Gary A. Lindenbaum

Patterns of alcohol and drug abuse in an urban trauma center: the increasing role of cocaine abuse

Alcohol continues to play a major etiologic role in blunt trauma. It is involved in 65-70% of fatal highway crashes. The role of illicit drugs, although accepted as an etiologic factor in trauma, is less well described. This is especially true of blunt and penetrating trauma related to violent crime. During a 9-month period, in a randomly selected group, blood and urine samples were taken from 169 traumatized patients for alcohol and general toxicology screens. There were 81 cases (47.9%) related to violent crime. One hundred twenty-six patients (74.5%) tested positive for illicit or prescription drugs in their blood. These included cocaine (54.4%), cannabinoids (37.2%), barbiturates (7.1%), amphetamines (4.7%), benzodiazepines (10.1%), opiates (9%), and codeine (1%). Sixty-one patients (35.5%) tested positive for alcohol. Alcohol was found in 6.2% of violent crime-related cases. Illicit drugs were found in 80.3% of violent crime-related cases. Alcohol and drugs, especially illicit drugs, are major etiologic factors in both accidental and crime-related trauma in the urban population. All patients admitted to trauma centers, especially urban trauma centers, should be screened for alcohol and drugs.

Thoracoscopic drainage and decortication as definitive treatment for empyema thoracis following penetrating chest injury.

PURPOSE The purpose of this study is to describe our experience with thoracoscopic drainage and decortication as definitive treatment for empyema thoracis following penetrating chest trauma. METHODS Over a 9-month period, eight patients at two institutions were treated for empyema thoracis that developed following penetrating chest injury. Seven patients sustained gunshot wounds and one a stab wound. All were treated for hemothorax with a closed tube thoracostomy. Associated injuries included six spinal cord injuries, a liver and diaphragmatic injury, a subclavian injury, and a carotid injury. Each patient subsequently developed an empyema. All patients underwent one thoracoscopic drainage and decortication of the empyema. RESULTS In all patients, complete resolution of the empyema was achieved with the thoracoscopic technique. Chest tubes were removed a median of 8.5 days after the procedure. Median blood loss was 200 mL. The average duration of the operation was 110 minutes. There were two complications, a persistent air leak and a trapped lung, both treated with thoracoscopic intervention. CONCLUSION Thoracoscopic drainage and decortication offers an alternative to thoracotomy for definitive therapy of empyema thoracis developing after penetrating chest trauma.

Diagnosis and management of traumatic ventricular septal defect

Four cases of ventricular septal defect secondary to stab wounds of the heart are presented. One of three patients arriving at the Emergency Department in shock and who were resuscitated required an emergency thoracotomy. These patients had immediate repair of their external cardiac wounds in the Operating Room. Cases 1 and 3 developed heart failure and loud systolic murmur postoperatively. Case 4 was treated with chest tube for a left hemothorax and developed heart failure after discharge. In Cases 1, 2, and 3, 2-D echocardiography detected and located a VSD. In Case 3 Doppler measurement showed elevated RV pressure (45 mm Hg) and decreased peak tricuspid to mitral flow ratio (0.36, normal = 0.6). All patients underwent cardiac catheterization. In Case 4 there was associated mitral regurgitation. Cases 1 and 3 had pulmonary to systemic flow ratios greater than 3:1. Cases 1, 3, and 4 underwent operative repair. In Case 1 the VSD was closed with a dacron patch, and in Cases 3 and 4 it was sutured with Teflon pledgets. In Case 4 a puncture wound of the mitral valve annulus was simultaneously repaired. All patients are alive but in Case 1 postoperative 2-D echocardiography demonstrated partial dehiscence of the patch which has not required reoperation and in Case 3 post-repair 2-D echocardiography and Doppler flow studies have shown an intact VSD repair. This series of post-traumatic VSD demonstrates its varying clinical presentation and the diagnostic and followup benefits offered by 2-D echocardiography, especially when combined with Doppler flow measures.(ABSTRACT TRUNCATED AT 250 WORDS)

Value of creatine phosphokinase isoenzyme determinations in the diagnosis of myocardial contusion

Myocardial contusion is an injury often missed in the patient with severe multisystem trauma. Fifty patients with physical findings or mechanisms of injury that were suggestive of possible nonpenetrating injury to the heart were studied with serial creatine phosphokinase isoenzyme (CPK/MB), continuous arrhythmia monitoring, and ECGs for at least 72 hours. Two-dimensional echocardiograms were obtained on all patients within 48 hours of admission. Seventy-two percent (36 of 50) had detectable CPK/MB. Ten patients had echocardiograms suggestive of cardiac contusion. Of these ten, three had no detectable CPK/MB and six had CPK/MB of less than 5%. CPK/MB had a sensitivity of 70% and a specificity of 27.5%. We conclude that in the patient with multisystem injury, CPK/MB determinations are not reliable. The decision to evaluate the patient with echocardiography should be made on the basis of physical findings and, more importantly, on mechanism of injury.

