Essentiality of the lateral cervical spine radiograph.

Proper interpretation of the lateral cervical spine (C-spine) film is a prime emergency medicine responsibility. Patients with potential neck injury must be identified rapidly and handled carefully; their C-spine films must be interpreted quickly and accurately. We stress the urgency in obtaining a good, readable lateral C-spine film and present a systemic "ABCs" approach to reading this film. This approach includes specific, sequential attention to Alignment, Bony integrity, Cartilaginous structures, and the surrounding Soft-tissue spaces. In the cases of 50 consecutive patients with C-spine injuries (49 adults, one child) seen recently in our emergency medicine program, we have correlated traumatic mechanisms with specific injury patterns. These analyses have been meshed with data from the patients' medical records and radiographs. In a significant number of instances (greater than 25% in this series), objective, careful radiographic interpretation is more important to the patient's objective, careful radiographic interpretation is more important to the patient's welfare than is any other diagnostic modality -- including history and physical examination.

Rapid orthopedic and neurologic evaluation.

A technique is presented for rapid evaluation of the extent of orthopedic or neurologic injury. Consistent use of the method, a combination of active motion against resistance and standard neurologic tests, has helped avoid unnecessary radiation and costs while correlating well with physical and radiographic findings in the awake, cooperative, injured individual.

Shock and resuscitation. III. Accurate refractometric COP determinations in hypovolemia treated with HALFD.

In 38 critically burned patients with symptomatic hypovolemia being treated by intravenous fluids, the accuracy of colloid oncotic pressure (COP) calculated from the refractometrically-determined serum total protein (TPRI) was compared with COP values determined by a commercially-available clinical oncometer. Sera were obtained randomly from seven patients receiving Ringer's lactate solution, five receiving a hypertonic solution (240 mOsm Na+) and 26 receiving a hypertonic solution containing albumin (12.5 gm/liter, HALFD method). There was poor correlation between COP measure and that calculated from RI in patients receiving colloid-free fluid, but high correlation (r = 0.925) in patients receiving HALFD. There was high correlation (r = 0.951) between measured COP and values calculated from TPRI in patients receiving hypertonic fluid, colloid containing hypertonic fluid, or no fluid:COP = 4.08 (TPRI)--4.61.

Studies in burns, XVI: The effect of surgical trauma on metabolic heat production.

As part of an ongoing study of the naturally-occurring skin lipid ethyl linoleate as an adjunct for reducing post-burn hypermetabolism and hyperevaporation, we have conducted a series of evaluations of metabolic heat production (M) using a clinical partitional calorimeter. In this article, we describe the metabolic chamber and its use in evaluating the change in M in pre- and postoperative patients. We determined that dry heat losses (radiation and convection) comprise the major components of heat loss in the "normal" and traumatized individual with intact skin. In the post-operative state, metabolic heat production increases significantly above the preoperative levels, the percentage of change being accurately described by a first order exponential equation. In the postoperative patient, possibly because of a physiologic shift in source of metabolic substrate, stored heat increases significantly. These data may be useful in allowing approximate correction of the metabolic heat equation when studying the burn patient where no "control" is attainable and where some approximation of the contribution of "pure" trauma must be made.

Studies in shock and resuscitation, I: use of a hypertonic, albumin-containing, fluid demand regimen (HALFD) in resuscitation.

