John B. Cone

Missed injuries in a rural area trauma center.

BACKGROUND Missed injuries can lead to delays. In the rural environment, where patients are frequently seen in multiple hospitals prior to reaching the trauma center, different problems arise. METHODS Level-1 trauma center admissions from January 1993 through June 1995 were reviewed. Missed injuries were those not identified within 24 hours of injury. Data extracted included demographics, mechanism, severity and outcome. Comparisons were made between missed injury patients and typical trauma patients. RESULTS Of 3,996 patients, 70 missed injuries were identified in 56 patients. Compared with typical trauma patients, missed injury patients suffered more blunt trauma, were more severely injured, had longer intensive care unit and hospital stays, and a lower mortality rate. Transferred patients accounted for 60% of missed injuries. CONCLUSIONS Transferred patients with blunt injury have the highest risk for missed injury. Delayed transports and prior examination may contribute to complacency. All trauma patients must be repeatedly evaluated thoroughly, and all diagnostic studies reviewed for adequacy.

Toxic megacolon secondary to pseudomembranous colitis

Toxic megacolon has rarely been reported in the course of antibiotic-induced pseudomembranous colitis. We have been able to collect 20 cases from the literature and add one new case. The mortality in the collected series was 33 per cent. The critical factor in improving survival is early recognition of the pseudomembranous colitis. Most patients can be managed medically by removal of the offending antibiotic, bowel rest, vancomycin, and steroids. If toxic megacolon develops in the face of appropriate medical management, an aggressive surgical approach is indicated, as with ulcerative colitis. Subtotal colectomy appears to be the procedure of choice.

The tumescent technique to significantly reduce blood loss during burn surgery

INTRODUCTION Burn surgery is complicated by blood loss. The tumescent technique of subdermal injection of epinephrine has been utilized to decrease intraoperative blood loss. We hypothesized that this would safely decrease blood loss during burn surgery. METHODS Twenty patients utilized the tumescent technique. The tumescent group had subdermal injections of epinephrine beneath the excision and donor site plus thrombin spray and warm saline soaked laparotomy pads. Ten patients grafted prior to adopting the tumescent technique utilized thrombin spray and warm saline soaked laparotomy pads for hemostasis. Blood loss was determined by operative estimation and calculation. Data were analyzed by Students t-test and paired t-test. RESULTS The two groups were demographically similar. The tumescent group had significantly less total blood loss and blood loss per unit area excised. There were no clinically detectable arrythmias, changes in heart rate or blood pressure noted. CONCLUSIONS The tumescent technique significantly reduced intraoperative blood loss. It is safe, inexpensive and easy to use. The subdermal epinephrine/saline injection creates a smooth, tense surface which assists with debridement and donor harvest.

Hypertonic Lactated Saline Resuscitation of Severely Burned Patients Over 60 Years of Age

Twenty-six adults more than 60 years old with burns greater than or equal to 30% of the body surface area were resuscitated using hypertonic lactated saline (HLS). Hemodynamic parameters of resuscitation were measured in ten of the patients using a Swan-Ganz catheter. In spite of signs of hemodynamic stability, these patients demonstrated mean cardiac indices (CI) below their age-corrected norms and pulmonary capillary wedge pressures (PCWP) below 5 mm Hg through 24 hours, yet 92% of the patients produced normal or super-normal volumes of urine. Hemodynamic monitoring may be helpful for precise fluid replacement in extensively burned elderly patients; however, a normal CI and PCWP may not be the appropriate endpoint for resuscitation of the elderly when using HLS. This review supports the concept that HLS resuscitation of critically burned older patients is both safe and efficacious, leading to an 81% survival of this severely compromised group well past the resuscitation phase of injury.

A prospective analysis of silver sulfadiazine with and without cerium nitrate as a topical agent in the treatment of severely burned children.

Previous studies have indicated that combining cerium nitrate with silver sulfadiazine (Silvadene, Marion Labs) yields a superior topical agent for the treatment of burns. Cerium nitrate in silver sulfadiazine was tested in a controlled study with silver sulfadiazine alone. The study population consisted of two groups of children suffering burns greater than 30% of the body surface. The patients ranged in size from 1 to 21 years. The study period was for the first 10 weeks of hospitalization. Quantitative surface cultures were used to monitor burn wound flora. No superiority for the silver sulfadiazine-cerium nitrate combination was demonstrated. In fact, cultures indicate a significantly greater percentage of Gram-negative pathogens in patients treated with the cerium mixture. Cerium nitrate could possibly prove of greatest benefit if used as a reserve therapy for colonizing organisms which do not routinely respond to silver sulfadiazine.

