Two acute pediatric abdominal catastrophes from strangulated left paraduodenal hernias.

We present two cases of catastrophic intestinal obstruction from to strangulation of a left paraduodenal hernia (PDH). PDH is the most common internal hernia. Early diagnosis and treatment are essential because of the high morbidity and mortality associated with strangulation. Early involvement of the surgical team without an overly extensive evaluation in the emergency department is important if this diagnostic suspicion exists. PDH should also be considered when there is a history of chronic, intermittent abdominal pain of unclear cause. To our knowledge, these cases are the first described cases of sudden demise within a few hours of onset of symptoms of a left PDH.

Findings in gunshot wounds from tandem projectiles.

Tandem projectiles are unusual events which can cause erroneous case interpretations if one is unfamiliar with them. This paper presents two such cases. The first case involved three .32 caliber bullets, two of which became lodged in a revolver barrel because of faulty ammunition. A third fired bullet subsequently pushed itself and the lodged bullets out of the barrel resulting in a single entrance wound with three bullets in the body. The second case involved a 20 gauge shotgun shell which apparently was inadvertently loaded into a 12 gauge shotgun. This resulted in an unusual entrance wound and unusual X-rays with fragments of the 20 gauge shotgun shell, as well as 12 gauge shotgun shell wadding, being removed from the same wound. The pertinent findings in such cases are discussed so that they may be correctly identified when they occur.

Massive pulmonary embolus after surgery for renal cell carcinoma extending into the inferior vena cava: a case report.

Fatal massive pulmonary embolization following removal of an intracaval renal cell carcinoma was encountered. This case teaches that vena cava interruption should be considered as part of the perioperative management of patients with renal cell carcinoma tumor thrombus extending into the inferior vena cava.

False-positive postmortem EMIT drugs-of-abuse assay due to lactate dehydrogenase and lactate in urine.

Three cases of multiple false-positive drug tests are described. Postmortem urine specimens were screened using the enzyme-multiplied immunoassay technique. All patients had proteinuria and lactic aciduria. These false-positive reactions were due to the presence of lactate dehydrogenase (LDH), lactic acid, and protein. This finding was confirmed by creating a multiple false-positive sample with a solution of LDH and lactate in 5% bovine serum albumin at pH 6.

Death attributed to ethyl chloride.

A young college student was found unresponsive, head down in his pillow with a metal canister containing ethyl chloride in or beside his right hand. Resuscitative efforts failed. Qualitative screening detected ethyl chloride in the vitreous fluid and antemortem and postmortem blood. Quantitation was carried out on available fluids with the following results: hospital blood, 20 mg/dL; postmortem blood, 65 mg/dL; and vitreous fluid, 41.7 mg/dL. No other drugs or volatiles were found. Death was subsequently attributed to an overdose or adverse reaction to this product.

Pelvic fractures associated with open perineal wounds: a survivable injury.

Blunt pelviperineal trauma has been associated with mortality rates of 32% to 58% in recent literature. A review of our institution's experience revealed a much lower mortality rate, prompting further investigation. Nine hundred-seventy five patients with pelvic fractures were admitted to our institution from July 1984 through June 1991. The mortality rate for all pelvic fractures was 7.3%. During this interval 21 patients (2.2%) were admitted with open pelvic fractures. Only one patient in this group died. Our low mortality figures were the result of better control of pelvic hemorrhage and sepsis, and a lower incidence of associated injuries to the head and thorax, representing a more favorable mechanism of injury.

The single indication for cystography in blunt trauma.

To define the indications for cystography in blunt trauma, two studies were completed. First, a 15-month retrospective evaluation revealed 26 patients with bladder trauma. All 26 patients presented with gross hematuria. This was followed by a randomized prospective study of all patients with blunt trauma. Patients were randomized to be evaluated with cystography for any degree of hematuria or the diagnosis of pelvic fracture versus those to be evaluated only for the presence of gross hematuria. Eleven patients had pelvic fractures and no hematuria. One hundred nine patients had microscopic hematuria and a 39 per cent incidence of coexistent pelvic fractures. Thirty-one patients had gross hematuria and a 26 per cent incidence of pelvic fracture. Bladder injuries were seen only in this latter group. Cost analysis of the prospective study revealed a potential savings of $26,322 if gross hematuria had been the sole indication for cystography in blunt trauma. This approach has potential cost savings and, more importantly, will not compromise the quality of trauma care.

Death by power car window. An unrecognized hazard.

The unusual accidental asphyxial death of a 26-month-old girl involving a car power window is reported. The circumstances and investigation results are discussed, as well as how such tragedies may be avoided.

High ligation of the greater saphenous vein for treatment of lower extremity varicosities: the fate of the vein and therapeutic results.

This study was carried out to determine the subsequent fate of the greater saphenous vein and the efficacy of its high ligation along with surgical excision or sclerotherapy of varicosities. From 1988 to 1990, 22 patients underwent high ligation and sclerotherapy, 22 underwent high ligation and varicose vein excision, and four underwent high ligation alone. There were 36 women and 12 men patients. The average patient age was 48. Sixty limbs were scanned by duplex ultrasound pre- and postoperatively to determine the status of the greater saphenous vein. Average follow-up time was 10 months. Patients and surgeons rated the results of therapy for ablation of varicosities and alleviation of symptoms. Surgical complications were evaluated. At postoperative scan, 47 greater saphenous veins (78%) were found to be completely patent, nine (15%) were thrombosed for a short segment (less than 10 cm) and four (7%) were more significantly thrombosed. Those limbs in which high ligation and sclerotherapy were performed had the highest complete patency rate (96%). Patient and surgeon satisfaction was good to excellent in every case. The only complications were three symptomatic greater saphenous vein thromboses. Although follow-up is relatively brief, complete patency of the ligated greater saphenous vein was found in most cases. High ligation allows preservation of a patent greater saphenous vein, which can be used as an arterial conduit at a later date and gives therapeutic results comparable to stripping without the additional morbidity.

Intraglomerular metastases from papillary carcinoma of the thyroid.

Papillary carcinoma of the thyroid usually spreads to the lymph nodes. Vascular metastatic spread is unusual. We report a case of papillary carcinoma of the thyroid with extensive vascular dissemination and remarkable intraglomerular metastases to both kidneys.