Venous thromboembolism after penetrating chest trauma is not a cause of early death.

BACKGROUND: Venous thromboembolism has been recognized as a potentially life-threatening complication following major thoracic trauma. Little or no attention has been directed at the difference in rates of venous thromboembolism in subjects with penetrating and nonpenetrating chest trauma. METHODS: The reported experience with venous thromboembolism in subjects with chest trauma has not segregated the effect penetrating vs. closed chest trauma. The influence of long-term hospitalization to the formation deep vein thrombosis, pulmonary embolism or subsequent death. The present study evaluated the causes of early death occurring within 96 hours of hospitalization for penetrating chest trauma. The clinical records and autopsy reports of 32 individuals, who died within 96 hours of admission to hospital for penetrating chest trauma, were evaluated for the presence of deep vein thrombosis and pulmonary embolism. RESULTS: All 32 subjects were male with an average age of 31 years. Eighty percent were successfully resuscitated in the emergency room. Forty percent (40%) required an emergency or operating room thoracotomy. The initial revised trauma score (RTS) was below 4 in each case. Thirty-two percent (32%) of the patients died on the fourth day; 48% died between 1 and 3 days of admission and 20% died in the emergency room. None of the patients had any clinical signs or evidence of deep vein thrombosis or pulmonary embolism. Moreover, the autopsy findings were negative for deep vein thrombosis and pulmonary embolism. CONCLUSION: Deep vein thrombosis and pulmonary embolism is rarely a cause of death within the initial 96 hours of hospitalization in individuals sustaining penetrating chest trauma.

Consumer product-related ocular trauma.

Leading causes of consumer product-related ocular trauma have not been well described. To delineate these causes in a nationally representative sample, data collected by the US Consumer Product Safety Commission (USCPSC) were reviewed. Data were obtained from the National Electronic Injury Surveillance System (NEISS), a national probability sample survey conducted by USCPSC that continuously monitors consumer product-related injuries treated in hospital emergency rooms across the United States. These data formulated the product summary report for the calendar year 1991. The sampling frame for the NEISS consisted of hospitals listed on the Center for Health Statistics Master Inventory File stratified geographically by size of hospital and number of emergency-room visits. During the calendar year 1991, there were a nationally estimated 298,852 consumer product-related eye injuries treated in hospital emergency rooms. Appoximately 500 different products were implicated in these injuries, with the leading cause being contact lenses (hard and soft), accounting for an estimated 26,490 emergency-room visits. This is followed by welding equipment (12,771 visits), hair curlers/curling irons (5946 visits), and workshop power grinders (5476 visits). Consumer products account for a sizable number of ocular injuries requiring treatment in hospital emergency rooms. Research on outcomes and prevention strategies of the injuries is warranted.

Retinal hemorrhage secondary airbag-related ocular trauma.

A case is presented in which a driver, who was wearing a three-point restraint system, was involved in a collision that triggered deployment of the vehicle's driver's-side airbag. The victim complained of blurred vision after the crash and on examination was found to have suffered a retinal hemorrhage in his right eye. Since no other cause could be determined, his injury was considered to be a result of contact with the deploying airbag.

Asymptomatic pneumoperitoneum diagnostic and therapeutic dilemma.

The most common cause of pneumoperitoneum is iatrogenic postsurgical free air that enters the abdominal cavity during laparotomy. In these patients, pneumoperitoneum usually resolves within the first week of surgery and laparoscopic procedures. In patients who have not had recent laparotomy or laparoscopy, pneumoperitoneum indicates rupture of an intra-abdominal viscus in about 90 per cent of the time. Perforated gastric and duodenal ulcers account for the greatest number of these cases. The other 10 per cent are due to a variety of nonsurgical causes that can often be treated by supportive and non-operative measures. Lack of clinical awareness about these small but significant subset of patients who present with spontaneous benign pneumoperitoneum is a source of needless laparotomies that can at times lead to serious postoperative complications. Benign pneumoperitoneum can be categorized according to the source of the gas as suggested by Gantt. The thoracic cavity is by far the most common source, followed by the GI and female genital tracts and a host of other miscellaneous causes. We report here six patients who presented to Howard University Hospital with nonsurgical pneumoperitoneum. Four of these patients underwent negative laparotomies and one died postoperatively. The most common causes of benign pneumoperitoneum are discussed and a review of the literature is presented.

