David J. Dries

Interferon gamma in trauma-related infections

ObjectiveThe efficacy of interferon gamma therapy in reducing infection and improving outcome from infection in patients sustaining major injury was examined.DesignRandomized double-blind placebo control trialSettingNine level one university affiliated trauma centers in the United States.Patients and participantsFour hundred sixteen patients with injury severity score (ISS) ≥25 or ISS ≥20 with evidence of wound contamination.InterventionRecombinant human interferon gamma 100 ug or placebo was given subcutaneously daily for up to 21 days in addition to standard antibiotic therapy.Measurements and resultsComparable rates of major and minor infections were observed. Among the patients treated with interferon gamma there were fewer deaths related to major infection regardless of type [7–(3%) vs 18–(9%)]. The results, however, were dominated by one center which had the highest enrollment, infection and death rates.ConclusionsFurther studies are warranted to investigate the role of interferon gamma therapy in improving outcome with major infection.

A comparison study of chest tube thoracostomy: Air medical crew and in-hospital trauma service

Chest tube thoracostomy (CTT) is not frequently performed by non-physician-staffed air medical crews (AMC) due to concern regarding safety, efficiency and training requirements. This study compared two groups of patients requiring CTT, one group with insertion performed by an AMC and the other by a physician trauma service (TS) in the emergency department on patient arrival. The CTT of 172 patients managed at a Level I trauma center between October 1988 and September 1990 were reviewed. Seventy-two patients were managed by the AMC and received CTT in a prehospital setting; the air medical personnel placed the chest tube cleanly in all cases. Chest tubes placed by AMC were removed within 48 hours of transport to minimize infection risk. One hundred patients requiring CTT in the hospital setting were randomly selected from the trauma registry during a similar time span. The study compared the patients Injury Severity Scores (ISS), and trauma scores, any placement complications and the overall mortality. While the AMC often treated patients with higher acuity, as reflected by ISS and trauma scores and overall higher mortality, the rate of complications between CTT performed by AMC and TS was similar. Appropriately trained AMC can safely perform CTT without putting patients at increased risk.

Transoral Crossbow Injury to the Cervical Spine: An Unusual Case of Penetrating Cervical Spine Injury

The complexity of missile injuries to the cervical spine has increased as the technology that causes these injuries has become more sophisticated. Management requires adaptation of conventional neurosurgical approaches to the cervical spine in an effort to limit neurological deficit and establish stability. We report an unusual case of a 19-year-old man who suffered transoral penetration of the cervical spine by an arrow released by a crossbow at close range.

Sublethal Endotoxemia Promotes Pulmonary Cytokine-Induced Neutrophil Chemoattractant Expression and Neutrophil Recruitment but Not Overt Lung Injury in Neonatal Rats

Gram-negative sepsis and septic shock remain major causes of morbidity and mortality in the newborn. Respiratory failure is a common feature in neonatal sepsis regardless of the presence or absence of associated pneumonia. In adult animal models, cytokine-induced neutrophil chemoattractant (CINC) is a potent chemoattractant for neutrophils and believed to play a role in endotoxin-induced lung injury. We examined this in a neonatal model. Ten-day-old Sprague-Dawley rats were injected with Salmonella enteritidis endotoxin (ETX) 0.03 mg/kg i.p. and sacrificed at baseline, 30 min, 1, 2, 4, 8 and 16 h post-ETX. Blood was collected by cardiac puncture. After bronchoalveolar lavage, lung tissue was collected and evaluated for neutrophil (polymorphonuclear leukocyte) recruitment by myeloperoxidase assay (MPO). Lung CINC expression was measured by Northern blot and ELISA. Peripheral blood leukocytosis was noted at 1 h (p < 0.001) with counts below baseline at 2 and 4 h. Differential counts revealed neutrophilia at 8 h (p < 0.001). MPO revealed pulmonary PMN recruitment peaking at 1 h (p < 0.05) and CINC RNA and protein expression peaked slightly later at 2 h (p < 0.001). No overt lung injury was noted by bronchoalveolar lavage cell counts or by histology. Therefore, pulmonary CINC expression and neutrophil recruitment follows LPS exposure in neonatal rats. This may represent priming of the lung tissue and a secondary event may be necessary for injury to occur

Introduction of pulse oximetry in the air medical setting.

