Prophylaxis against thromboembolism in patients with traumatic brain injury: a survey of UK practice.

Venous thromboembolism is a major complication associated with traumatic brain injury and is responsible for significant morbidity and mortality. There has been a general reluctance over the years to use anticoagulant prophylaxis for patients with head injury who have suffered intracranial bleeding or for whom intracranial surgery is needed. We conducted a postal questionnaire survey of all neurosurgical centres in the United Kingdom, enquiring about the use of thromboprophylactic methods in the management of patients with traumatic brain injury. A diversity of practice and opinion in the use of such methods was evident from the replies received. The survey highlighted concern about the failure to implement even the most simple means of prophylaxis. The evidence for the use of the various methods of prophylaxis is reviewed.

Missed diaphragm rupture following blunt trauma.

Traumatic rupture of the diaphragm resulting from blunt trauma remains a challenging clinical entity. Diagnosis remains difficult and is often delayed. A prompt diagnosis requires a high index of suspicion. We describe two patients with ruptured diaphragms in whom the diagnosis was made at different stages of their illness. The diaphragmatic injury reflects the magnitude of their associated injuries and probably contributes to the overall mortality.

An unusual complication of a central venous catheter in a neonate.

The use of central venous catheters in neonates is associated with early and late complications. It is recognized that catheter tip migration and perforation of a viscus can occur at any time with a potentially fatal outcome. We present a case in which the successful placement of a central line was followed 2 weeks later by a sudden respiratory deterioration necessitating intubation and ventilation. The catheter tip had eroded through the wall of a pulmonary artery and a bronchus into the bronchial tree. The report highlights the serious morbidity arising from the use of central venous lines in neonates and stresses the importance of X-rays in establishing the correct position of all catheters. A sudden change in the condition of a patient should raise the suspicion of a catheter-related problem.

Microbial contamination of gum elastic bougies.

The gum elastic bougie is a simple device that is used to assist in the management of the difficult intubation. It is not uncommon for a bougie to be re-used many times. This study investigated the incidence of microbial contamination of the bougies in one hospital. Potentially pathogenic organisms were identified both on the bougies and in their storage containers. This has implications for their cleaning and maintenance, and raises the question as to whether we should replace them with single-use, disposable devices.

A case for steroids in acute lung injury associated with the retinoic acid syndrome.

A 62-year-old woman with acute promyelocytic leukaemia was treated with all-trans retinoic acid. On day 2 she suffered with dyspnoea and general fatigue. Marked hypoxia suggested the occurrence of retinoic acid syndrome. She underwent endotracheal intubation and mechanical ventilation with the administration of dexamethasone. Her symptoms promptly abated. She was subsequently treated with conventional chemotherapy and achieved complete remission.