Postoperative adult respiratory distress syndrome: the Howard experience.

To describe the natural history of adult respiratory distress syndrome (ARDS), we compared the clinical course of two groups of postoperative critically ill patients who developed respiratory failure requiring prolonged endotracheal intubation (minimum: 4 days). The two groups with ARDS (Group 1) and without ARDS (Group 2) were compared for the following clinical parameters: PO2/FIO2 ratio, cardiac index, pulmonary capillary wedge pressure, systemic and pulmonary vascular resistance, pulmonary compliance, serial chest radiograph findings, presence or absence of sepsis, oxygen transport parameters, morbidity, and mortality. Twenty patients are described over a 9-month period ending in March 1990-10 patients in each group. Characteristic differences between the two groups in terms of oxygen consumption, pulmonary compliance, pulmonary vascular resistance, numbers of organ systems failing, and mortality were noted. Our experience supports the recommendations of early institution of positive and expiratory pressure and optimizing oxygen delivery parameters in the management of ARDS.

Selenium deficiency in long-term total parenteral nutrition.

Although selenium is an essential trace element, it is often not routinely added to total parenteral nutrition (TPN) formulations. When selenium is not added, patients are at risk for selenium deficiency. This report describes such a patient. He had several operations for colon cancer, including a massive resection of the small bowel that resulted in a short bowel and a fistula. TPN was started after his last operation. After he was discharged, he had a normal, active lifestyle, except that he limited oral intake to water and an occasional soft drink. After 3 years of almost exclusive nourishment by TPN, he developed whitened nail beds. Investigation for possible trace element deficiency resulted in a finding that he had very low levels of selenium in his blood. He did not have any of the cardiac or skeletal muscle abnormalities that have been associated with selenium deficiency. After supplementation with selenium, his blood levels of selenium rose and the nail bed changes were reversed.

Stab wounds to the chest: a retrospective review of 100 consecutive cases.

In a retrospective review of 100 consecutive cases of stab wounds to the chest, 44 patients were successfully treated with tube thoracostomy, 14 patients required thoracotomy, 17 patients with small pneumothoraces were observed, and 25 patients were asymptomatic. The overall mortality was 4%, operative mortality was 7.1%, and the mortality rate for cardiac injuries was 50%. Of the eight patients with cardiac injuries, three were dead on arrival to the hospital and one patient died in the operating room. Patients treated with tube thoracostomy had a shorter hospital stay than patients managed by observation alone. Our findings support the opinion that asymptomatic patients (normal chest x-rays) may be discharged after 24 hours of observation and asymptomatic patients with nonprogressive small pneumothoraces (less than 20%) not requiring a chest tube may be discharged after 48 hours of observation. All patients should have close outpatient follow-up.

Tracheopleuropulmonary injuries following enteral tube insertion.

Eighty-three cases of tracheopleuropulmonary injuries complicating enteral tube feeding are analyzed to identify the patterns of injury, and precipitating factors and ways to avoid them. Six new cases observed by the authors and 77 other cases cited in British literature between 1976 and 1987 are presented. In recent years, reports of this complication have been increasing, apparently in a geometrical progression: 8%, 18%, and 74% were reported between 1976 to 1979, 1980 to 1983, and 1984 to 1987, respectively. Sixty-one percent occurred in patients aged 60 years or older. Most of the patients (84%) were seriously ill, which compounded their complications. Seventy-four percent of all injuries were committed by house staff; the narrow bore tube with guide wire was used in 77% of cases. Less than reliable methods were used to confirm tube position in most instances. The presence of cuffed endotracheal tubes did not offer protection. The patients on mechanical ventilation tended to deteriorate if they developed a pneumothorax once the malpositioned tubes were removed. Of the cases reviewed for this report, 18 deaths occurred; 72% being directly related to the tube injuries. Lack of awareness, inadequate confirmatory methods, and insufficient supervision accounted for most of these preventable complications. Educating house/nursing staff in the use of the new tubes, closer supervision, and the application of equal measures of care and caution as employed in other invasive and potentially dangerous procedures are recommended to avoid disastrous outcome.

