Needle thoracostomy may not be indicated in the trauma patient.

OBJECTIVE: The aim of this study was to evaluate the usefulness of needle thoracostomy catheter (NTC) placement in trauma. METHODS: A consecutive case series was conducted from November 1996 to September 1997. All patients admitted to a level I trauma centre who had NTCs placed prior to arrival in the Emergency Department were included. No patients were excluded or omitted. During the course of the study 2801 patients were admitted to our trauma centre. Nineteen patients (0.68%) had NTCs placed prior to arrival in the emergency department. RESULTS: Twenty-five needle thoracostomies were performed in 19 patients. This group represented 0.68% of the trauma admissions. Four patients were found to have evidence of a pneumothorax with an air leak (28%). The NTC failed to decompress the chest in one of two patients who had physiologic evidence of a tension pneumothorax. Eleven patients (58%) were endotracheally intubated prior to NTC. CONCLUSIONS: This study suggests that field NTC placements are often ineffective and may be over-used. Further study on the usefulness of NTC is required.

Anterior ischemic optic neuropathy: a complication after systemic inflammatory response syndrome.

BACKGROUND: Patients are surviving previously fatal injuries. Unique morbidities are occurring in these survivors. Anterior ischemic optic neuropathy represents a previously unrecognized cause of blindness in the trauma victim. We hypothesize that this phenomenon is caused by unique characteristics of optic edema/ pressure or decreased blood flow associated with massive resuscitation. METHODS: Between November of 1991 and August of 1998, there were 18,199 admissions to our trauma center. Of this group, 350 patients required massive volume resuscitation (>20 liters infused over first 24 hours). Patients having closed head injuries, facial fractures or direct orbital trauma were excluded from study. The following variables were studied: demographics, injury severity (Injury Severity Score, highest lactate, worst base deficit, and lowest pH) crystalloid and transfusion requirements, ventilator requirements (PEEP) RESULTS: Of the 350 patients with massive resuscitation, 9 patients were diagnosed with anterior ischemic optic neuropathy (2.6%). Of these, seven patients required celiotomy (78%). Six of the seven celiotomy patients had damage control celiotomies and abdominal compartment syndrome (86%). One patient had a repair of a subclavian artery; one had a complex acetabular repair. Blindness was unilateral in five patients and bilateral in four. All nine patients had evidence of global hypoperfusion, systemic inflammatory response, massive resuscitation, and high ventilatory support; one patient required cardiopulmonary resuscitation. CONCLUSION: Prone positioning is known to be associated with an increased intraocular pressure. We postulate that the combination of massive resuscitation and prone positioning will increase the incidence of anterior ischemic optic neuropathy. As such, we recommend that prone positioning for adult respiratory distress syndrome be reserved for only those patients at risk of death.

Elective bedside surgery in critically injured patients is safe and cost-effective.

OBJECTIVE: The success of elective minimally invasive surgery suggested that this concept could be adapted to the intensive care unit. We hypothesized that minimally invasive surgery could be done safely and cost-effectively at the bedside in critically injured patients. SUMMARY BACKGROUND DATA: This case series, conducted between October 1991 and June 1997 at a Level I trauma center, examined bedside dilatational tracheostomy (BDT), percutaneous endoscopic gastrostomy (PEG), and inferior vena cava (IVC) filter placement. All procedures had been performed in the operating room (OR) before initiation of this study. METHODS: All BDTs and PEGs were performed with intravenous general anesthesia (fentanyl, diazepam, and pancuronium) administered by the surgical team. IVC filters were placed using local anesthesia and conscious sedation. BDTs were done using a Ciaglia set, PEGs were done using a 20 Fr Flexiflow Inverta-PEG kit, and IVC filters were placed percutaneously under ultrasound guidance. Cost difference (delta cost) was defined as the difference in hospital cost and physician charges incurred in the OR as compared to the bedside. RESULTS: Of 16,417 trauma admissions, 379 patients (2%) underwent 472 minimally invasive procedures (272 BDTs, 129 PEGs, 71 IVC filters). There were four major complications (0.8%). Two patients had loss of airway requiring reintubation. Two patients had an intraperitoneal leak from the gastrostomy requiring operative repair. No patient had a major complication after IVC filter placement. Total delta cost was $611,994. When examined independently, the cost was $324,224 for BDT, $164,088 for PEG, and $123,682 for IVC filter. OR use was reduced by 506 hours. CONCLUSIONS: These bedside procedures have minimal complications, eliminate the risk associated with patient transport, reduce cost, improve OR utilization, and should be considered for routine use in the general surgery population.