We have reevaluated and clinically tested the current concepts of shock and resuscitation on a logical, physiological, and physical basis. We have considered the currently accepted resuscitation paradigm which is based upon the thesis that early rapid resuscitation of "lost" fluid volume is mandatory and that adequacy of resuscitation can be evaluated by central venous pressure, PAP, PAWP, pulse rate, blood pressure, and/or urine volume. Such methods also accept as natural concomitants that capillary beds are "damaged by injury"; that they "leak" salt, fluid, and albumin; and that these are expected occurrences which are injury-related. We have also examined and clinically evaluated the thesis that MAP is a primary reflector of the relationships between volume and the size of the currently available functional vascular space. (Currently available functional vascular space is mediated through the baroreceptor (stretch receptor)/neuroendocrine mechanisms.) Under this hypothesis, fluid resuscitation comprises infusion of a volume per unit time given so as to replete currently measurable fluid losses and to normalize and/or sustain MAP and the normal osmolar and oncotic relationships at the capillary/tissue interface while holding hydrostatic pressure at normal. Using burn injury as a model, we compared statistically homogeneous, randomly selected groups of burn patients who were resuscitated using a hypotonic fluid (130 mOsm/liter) alone (group R: 7 patients), hypertonic fluid (240 mOsm/liter) alone group H: 5 patients), or the hypertonic fluid containing albumin (12.5 g/liter) (group A: 7 patients). The results indicate that significantly smaller volumes of fluid were needed to resuscitate the patients in group A with a significantly more rapid normalization of physical, physiological, and biochemical parameters. We conclude that the physically and physiologically appropriate method of resuscitation, demonstrated in burn injury, comprises the use of a fluid given at a rate: (1) to maintain mean arterial and hydrostatic pressures within normal range; (2) that delivers a volume per unit time which does not exceed the capacity of the currently available functional vascular space; (3) that replaces concurrent measurable fluid losses; (4) that is hypertonic (to normalize capillary/tissue osmotic gradients); and (5) that contains colloid (to normalize capillary/tissue osmotic gradients); and (5) that contains colloid (to normalize capillary/tissue oncotic gradients). We further conclude that salt, fluid, and colloid loss into the interstitium during resuscitation frequently is due to the rate delivered and/or the physical nature of the fluid used and not to capillary bed damage outside the zone of injury.

Shock and resuscitation. II: Volume repletion with minimal edema using the "HALFD"(Hypertonic Albuminated Fluid Demand) regimen.

A hypertonic albuminated fluid demand regimen (HALFD) for resuscitation has been used in burn patients since January 1, 1976. The effects of the HALFD method were compared with hypertonic fluid and Ringer's lactate resuscitation. Specific attention was directed to fluid, colloid, and volume changes. Resuscitation was guided by maintaining the mean arterial pressure between 60 to 110 torr, and urine volume at 30 to 50 ml/hr. Patients treated with the HALFD method fared significantly better clinically, needed less fluid, had less weight gain and plasma leak, and experienced slower plasma volume repletion than those treated more traditionally. We conclude that the HALFD method is a physically and physiologically appropriate paradigm for resuscitating the volume-depleted patient.

Perichondritis (Tietze's syndrome) at the xiphisternal joint: a mimic of severe disease.

Tietze's syndrome (peristernal chondritis or perichondritis) is a self-limited, painful inflammatory condition of the costochondral, sternoclavicular, manubriosternal or xiphisternal junctions. It is benign, and affects all ages, sexes and races equally. The principal manifestations are pain and, frequently, a mass most commonly at the costochondral junctions. In 1974, C.J. described the first cases to be reported at the xiphisternal junction. We describe here 24 cases at that site. These patients' presenting symptoms suggested cardiac, pulmonary, intraabdominal and other severe disease processes. Diagnosis was made on clinical grounds based on a high index of suspicion. Treatment comprised infiltration of local anesthetic to the afflicted joints with prompt, complete and prolonged relief in 21 (87.5%) of the cases, and complete temporary relief in three (12.5%). We suggest that a possible mechanism for the referral of pain is the relationship of the xiphisternal joint to a variety of structures including autonomic nerves that accompany the internal mammary arteries.

Studies in burns: XV. Use of a topical lipid in treating human burns.

Sixty patients were selected from the 24-month burn population admitted to the Medical College of Georgia. Selection was on the basis of age, size of burn, and survival beyond 120 hours. Thirty-one of these patients were treated with ethyl linoleate agent (hELate) in addition to the modalities we routinely use for burn care. hELate was applied in a dose of 25 mg/kg only once in the period after burn. Significant pain relief and enhancement of wound healing (with return of hair and pigment) occurred in the hELate-treated patient. Less narcotic was needed, fewer grafts and reconstructive procedures were required, and hospital stay was reduced significantly. It is suggested that hELate is a safe and useful adjunctive to burn care.

Postburn respiratory injury.

A common and frequently overlooked concommitant of burn injury is postburn pulmonary damage. The lesion may be secondary to inhalation or mechanical obstructive or toxic problems; or it may be associated with indirect damage from hypovolemia, shock, central nervous system disturbances or drugs. Therapy comprises establishing a clear airway; administration of sufficient humidity and oxygen to maintain adquate arterial pO2; sequential pO2 monitoring; surface decompression of the thorax; systemic antibiotics and sequentially increasing--and later decreasing--airway support. The diagnosis of postburn pulmonary injury is clinical. Aggressive, sequential management of the patient, supported vigorously by laboratory evaluation, is essential.