Subclavian vessel injuries: difficult anatomy and difficult territory.

INTRODUCTION: Thoracic and thoracic related vascular injuries represent complex challenges to the trauma surgeon. Subclavian vessel injuries, in particular, are uncommon and highly lethal. Regardless of the mechanism, such injuries can result in significant morbidity and mortality. MATERIALS AND METHODS: Systematic review of the literature, with emphasis on the diagnosis, treatment and outcomes of these injuries, incorporating the authors' experience. CONCLUSIONS: These injuries are associated with significant morbidity and mortality. Patients who survive transport are subject to potentially debilitating injury and possibly death. Management of these injuries varies, depending on hemodynamic stability, mechanism of injury, and associated injuries. Despite significant advancements, mortality due to subclavian vessel injury remains high.

Intraaortic balloon rupture.

To identify patients at risk and assess management strategies, nine Datascope intraaortic balloon (IAB) ruptures in 8 patients were reviewed. This is a 2.4% incidence for this complication (382 insertions over 75 months). Time to initial rupture was 4.7 days, range 1.1 to 6.8 days. This was 1.3 days after the average intact device was removed. Women were three times more likely to sustain rupture than men (4 vs. 1.3%, P less than 0.05). Rupturing IABs were characterized by a greater magnitude of diastolic augmentation than intact IABs, 69.4 +/- 24.9 vs. 25.5 +/- 12.6 Torr (P = 0.01). A hypertensive treatment history was more prevalent in patients rupturing (83 vs. 41%) (P less than 0.05). Rupture was diagnosed by finding blood in the safety chamber in all patients. There was no gas embolization nor did any patient become infected. Ruptured devices showed abrasion wear in the most distal portion of the IAB, where the aorta is smallest. In vitro testing with CO2 showed no driving gas loss but withdrawal of the surrounding fluid into the IAB system. Ruptured IAB replacement in four patients was associated with three survivors. In four patients the device was not replaced and two patients survived. There were no complications as a consequence of IAB rupture (all values +/- SD).

Receptor affinity and pharmacological potency of a series of narcotic analgesic, anti-diarrheal and neuroleptic drugs.

A series of 26 drugs was tested for in vitro binding to opiate receptors in the presence and absence of 0.1 M NaCl. The results were correlated with assays for in vivo pharmacological potency. Highly significant correlation was found between binding in the presence and absence of sodium ions and analgesic potency. For 10 drugs tested for anti-diarrheal potency significant correlation was observed with binding to brain opiate receptors when binding was carried out in sodium-containing medium. These data add support to the hypothesis that stereospecific opiate binding sites are pharmacological receptors which mediate analgesia and anti-diarrheal action. We found that neuroleptics can bind to opiate receptors with affinities in the micromolar range, in agreement with reports by others. The anti-diarrheal compound loperamide exhibits no significant central opiate effects but binds to opiate receptors from brain in vitro with high affinity. Evidency is presented suggesting that the lack of specific analgesic effect is the result of poor penetration through the blood--brain barrier. Our results lend further support to the similarity of opiate receptors in the brain and in the intestinal tract.