the advancement of the needle. The second person exerts sufficient pressure on the plunger of the syringe to produce intermittent minimal flow of saline. The effect is that of barbotage. In several instances the saline at needle end of the tubing unexpectedly became opaque or discolored. The advantages are attributable to the small volume of the extension tubing filled with saline.

Interpleural analgesia after thoracotomy.

We examined the effects of the following variables on interpleural analgesia after thoracotomy: addition of epinephrine to local anesthetic, thoracostomy drainage, two-catheter placement, and location of catheter tips. Twenty patients were randomized to have one catheter (paravertebral tip location) or two catheters (paravertebral and lateral thoracic wall tip locations). Interpleural catheters were sutured to the parietal pleura by the surgeon at time of wound closure. Patients were then randomly assigned to receive 20 mL of 0.5% bupivacaine with 1:200,000 epinephrine through the single catheter or 10 mL of 0.5% bupivacaine with or without 1:200,000 epinephrine through each of the two catheters while supine. Bupivacaine concentrations in whole blood and in thoracostomy drainage fluid were assayed by gas chromatography. Actual content of bupivacaine in the drainage fluid was calculated. Degree of analgesia was assessed by verbal numerical pain scores over the first 4 h and opioid demand thereafter. Addition of epinephrine to bupivacaine did not influence the degree of analgesia. Approximately 30%-40% of any administered dose of bupivacaine was lost via the thoracostomy tube over a 4-h period. There was no correlation between the true initial dose (100 mg minus thoracostomy drainage) and Cmax. Use of two catheters resulted in significantly less opioid requirements after an initial 8-h period. Failure to achieve adequate interpleural analgesia in postthoracotomy patients may be related to loss of anesthetic via thoracostomy drainage, presence of extravasated blood and tissue fluid in the pleural space, and possibly sequestration and channeling of flow of local anesthetic by restricted motion of an operated lung.(ABSTRACT TRUNCATED AT 250 WORDS)

A comparison of regional intravenous guanethidine and reserpine in reflex sympathetic dystrophy. A controlled, randomized, double-blind crossover study.

Both regional intravenous guanethidine and reserpine have been reported as effective in the treatment of reflex sympathetic dystrophy. Reserpine depletes storage of norepinephrine, and guanethidine interferes with transport of norepinephrine while depleting storage in the sympathetic nerve terminal. The purpose of this study was to compare drug efficacy in double-blind fashion. Twelve patients, 10 of whom had previous stellate or lumbar sympathetic blocks, were entered into this double-blind cross-over study. Each patient successively received 20 mg guanethidine in 50 ml 0.5% lidocaine, 1.25 mg reserpine in 50 ml 0.5% lidocaine, and 50 ml 0.5% lidocaine with a 1-week interval between medications. At the end of the study and before the code was broken, each patient had the option of continuing treatment with any of the three drugs: the patient merely asked for the first, second, or third drug. Pain assessment used verbal ordinal, numeric, and visual analog scales. Follow-up lasted for a minimum of 6 months. Changes in pain intensity for the first 3 days did not differ significantly among guanethidine, reserpine, and control groups. Pain relief from 2 to 14 months was achieved in two patients receiving reserpine, one receiving guanethidine, and none receiving lidocaine. None of the patients experienced permanent relief. No difference was found between reserpine and guanethidine.

A two-person technique for epidural needle placement and medication infusion.

Traditional techniques of epidural needle placement have not proved satisfactory in patients who have had a previous laminectomy and may have epiduroarachnoiditis. A two-person technique was developed to: 1) simplify performance of difficult, epidural needle placement; 2) allow both resident and staff a simultaneous "hands-on" teaching experience; 3) allow a painless method of medication administration in patients with altered epidural anatomy; and 4) allow a simple method for determination of epidural space pressures. A glass syringe and extension tubing filled with saline are connected to the epidural needle. The needle is advanced by the operator while the pressure is monitored by the assistant. Once in the epidural space, the extension tubing is held vertically to act as a manometer. The column of saline falls and fluctuates with heart beat, providing verification of correct needle placement. Medication is placed in the barrel of the syringe and allowed to infuse by gravity. The two-person technique has achieved both patient and resident acceptance, and allows a painless method of medication administration in patients with altered epidural space anatomy.

An algorithm for the treatment of pain in advanced cancer.

An algorithm is presented that has been developed over the past three years to provide pain relief in advanced cancer. The hospital records of 92 patients were reviewed to evaluate the validity of the algorithm. The algorithm is as follows: the 24 hour oral consumption of opioids was converted to sustained release morphine. If ineffective usually over 360 mg daily the total 24 hour oral dose was divided by 6 to convert to I.V. If this was ineffective, usually over 10 mg/hr of morphine, the intravenous dose was divided by 10 and infused epidurally. Local anesthetic was added for plexus involvement. After four days, the patient was weaned from local anesthetic solution. If sharp pain or pain to movement persisted, 6% phenol in 1 to 2 ml aliquots was injected every 8-12 hours to a total of 5-8 ml. While the conversion from intravenous to epidural morphine was 10:1 that from epidural to intravenous was only 1:3. Intravenous dose converts directly to the subcutaneous. The conversion from intravenous to oral is 1:3. There view showed that the dosages at which the conversions were made varied considerably. The reasons for the wide variation are presented. In summary the algorithm is a good practical guide for treatment of cancer pain.

