Gene A. Grindlinger

Acute paranasal sinusitis related to nasotracheal intubation of head-injured patients

One hundred eleven head-injured patients were examined for paranasal sinusitis during early convalescence. Glascow coma scale (GCS) was less than 8 in 79 patients. Ninety-three patients had sustained blunt injuries, and 18 had penetrating ones. Sixty-five orotracheal intubations (OTI) and 31 nasotracheal intubations (NTI) were performed at the scene or on hospital arrival. Fifteen patients were not tracheally intubated. Paranasal sinus air fluid levels (AFL) were present in 30 patients on their admitting computerized tomography scans.Paranasal sinusitis developed in 19 patients with a mean GCS of 5.4 ± 3.3 (SD). Sixteen of the 19 had NTI, and three had OTI (p < .05). Of 30 patients with AFL, sinusitis occurred in 13. Ten of these 13 had NTI, and three had OTI (p < .05). Penetrating injury did not increase the risk of sinusitis (p > .1). Seventeen of the 19 infections were polymicrobial. Sinusitis after head trauma is related to NTI, AFL, and severity of head injury.

The clinical significance of myocardial contusion.

In an attempt to identify a group of blunt trauma victims with asymptomatic myocardial contusion (MC) who do not benefit from intensive cardiac monitoring, we prospectively divided 336 patients admitted to the SICU with possible MC following blunt trauma in the 6 years prior to January 1990 into three groups: Group 1 (n = 155, age 30.5 +/- 9 years) consisted of those patients admitted for mechanism of injury, J-point elevation, with or without minor chest injury. None developed arrhythmias. Their SICU length of stay (LOS) was 2.41 +/- 0.77 days. Group 2 (n = 43, age 31.5 +/- 10 years) patients had the same admission criteria as the patients in group 1 plus an abnormal emergency department ECG, i.e., arrhythmia, heart block, ischemia. None had cardiac complications. Their SICU LOS was 2.47 +/- 0.94 days. Group 3 (n = 138, age 40 +/- 20 years) patients had four or more rib fxs, a pulmonary contusion, a flail chest, or extra-thoracic injuries or were greater than 60 years of age. All required SICU admission for their non-cardiac injuries. Nineteen patients had cardiac complications requiring treatment. None had a cardiac death. Their SICU LOS was 10 +/- 22 days. We conclude that young patients with minor blunt thoracic trauma and a normal or minimally abnormal ECG do not benefit from cardiac monitoring.

Volume loading and vasodilators in abdominal aortic aneurysmectomy

Preoperative infusion of volume to increase the wedge pressure will maintain stable flow and arterial pressure at the time of aortic declamping. Usually 1,500 ml of balanced salt solution given with 75 g of albumin is sufficient to accomplish this purpose. Pressor or inotropic agents are not required. In our experience 14 percent of patients will have a down-slope in the preoperative myocardial performance curves. In these persons, volume infusions should be adjusted to keep the pulmonary arterial wedge pressure on the ascending portion of the curve. The use of vasodilator agents in normotensive patients has a deleterious effect on cardiac performance.

Presence of negative inotropic agents in canine plasma during positive end-expiratory pressure.

Application of positive end-expiratory pressure (PEEP) will reduce cardiac output (CO). Humoral mediation of this event by circulating negative inotropic agents was examined using a rat papillary muscle bioassay. Twenty-seven dogs were anesthetized with an iv pentobarbital infusion. Plasma was obtained before and after 30 minutes of PEEP. The plasma was oxygenated in a small (4.5-ml) papillary muscle chamber using a diffusion membrane. An average POi of 416 mm Hg was achieved. PEEP plasma reduced developed tension (Tpd) from 2.18 ± 1.0 to 1.90 ± 1.05 g (P < 0.0001). A fall in Tpd was observed whether or not CO was maintained constant with fluid infusion. Resting tension was unchanged. The percent reduction in Tpd correlated with the fall in CO (r · = 0.63, P < 0.01) when fluid was not infused to maintain CO. Reapplication of control plasma restored Tpd. Barbiturate levels in anesthetized dogs rose from 17.3 to 19.4 μg/ml during PEEP (P < 0.1). Addition of pentobarbital to normal plasma led to a slight decrease in Tpd only when the concentration exceeded 99 μg/ml. In three experiments on ex vivo perfused hearts, application of PEEP led to lowering of peak systolic pressure (PSP) within 5 minutes. Removal of PEEP restored PSP in a similar time. The results support the hypothesis that the decline in CO with PEEP is mediated in part by a circulating negative inotropic agent. Ore Res 45: 460-467, 1979

The efficacy of sequential compression devices in multiple trauma patients with severe head injury

Thirty-two multiple trauma patients with severe head injury and a Glasgow Coma Scale (GCS) score of 8 or less were prospectively studied to assess the occurrence of deep venous thrombosis (DVT) and pulmonary embolism (PE). All patients required mechanical ventilation. A sequential compression device (SCD) was used in 14 patients and 18 patients received no prophylaxis for thromboembolism. Bilateral lower extremity technetium venoscans and ventilation/perfusion (V/Q) lung scans were performed within 6 days of admission and every week for 1 month or until the patient developed DVT or PE or was discharged from the SICU. Deep venous thrombosis occurred in two patients (6%) at 16 and 28 days following trauma. Twenty-five patients had normal or low probability V/Q scans. Six had high probability V/Q scans confirmed by pulmonary arteriograms (PAGs) at 12.5 +/- 4 days. Clinical signs of PE were absent in all patients with a positive PAG. There were no differences in age, Injury Severity Score (ISS), GCS Score, APACHE II Score, or Trauma Score between the patients who developed DVT or PE and those who did not. A SCD was used in four of the eight patients with DVT or PE. All but one patient with DVT or PE underwent placement of a vena caval filter. Multiple trauma patients with severe head injury (GCS score < or = 8) are at high risk for thromboembolism. The available means of prevention and diagnosis of DVT or PE in multiple trauma patients with severe head injury are not entirely effective.