The wandering bullet.

The phenomenon of bullet embolization has been documented in various organs or major organ systems. A case report of a gunshot wound injury to the left hemithorax with penetration of the esophagus and embolization to the stomach is presented. Diagnostic evaluation and therapy are discussed.

Candida sepsis.

Thirty cases of Candida sepsis occurring at Howard University Hospital between January 1983 and December 1985 were studied. A retrospective analysis was done to determine which risk factors or methods of treatment led to higher morbidity and mortality. Nosocomial infections with fungi are becoming more widespread as patients survive illnesses once deemed terminal. Patients had positive blood cultures for Candida accompanied by signs of systemic sepsis. Risk factors included diabetes, central hyperalimentation, malignancy, intraabdominal abscesses, and fistulae. The correlation between the total dose of amphotericin administered and patient recovery was analyzed.

Chylothorax: an omnipresent reality in thoracic surgical procedures.

Loss of integrity of the thoracic duct will produce a chylous thoracic effusion. latrogenic chylothorax occurring during an intrathoracic surgical procedure in the vicinity of the thoracic duct is an omnipresent reality. The fluid is characteristically milky in appearance, sterile, and high in fat content.There seems to be a general agreement that initial management be conservative, namely, dietary control and adequate drainage. The success of conservative management will depend on collateral lymphatic channels developing. If conservative measures fail, thoracotomy for ligation of the duct is indicated. When to terminate nonoperative therapy and opt for operative is controversial.

Vascular access in the cancer patient.

Patients requiring frequent blood sampling and/or frequent intravenous fluid administration can be difficult to manage clinically once peripheral veins become exhausted. Not only can peripheral vascular access be difficult in these patients, but patients begin to dread the attempts at blood sampling and intravenous line placement more than the chemotherapy regimen.At Howard University Hospital, several different types of commercial vascular access devices have been employed that afford reliable and dependable use in cancer patients requiring chemotherapy and blood monitoring. With the increased use of these devices, one unpleasant aspect in the management of the cancer patient, that of repeated attempts at vascular access, can be eliminated.

Superior mesenteric vein thrombosis: a case report.

Superior mesenteric vein thrombosis is an abdominal emergency that is rarely diagnosed early. Abdominal pain, vomiting, fever, and hematochezia are the characteristic presenting complaints. Tenderness, distension, and diminished intestinal sounds were the prominent abdominal physical findings in this case and were often associated with tachycardia and hypotension. This is a case that demonstrates all the nonspecifics, and one in which the patient survived beyond all others reported in the literature to date.

Computed tomography of adult colonic intussusception: clinical and experimental studies.

The CT features of a case of adult ileocolic intussusception and of experimentally induced ileocolic, cecocolic, and colocolic intussusceptions are presented. Both the clinical and experimental cases demonstrated (1) "target" masses with enveloped, eccentrically located areas of low density and (2) interspersed low- and high-density stripes within the intussusception producing a "layered" or "stratified" pattern. This layered pattern of abdominal masses may be characteristic of intussusceptions regardless of location.

Penetrating neck wounds.

Over a 15 year period 120 patients with neck injuries that penetrated the platysma were studied. Appropriate treatment was initiated in the emergency room. Sixty-one patients underwent exploration and 59 were observed. Two of the observed patients later required delayed operation. In 9.2 percent of the patients, two or more injuries were present within the neck, whereas in 30 percent the neck injury was only one of many bodily injuries. Length of hospital stay for the operative group of patients was 9 days and for the nonoperative group 5 days. There was one death. The complication rates in the operative and nonoperative groups were 2.5 and 1.7 percent, respectively. The major structures injured were within the venous system. The neck injuries were classified according to three zones defined by Saletta and Jones and their co-workers [4,5]. The majority were Zone II injuries. Our morbidity and mortality rates are slightly lower than those reported in most series. This review supports the concept that therapy for penetrating injuries to the neck should be individualized.