A statistical model for pain in patient-controlled analgesia and conventional intramuscular opioid regimens.

A statistical model was developed: 1) to compare the efficacy of patient-controlled analgesia (PCA) and traditional intramuscular (IM) opioids for pain relief in 40 patients after total knee replacement and, 2) to evaluate pain cycles associated with each technique. Hourly visual analog pain scores were subjected to two-way analysis of variance (ANOVA) and time-series analysis. Hourly verbal analog pain scores were used to determine predominant pain levels. According to ANOVA, PCA was no more effective than were IM opioids. Time-series analyses documented a complete cycle of pain every 5.3 hours in patients receiving IM opioids but no pain cycle with use of PCA. Analysis of PCA verbal analog scores demonstrated self-administration of opioids to "moderate" levels of pain relief with use of PCA, not to complete analgesia. These results suggest that certain patients may not envision complete postoperative analgesia as being possible. Hence, they self-administer opioids for pain relief with PCA according to their expectations. Population characteristics may modify PCA efficacy. These characteristics should be delineated and the use of PCA targeted to appropriate patients.

Differential spread of blockade of touch, cold, and pinprick during spinal anesthesia.

The differential levels of sensory blockade of pinprick, cold, and touch were monitored throughout the course of spinal anesthesia administered to 50 patients to determine variations in the degree of spread during onset, plateau, and regression, and to establish the effects of epinephrine and the effect of posture during injection. A significant difference was observed between the dermatomal level of sensory loss of touch and the dermatomal level of loss of either pinprick or cold during onset, at 5 min in patients given tetracaine with epinephrine, at time of maximum spread in patients given tetracaine with epinephrine or in the sitting position, and in all groups during regression. Loss of touch began later, never extended as far cephalad, and regressed sooner. The extent of this difference was greatest during regression, when the anesthetic was given to patients in the sitting position, after epinephrine. The level at which the sense of touch was lost seemed to mark the limits of the zone of solid spinal anesthesia; these limits could not be assessed effectively using pinprick. We propose that loss of touch sensation be used to assess whether anesthesia is adequate to avoid tourniquet pain. If there is loss of touch sensation above the L1 dermatome, it is unlikely that tourniquet pain will occur.

Vasoconstrictors in spinal anesthesia with tetracaine--a comparison of epinephrine and phenylephrine.

A randomized double-blind study was conducted in 50 orthopedic patients to determine the effect of epinephrine and phenylephrine on the anesthetic properties of intrathecally administered tetracaine. Two doses of each vasoconstrictor agent were studied: 0.2 mg of epinephrine, 0.3 mg of epinephrine, 1 mg of phenylephrine, and 2 mg of phenylephrine. The results show that both vasoconstrictor agents in the doses used significantly prolong duration of sensory anesthesia and motor blockade produced by the subarachnoid administration of tetracaine. At equipotent doses no differences existed between the ability of epinephrine and phenylephrine to prolong the duration of spinal anesthesia produced by tetracaine.

A dose-response study of bupivacaine for spinal anesthesia.

A randomized double-blind study was performed to elucidate the interrelationships among volume, concentration, and dosage of bupivacaine administered intrathecally. Sixty male patients between the ages of 40 and 80 years having transurethral surgery in the lithotomy position were studied using 10-, 15-, and 20-mg doses of glucose-free bupivacaine as either a 0.5 or a 0.75% solution. Success rate, time of onset and duration of anaglesia and motor block, and cardiovascular responses were assessed. It was found that both 15 and 20 mg of either concentration of bupivacaine provide satisfactory spinal anesthesia for transurethral urologic procedures. However, three of 20 patients receiving the 10-mg dose required supplementation with general anesthesia. Comparison of various volumes and concentrations of bupivacaine indicates that total dosage of bupivacaine is more important than volume or concentration. In several patients with sensory block involving cervical dermatomes, there was no significant hypotension or bradycardia, which suggests that cardiac output and venous return were maintained, perhaps because of the use of lithotomy position.

A clinical double-blind study of dibucaine and tetracaine in spinal anesthesia.

The effects of 0.25% dibucaine and 0.5% tetracaine used for the production of spinal anesthesia were compared in 30 healthy surgical patients. Fifteen patients were assigned to each of the two agents using a randomized, observer and patient-blinded method. Success rate, times of onset and regression of analgesia, intensity of motor blockade, and cardiovascular effects were assessed and the results were analyzed statistically. There were no differences in success rate, in latency, or in duration of action between the two spinal anesthetic agents. Tetracaine was found to be associated with a significantly greater decrease in arterial pressure and more complete motor blockade.