Survival determinants in patients undergoing emergency room thoracotomy for penetrating chest injury

Survival determinants were examined in patients undergoing ERT-PCI who were admitted to the Surgical Intensive Care Unit (SICU) between January 1, 1982 and August 1, 1991. Twenty-one of 290 patients undergoing ERT-PCI (aged 14-36 years) were admitted to the SICU. Of the 21, nine survived to discharge with normal neurologic function. Four survived with neurologic impairment. Eight expired 1 to 12 days after admission. The ERT was done immediately upon hospital arrival or subsequently in the Emergency Department for impending arrest despite resuscitation. All survivors had a pulse or blood pressure either in the field or upon arrival in the ER. Seven of nine who survived neurologically intact were awake on arrival in the ER, the other two were moving their extremities. One of four who survived with neurologic impairment was awake on arrival; three were comatose. Five of the eight who died were in full arrest in the field and upon arrival in the ER. Two of these patients were brain dead shortly after SICU arrival. All survivors had vital signs either in the field or on ER arrival. Patients with penetrating chest wounds without vital signs in the field who do not recover vital signs by hospital arrival do not benefit from emergency room thoracotomy. Evidence of mentation in the field or on arrival may predict ultimate neurologic outcome of survivors.

Changes in mitogen responsiveness lymphocyte subsets after traumatic injury: relation to development of sepsis.

Head injury and multiple trauma patients were evaluated for mitogen responsiveness and lymphocyte subset frequencies within the first few days after injury. The profile obtained was compared to the patients clinical course to see if there was a relation between early immune abnormalities and the subsequent development of unanticipated sepsis. Lymphocytes from multiple trauma patients were generally hyporesponsive to in vitro stimulation with a suboptimal dose of the mitogen phytohemagglutinin (PHA). In contrast, the response of head injured patients was comparable to that of the control group. There was a significant decrease in the relative number of multiple trauma patients T4 (29.3 vs 48.6%) and T11 (48.9 vs 74.7%) positive populations (P less than 0.01). There was no change in the percentage of T8-positive cells (19.0 vs 20.5%). Patients with head injuries also had a decrease in T4-positive cells (35.9%). The percentage of cells with B cell and natural killer (NK) markers remained normal. Thus trauma patients appeared to have an increase in null cells. Six patients whose PHA responses were among the lowest developed sepsis early after trauma. The changes in subset distributions although possibly contributing to a decreased responsiveness did not predict the ability to respond to PHA or the development of sepsis.

Evolution in the management of the complex liver injury at a Level I trauma center.

BACKGROUND Management of the severe liver injury evolved from mandatory surgical repair to a more selective approach. This paper reviews the changes in management of the severe liver injury at a Level I trauma center. METHODS We reviewed the records of patients with severe liver injury admitted to a Level I trauma center between January 1984 and December 1995. The patients were divided into two groups, G1 and G2, based on their date of admission before or after January 1991. The two groups were compared for blood products use, management of the liver injury, and outcome. RESULTS One hundred six patients were compared for age, sex, Acute Physiology and Chronic Health Evaluation II score, Injury Severity Score, abdominal Abbreviated Injury Scale score, and the presence of concomitant injuries. There was no difference in management or outcome of the victims of penetrating injury between G1 and G2 (n = 48). The blunt injury patients in G1 (n = 22) had more liver surgery (p = 0.006), blood transfusion (p = 0.040), intra-abdominal sepsis (6 vs. 0), and higher mortality (p = 0.041) than those in G2 (n = 36). CONCLUSION Isolated severe blunt liver injury may be managed nonoperatively with better survival and less blood products use.

Clinical Characteristics of Nosocomial Sinusitis

Paranasal sinusitis is an important source of sepsis and morbidity in head injury victims and requires aggressive pursuit and therapy. Of 208 head-injured patients, 24 developed paranasal sinusitis. The Glasgow Coma Scale score of the sinusitis patients was 7.1 ± 3.9. Nineteen patients were intubated nasotracheally, and five were intubated orally. Sinus air fluid levels, indicative of bleeding into the sinus, were seen on 17 initial computed tomographic scans. Maxillary sinus suppuration occurred in 23 patients; in 20 it was the initial sinus involved. Twenty-one patients developed polymicrobial sinusitis. Coexisting infections were common. In 15 patients with concurrent tracheobronchitis or pneumonia, organisms identical to those in sinus aspirations were recovered from the sputum. Seven patients had associated bacteremia. Meningitis in six patients shared a common pathogen with their sinusitis. Nonoperative management successfully resolved sinus infection in 19 cases. Five patients required open sinusotomy.

Stability of Cervical Spine Fractures After Gunshot Wounds to the Head and Neck

Learning Objectives: After participating in this CME activity, the obstetrician/gynecologist should be better able to: 1. Accurately counsel patients on the risks and benefits of initiating hormone therapy (HT) for vasomotor symptoms (VMS). 2. Apply current evidence to select appropriate HT for treatment of VMS in uncomplicated postmenopausal women. 3. Compare the risks and benefits of HT for special subpopulations of menopausal patients, such as women with a history of breast cancer, BRCA mutation carriers, those with hypertension, women older than 65 years, and those at a high risk for or with a history of venous thromboembolism.