The importance of adequate oxygenation in critically ill patients is widely recognized. Pulse oximetry (PO) is a non-invasive, rapid technique of arterial hemoglobin oxygen saturation (SaO2) measurement. This report is a review of our experience using the PO during air medical transport. A chart review was conducted on patients who used air medical transport between October 1988 and March 1989. Types of patients included trauma and ICU patients who were transported from either accident scenes or outlying hospitals. SaO2 and vital sign (VS) measurements were obtained pre and postflight, and inflight interventions were documented. Four groups of patients were identified: Group 1: PO used, inflight intervention employed; Group II: PO used, no inflight intervention employed; Group III: no PO used, inflight intervention employed; Group IV: no PO used, no inflight intervention employed. A dependent, paired-t-test was used to compare pre and postflight SaO2 and VS measurements. The mean difference between pre and postflight measurements of SaO2, systolic blood pressure, and pulse rate were calculated within each group. Then, an ANOVA with post-hoc Newman-Keuls Test compared the means between the four groups. Of the 137 patients reviewed, 82 used PO and 55 patients did not due to technical or anatomic problems. Of the 82 patients who used PO, 19 received an inflight intervention.(ABSTRACT TRUNCATED AT 250 WORDS)

Heparin therapy in venous thrombosis

Abstract DVT has been reported to occur in up to 42% of trauma patients. Complications of DVT can include PE, which may lead to death. DVT treatment can be accomplished pharmacologically with UH, LMWH, and thrombolytics. Thrombolytics have a high adverse event profile and are contraindicated in many patients, which limits their usefulness in practice. UH is widely used for its favorable adverse effect profile with careful monitoring of the APTT, ease of rapid anticoagulation by using one of several heparin-dosing nomograms, and proven track record in the prevention of DVT extension and recurrence. Drawbacks of UH include frequent changes in dosing while titrating anticoagulant effect, frequent laboratory monitoring of the APTT, and increased risk of bleeding. In the future the use of LMWH may increase to treat DVT because of fixed-dose administration, once or twice daily dosing, and lack of laboratory monitoring. Studies have shown a reduced risk of major bleeding and a decreased recurrence of DVT when LMWHs are compared with UH. Further studies are needed to determine whether LMWH will become the mainstay of treatment for DVT.

Hypernatremic dehydration in pediatric critical care transport

Case Reviews Our flight team was called to a local hospital to transport a 2-week-old boy diagnosed with hypernatremic dehydration to our pediatric intensive care unit (PICU). Because of the close proximity to our base, this transport was done by ground ambulance. This patient had pre sented to the referring hospital 5 hours before our arrival with mild to moderate dehydration manifested by dry skin and a sunken anterior fontanel but with good skin turgor, pink color, moist mucous membranes, and brisk capillary refill. He had protective airway reflexes with a good respiratory effort and good air exchange. Laboratory tests drawn after the placement of a 22-gauge peripheral intravenous line revealed a venous pH = 7.26, p0, = 40 torr, Na = 200 mEq/L, K = 5.0 mEq/L, and glucose = 84 gm/dL. He then was bolused twice with 10 mL/kg of normal saline. On our arrival, his clinical examination was as follows: he was awake and alert with an oxygen saturation of 98% on 10 L of oxygen by face mask. He had a sunken anterior fontanel, but his capillary refill was 2 seconds with good skin turgor and strong peripheral pulses. The only clinical abnormality was bradycardia with heart rates ranging from 84 to 100. The patient’s mother was at the bedside and said the infant had had no prob lems feeding, no diarrhea, but only one to two wet diapers per day. On the day of transport, she had taken him to the pediatrician, who had assessed that the boy had lost more than 2 pounds since birth and then referred him to the emergency department. After consulting with our medical control physician, the infant was given fluids of D5.9NS at a maintenance rate. It was decided not to give a fluid bolus because of the clinical examination consistent with normal intravascular volume status despite metabolic acidosis. The infant then was transported back to our facility during which time he remained stable. A few months later, our flight team transported a 2’/Z-year-old boy who weighed 11 kg and had hypernatremia. This child presented with an unsteady gait and lethargy and had a serum sodium level of 191 mEq/L. An arterial blood gas analysis was as follows: pH = 7.44, pOa = 89 tori-, pCOz = 43 torr, HCO, = 28 mEq/L, and BE = +4. An IV line was started, and he was given 30 mL/kg of normal saline as a bolus. On arrival, the flight crew found the patient to be awake, alert, and acting appropriately for his age. His capillary refill was less than 2 seconds; his skin was pink, warm, and dry; and he had strong peripheral pulses. However, he