Hypothermia in critically ill trauma patients.

OBJECTIVE: To determine the incidence and mortality of hypothermia in trauma patients. METHODS: Retrospective review of patients admitted to the Surgical Intensive Care Unit (SICU) over 4 1/2 years. Hypothermia was defined as a temperature < 35 degrees C. RESULTS: There were 7045 admissions to the SICU, of which 661 (9.4%) had a recorded temperature of < 35 degrees C. Over half (395) were trauma patients, with a mortality of 52.7%. The temperature ranged from 27.1 to 34.9 degrees C, with a mean for survivors of 34.0 degrees C and 33.1 degrees C for those that died. There was a significant difference in Apache II scores (16.6 vs 25.4) and Injury Severity Scores (26.1 vs 33.4) between survivors and non-survivors. CONCLUSIONS: The incidence of hypothermia in trauma patients is significant and is independent of the month of admission. Mortality is high but there is no threshold below which mortality is assured. Unlike historical data, 13 patients survived temperatures < 32 degrees C.

Cost-effective method for bedside insertion of vena caval filters in trauma patients.

BACKGROUND: The need for patient transport for inferior vena cava (IVC) filter placement impacts patient safety, comfort, charges, and nursing care. Bedside, ultrasound-guided IVC filter placement may offer an acceptable, cost-effective alternative. METHODS: Prospective cohort study of 55 consecutive trauma patients requiring IVC filter placement. During a 13-month period (August of 1995-September of 1996), patients meeting criteria for IVC filter were evaluated. Complications were recorded, and the potential financial savings were determined. RESULTS: Of 3,172 trauma admissions, 55 patients met IVC filter criteria and 49 patients had IVC filters placed under ultrasound guidance. In six patients (10.9%), ultrasound guided filter placement failed. There were four complications in four patients (8.2%). Over 13 months, charges were reduced by $69,800 when compared with radiology suite placement and $118,300 when compared with operative placement. CONCLUSIONS: Ultrasound guided, bedside placement of IVC filters is a safe, cost-effective method of pulmonary embolism prophylaxis in select trauma patients.

Hypothermia: impact on the trauma victim.

Secondary hypothermia may present the clinician with an extraordinary set of challenging problems. Rapid rewarming using both passive and active techniques is essential to correct the many reversible changes associated with hypothermia. Despite aggressive management, secondary hypothermia continues to exact a large toll in terms of the mortality of trauma victims.

Traumatic asphyxia syndrome.

Although the craniofacial changes associated with TAS are usually not life threatening, the syndrome is not benign. The mechanism of injury needed to create TAS is sufficient to warrant extreme caution in the approach to these patients. It is vital for the physician to recognize the pathophysiology of the injury pattern and to remain cognizant of the high likelihood of potentially lethal associated injuries. Aggressive and directed management of the cardiopulmonary systems coupled with prompt recognition and treatment of associated injuries is essential for optimal patient outcome.

Infant survival after cesarean section for trauma.

