Treatment of severe acute respiratory distress syndrome: a final report on a phase I study.

Adult respiratory distress syndrome (ARDS) has a high mortality. Its only effective treatment is respiratory therapy. If this fails mortality is probably 100 per cent. No other treatment for ARDS has proved effective including "magic bullets." Twenty patients suffering from ARDS secondary to trauma and/or sepsis failed to respond to treatment with mechanical ventilation and positive end-expiratory pressure. On the assumption that disseminated intravascular coagulation initiates ARDS by occluding the pulmonary microcirculation with microclots, the patients were treated with plasminogen activators. The patients responded with significant improvement in partial pressure of oxygen in arterial blood. No bleeding occurred and clotting parameters remained normal. We conclude that ARDS can be safely treated with plasminogen activator.

Pediatric restraint use in motor vehicle collisions: reduction of deaths without contribution to injury.

HYPOTHESIS: Restraint use for children in automobiles is mandated in every state, but injury patterns are unknown. Although use of pediatric retraints is associated with reducing morbidity and mortality, the injury distribution for specific anatomic sites may be altered in restrained vs unrestrained children. DESIGN: Review of trauma registry data, medical records, and autopsy findings. SETTING: Urban level I trauma center and tertiary care children's hospital. PATIENTS: All children aged 6 years or younger who were in motor vehicle collisions from June 1, 1990, through March 31, 1997. MAIN OUTCOME MEASURES: Age, weight, restraint use and type, collision data, Injury Severity Score (ISS), injury type, and outcome. RESULTS: We included 600 children. The restrained group showed a reduction in severe injuries for every anatomic site and had a lower mean ISS, fewer injuries, and more uninjured children. The restrained group also had a reduction in the incidence of hollow- and solid-organ abdominal injuries. CONCLUSIONS: Age-appropriate restraint devices decrease mortality and reduce the incidence of significant injury in motor vehicle collisions for all anatomic sites in young children. In contrast to injuries attributed to restraint use in adults, specific restraint-related injury patterns were not seen in children.

Acute gastric dilatation revisited.

First described by S.E. Duplay in 1833, acute gastric dilatation has since been well documented in the literature. Several theories of the pathogenesis of acute gastric dilatation have been postulated. In 1842, Karl Freiherr von Rokitansky described the superior mesenteric artery syndrome, followed by W. Brinton in 1859 with the atonic theory. C.R. Morris et al. introduced debilitation and anesthesia as predisposing factors. Although rare, gastric necrosis is the most severe consequence of acute gastric dilatation. Vascular insufficiency secondary to increased intragastric pressure is the critical factor. We report an unusual case of acute gastric dilatation with subsequent necrosis of uncertain etiology.

Pregnant women and car restraints: beliefs and practices.

OBJECTIVE: Motor vehicle collisions are a leading cause of death and disability in pregnant women. The purpose of this study was to examine current restraint practices by pregnant women. Additionally, the beliefs and knowledge of pregnant women about restraint laws and effectiveness were studied. METHODS: From May of 1997 to January of 1998, women were surveyed at initial prenatal visit at four obstetrical clinics. Data collected included age, gravida, ethnicity, educational level attained, payor source, restraint use, and knowledge of effectiveness of restraint use. RESULTS: A total of 807 women completed surveys. Most always wore restraints before pregnancy, but increased restraint use during pregnancy (79% vs. 86%, chi2, p = 0.02). Only 52% used restraints properly. Significantly fewer women believed restraints were beneficial to mother and fetus in late pregnancy compared with early pregnancy. Only 21% of women were educated on proper restraint use during pregnancy. Comparison by payor mix showed no difference in use or education received. CONCLUSIONS: Most women use restraints and continue to do so during pregnancy, but they use them improperly. Pregnant women are familiar with mandatory restraint laws but are less informed about restraint use in pregnancy. Few women receive education from health care providers about proper restraint use. This study highlights the need for aggressive educational efforts to improve car restraint use in pregnant women, thereby reduce maternal and fetal injury and death.

Does free fluid on abdominal computed tomographic scan after blunt trauma require laparotomy?

BACKGROUND: Abdominal computed tomographic (CT) scans are used in the evaluation of blunt trauma. The purpose of this study was to determine if isolated intraperitoneal fluid seen on CT scan necessitates laparotomy. METHODS: Trauma registry records of patients who underwent abdominal computed tomography from January 1994 through January 1997 were studied. Data were reviewed for age, gender, CT scan interpretation, associated injuries, and operative findings. RESULTS: Abdominal injury was identified in 126 patients. Seventy-eight patients had evidence of solid-organ injury and 17 patients had extraperitoneal injury. Isolated intraperitoneal fluid was identified in 31 patients. All patients with isolated fluid underwent laparotomy; 29 of these procedures (94%) were therapeutic. Bowel injuries occurred in 18 patients and mesenteric injuries in 8 patients. Five patients had intraperitoneal bladder rupture, and undetected solid-organ injuries were found in two patients. Other organs injured included the stomach, pancreas, ovary, and uterus. CONCLUSION: Exploratory laparotomy was therapeutic in 94% of patients. Isolated intraperitoneal fluid on CT scan after blunt trauma mandates laparotomy.

Spinal cord injury. A preventable public burden.

BACKGROUND: Spinal cord injury (SCI) is a devastating occurrence with important consequences for the individual and society. Previous studies have documented the epidemiology and costs of SCI and the rehabilitation needs after SCI; however, data about the preventability of SCI are lacking. OBJECTIVE: To test the hypotheses that most SCIs are preventable and that much of the cost of SCI is borne by the public. DESIGN: Retrospective review of medical records and trauma registry data. SETTING: A 417-bed county hospital with a level I trauma center. METHODS: To evaluate the preventability of SCI, the records of trauma patients sustaining SCI from July 1, 1990, through June 30, 1995, were reviewed. The criteria for preventability of blunt injuries included the following: failure to use restraint devices; intoxication of drivers, motorcyclists, or pedestrians; and falls or diving accidents involving the use of drugs or alcohol. The criteria for preventability of penetrating injuries included the following: illegal possession of a firearm, accidental discharge of a weapon, and suicide attempts. Statistics were performed with the paired Student t test and chi 2 with significance attributed to a P value less than .05. RESULTS: Spinal cord injury occurred in 150 patients; 71% of the injuries were the result of blunt trauma. Injury was potentially preventable in 74% of the blunt injuries and 66% of the penetrating injuries (P = .15). Patients with a penetrating SCI were younger (P < .001) and relied more on public funding than did those with a blunt SCI (65% vs 81%; P = .05). CONCLUSIONS: Most SCIs are preventable with strict enforcement of existing statutes. Furthermore, the financial burden of these preventable injuries is largely borne by the public.