Effect of cocarboxylase in dogs subjected to experimental septic shock

We examined the effects of cocarboxylase treatment on both the hemodynamic variables and metabolic function during endotoxic shock in dogs. Cocarboxylase inhibited deterioration in metabolic function as reflected by improved pH and base excess as well as maintenance of normal oxygen consumption. Significant improvements in mean arterial pressure and cardiac index were also seen. Cocarboxylase is a major coenzyme of mitochondrial pyruvate dehydrogenase and may exert its beneficial effects via this complex.

Are Roadside Pedestrian Injury Patterns Predictable in a Densely Populated, Urban Setting?

BACKGROUND Roadside pedestrian injuries represent a significant portion of trauma team activations, especially at urban trauma centers. Patient demographics and severity of injury vary greatly in this patient population. Herein, we hypothesize that injury patterns may be predictable, especially with respect to age. MATERIALS AND METHODS All patients with roadside pedestrian injuries evaluated at our urban, level one trauma center from January 2006 through December 2008 were retrospectively reviewed. Data were collected from the institutional trauma registry. Age was used as an independent variable and compared with injury type, substance abuse, discharge setting, and mortality. RESULTS There were 226 roadside pedestrian injuries during the study period. Patients were divided into groups according to age, under 20 y, 21-40 y, 41-65 y, and over 65 y. Head injuries were more prevalent in patients over age 65, 30.4% versus 14.0% (P = 0.05). There was a trend for increasing alcohol use in the younger population. The likelihood of discharge to a rehab facility increased with age, 0%, 11.8%, 38.2%, 50.0%, respectively (P < 0.001). Mortality was significantly higher in patients older than 65 y, 15.2% versus 3.3% (P = 0.049). CONCLUSIONS Roadside pedestrian injuries have predictable injury patterns based on age. Older patients are more likely to have a head injury, longer length of stay, need for a rehab stay, and have a higher mortality. Further studies are needed to correlate precise injuries with collision mechanism and evaluate specific risk factors in this high risk population.

Applying Expectancy Theory to residency training: proposing opportunities to understand resident motivation and enhance residency training

Medical resident education in the United States has been a matter of national priority for decades, exemplified initially through the Liaison Committee for Graduate Medical Education and then superseded by the Accreditation Council for Graduate Medical Education. A recent Special Report in the New England Journal of Medicine, however, has described resident educational programs to date as prescriptive, noting an absence of innovation in education. Current aims of contemporary medical resident education are thus being directed at ensuring quality in learning as well as in patient care. Achievement and work-motivation theories attempt to explain people’s choice, performance, and persistence in tasks. Expectancy Theory as one such theory was reviewed in detail, appearing particularly applicable to surgical residency training. Correlations between Expectancy Theory as a work-motivation theory and residency education were explored. Understanding achievement and work-motivation theories affords an opportunity to gain insight into resident motivation in training. The application of Expectancy Theory in particular provides an innovative perspective into residency education. Afforded are opportunities to promote the development of programmatic methods facilitating surgical resident motivation in education.

Nonoperative Management of Blunt Traumatic Cardiac Rupture: Considerations of a Novel Approach

Blunt traumatic cardiac rupture carries a dismal prognosis. Patients who survive to presentation are treated with prompt surgical repair. Operative intervention carries significant morbidity and mortality, as these patients present in extremis. Intervention can be complicated by prior cardiac surgery. Obliteration of the pericardial space from adhesions may offer the patient an alternative conservative option under rare circumstances. We present a case of an older man with blunt cardiac rupture caused by a motor vehicle crash. The patient remained hemodynamically stable as his rupture only communicated with a small space within his obliterated pericardial sac. He was managed nonoperatively.

Perioperative surface and transesophageal color-flow doppler evaluation of post-traumatic intracardiac shunt

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