HYPOTHESIS: Emergency cesarean sections in trauma patients are not justified and should be abandoned. SETTING AND DESIGN: A multi-institutional, retrospective cohort study was conducted of level 1 trauma centers. METHODS: Trauma admissions from nine level 1 trauma centers from January 1986 through December 1994 were reviewed. Pregnant women who underwent emergency cesarean sections were identified. Demographic and clinical data were obtained on all patients undergoing a cesarean section. Fetal distress was defined by bradycardia, deceleration, or lack of fetal heart tones (FHTs). Maternal distress was defined by shock (systolic blood pressure < 90) or acute decompensation. Statistical analyses were performed. RESULTS: Of the 114,952 consecutive trauma admissions, more than 441 pregnant women required 32 emergency cesarean sections. All were performed for fetal distress, maternal distress, or both. Overall, 15 (45%) of the fetuses and 23 (72%) of the mothers survived. Of 33 fetuses delivered, 13 had no FHTs and none survived. Twenty infants (potential survivors) had FHTs and an estimated gestational age (EGA) of greater than or equal to 26 weeks, and 75% survived. Infant survival was independent of maternal distress or maternal Injury Severity Score. The five infant deaths in the group of potential survivors resulted from delayed recognition of fetal distress, and 60% of these deaths were in mothers with mild to moderate injuries (Injury Severity Score < 16). CONCLUSIONS: In pregnant trauma patients, infant viability is defined by the presence of FHTs, estimated gestational age greater than or equal to 26 weeks. In viable infants, survival after emergency cesarean section is acceptable (75%). Infant survival is independent of maternal distress or Injury Severity Score. Sixty percent of infant deaths resulted from delay in recognition of fetal distress and cesarean section. These were potentially preventable. Given the definition of fetal viability, our initial hypothesis is invalid.

Identification of mycobacterial antigens for "ELISA" serology in the diagnosis of leprosy and tuberculosis.

Using an immunoblotting assay (ImBA), several immuno-crossreactive antigenic components (ImCRAC-myc) have been identified in the whole sonicates of M. bovis-BCG, and M. tuberculosis (Mtb) and M. leprae (ML) whereby the sera of 100% lepromatous leprosy (L-Lep) reacted to 29/33 KD doublet and that of 100% tuberculoid leprosy (T-Lep) reacted to 64 KD bands. The antigens upon purification from Mtb Sonicates were used in a direct ELISA to measure antibody isotypes in the sera from L-Lep, T-Lep, healthy Lep. contacts (Lep. c), normal Dutch controls (N) and tuberculosis (TB) patients. A significantly high IgG titre to the doublet 29/33 KD and to 64 KD were observed among L-Lep and T-Lep patients respectively in comparison to sera from other groups of individuals. In certain cases of L-Lep patients, raised IgM titre to either or both to 29/33 KD doublet and 64 KD were also found. On the other hand, consistantly but significant high IgA-antibody titre to cell wall (CW), cytosol (cyt) and P90 fractions of Mtb distinguished clearly the TB patients from Lep groups, normals (NN) and Lep-c. It appeared that such antibody reactivity of TB sera might be directed to the groups of 58-60, 38-40, 18-20 and 14 KD antigens of mycobacteria e.g. Mtb. On the basis of the present observations we conclude that the measurement of class specific antibody response to the panel of these antigens could diagnose differentially between Lep, TB and NN/Lep-c among the population at large in an endemic area.

Monoclonal antibodies to 33 KD protein of Mycobacterium tuberculosis with varying epitope specificities.

Five mouse monoclonal antibodies (McAb) 5D2, 5D5, 5F9, 3A8 and 3F2 against Mycobacterium tuberculosis (M. tb) 33 KD protein have been produced. All the McAbs except one were of IgG1, whereas the 3F2 was of IgM isotype. The ELISA and immunoblotting analysis show that 5D2, 5D5 and 5F9 are reactive to only 33 KD protein whereas 3A8 and 3F2 are also cross reactive to 29 KD and 29 KD + 64 KD respectively. ELISA inhibition assays using peroxidase labelled respective McAbs show that 5D2 and 5D5 recognize the same or overlapping epitopes whereas the remaining three McAbs (5F9, 3A8 and 3F2) are reactive to different epitopes of the 33 KD protein. These McAbs are cross reactive to the majority of mycobacterial strains other than M. tb including M. leprae (ML). However such reactivities may involve proteins of differing molecular sizes. Interestingly all these McAbs react to 25 KD and 29 KD of ML. The immunoreactivities of these McAbs to 33 KD appear to be directed to peptide epitopes but not to carbohydrate moiety. Both IgG and IgM antibody activities of lepromatous leprosy (L-lep) sera to 33 KD protein are heterogeneous and directed to more than 4 epitopes. The potential use of these McAbs in studying the pathomechanism of leprosy are currently being investigated.