Donald L. Kreipke

Reliability of indications for cervical spine films in trauma patients

Common emergency room practice mandates cervical spine (C-spine) films in all trauma patients with potential injuries. With the increasing costs of medical care, such liberal criteria may not be justified. This 1-year prospective study of 860 patients who presented to a Level I Trauma Center was undertaken to determine the signs and symptoms that would select the patients at risk of C-spine injury. The clinical presentation of each patient was correlated with the presence of C-spine fracture. Twenty-four patients (2.8%) had injuries demonstrated by plain film radiography. The incidence of fracture in 536 symptomatic patients was 4%. A significant likelihood of C-spine fracture was seen in patients with respiratory compromise (100%), motor dysfunction (54.5%), and altered sensorium (8.9%) (p less than 0.001). No fractures were seen in asymptomatic patients (p less than 0.001). Cervical spine radiography should be performed in patients with abnormal neurologic findings or symptoms referable to the neck. In alert asymptomatic patients, cervical spine radiography may be omitted.

Intracoronary administration of streptokinase in a canine model. Disturbance in thromboxane A2-prostacyclin balance.

The potential impact of local intracoronary infusion of streptokinase (SK) on vascular prostaglandin synthetic pathways was studied in a canine model. Control animals (n = 10) underwent left coronary artery (LCA) infusion of 50,000 units SK for 90 minutes; experimental animals (n = 10) underwent LCA infusion of normal saline. Plasma samples for radioimmunoassay (RIA) of prostacyclin (PGI-2) and thromboxane (TXA-2) were obtained from the coronary sinus (CS) as follows: one sample preinfusion, six samples during infusion, and three samples postinfusion in each animal. Comparisons between control and experimental plasma levels of PGI-2 and TXA-2 were made for each sampling time. The PGI-2 levels remained at or below the lower limits of detectability by RIA (the most sensitive assay available) in both control and experimental animals. TXA-2 levels were higher in experimental than in control animals at all sampling times, with the most significant differences occurring in samples 3 (after 30 minutes of infusion, .001 less than P less than .01), 4 (after 45 minutes of infusion, .05 less than P less than .10), and 5 (after 60 minutes of infusion, .02 less than P less than .05). We suggest (1) it is unlikely that any of the beneficial effects of coronary streptokinase infusions are PGI-2-mediated, (2) that the TXA-2 increases in our model may represent a pathophysiologic-biochemical correlate of previously identified morphologic evidence of endothelial damage in animals infused with fibrinolytic agents, and (3) that our findings may indicate that fibrinolytic infusions produce competing effects: lysis of thrombi and endothelial injury with TXA-2 production.(ABSTRACT TRUNCATED AT 250 WORDS)

MR of superior mesenteric arteryrenal vein fistula

Traumatic arteriovenous fistulas involving the superior mesenteric artery are rare. Diagnosis is most commonly made shortly after the injury. Symptoms, when present, are usually related to intestinal ischemia. Angiography has been the conventional modality used in diagnosing arteriovenous fistulas. We report a patient with a superior mesenteric artery to left renal vein fistula who presented in overt heart failure five years after a gun shot wound. The fistula was evaluated with magnetic resonance imaging.