Proximity Penetrating Extremity Trauma: The Role of Duplex Ultrasound in the Detection of Occult Venous Injuries

The diagnosis and management of occult vascular injuries caused by penetrating proximity extremity trauma (PPET) remains controversial. Over 18 months, we prospectively screened 37 patients (43 lower extremities) with PPET for occult arterial and venous injuries using noninvasive studies (physical examination, ankle-brachial indices, color-flow duplex ultrasonography (CFD)) and angiography (arteriography, venography). Eight isolated, occult venous injuries were detected (incidence, 22%). CFD detected seven of eight (88%) venous injuries. Venography was technically difficult to perform in this patient population and failed to detect four femoral-popliteal vein injuries. Major thromboembolic complications (pulmonary embolism, symptomatic deep vein thrombosis, venous claudication) occurred in 50% of the patients identified with femoral-popliteal vein injuries. Arterial injuries were detected in 4 of 42 (10%) extremities (arteriography, n = 3; CFD, n = 1) and were clinically benign. We conclude that following PPET, (1) isolated, occult venous injuries are common and are associated with significant complications and (2) CFD is useful for screening for occult venous injuries.

Delayed diagnosis of duodenal rupture

BACKGROUND Although duodenal rupture is usually diagnosed during the course of surgery for other injuries, a small portion of such injuries occur in isolation. In such cases, the significance of the clinical and diagnostic findings may not be appreciated for an extended period. The primary determinant of mortality in duodenal rupture is the presence of associated injuries, but delay in diagnosis is often a secondary factor. METHODS A retrospective case review of 8 patients with isolated duodenal rupture that was diagnosed more than 24 hours following the injury. RESULTS In 5 cases, physicians did not look for the occult injury. In 3, patients did not seek medical attention. Two patients were initially treated with primary duodenal repair and drainage with poor results. All patients were eventually treated with pyloric exclusion that resulted in no deaths and no duodenal fistulas. Three patients developed abscesses after pyloric exclusion. They were drained without difficulty. CONCLUSION Pyloric exclusion appears to offer a satisfactory option for dealing with the inflammation and contamination that result from prolonged soilage by duodenal contents.

The interrelationships between wound management, thermal stress, energy metabolism, and temperature profiles of patients with burns

This prospective randomized study was performed to evaluate the metabolic and thermal responsiveness of patients with burns to thermal stress with three protocols of wound care: group I (n = 7) treated with dressings and variable ambient temperature selected for patients subjective comfort; group II (n = 7) treated without dressings and variable ambient temperature for patient comfort; group III (n = 6) treated without dressings and ambient temperature of 25 degrees C, electromagnetic heaters were set to achieve patient subjective comfort; and group IV (n = 6) healthy volunteers. After baseline partitional calorimetry was performed, individual patients were cold-challenged while subjectively comfortable by sequentially lowering either the ambient temperature or the output from the electromagnetic heaters. Heat balance and temperatures were obtained after each perturbation in external energy support. For patients in groups I and II, subjective perception of thermal comfort (warm, neutral, neutral and fed, cool, or cold) was more strongly correlated (p < 0.02) with the changes in the rate of heat production than the actual ambient temperature. For patients treated with electromagnetic heaters, changes in heat production were most strongly correlated with the energy output from the electromagnetic heaters. Even though the environmental conditions required to achieve a particular level of comfort are quite different between treatment groups, the difference in temperature between the patients surface and ambient is approximately the same for groups I, II, and IV for each subjective state.(ABSTRACT TRUNCATED AT 250 WORDS)

Ibuprofen lowers body temperature and metabolic rate of humans with burn injury.

A group of 15 burned children and young adults with large burns (mean, 41% +/- 15% BSA) were administered ibuprofen (40 mg/kg for 3 days). Each patient served as his or her own control in this crossover study (with and without ibuprofen). Paired calorimetric and temperature studies and urinary nitrogen measurements were performed. No nitrogen-sparing effect was identified for this dose of ibuprofen. However, patients demonstrated a statistically significant reduction in average rectal temperature (0.67 degrees C decreases) (p less than 0.01) and in metabolic rate (11.4% decreases) (p less than 0.01) while taking ibuprofen. Linear regression analysis of the reduction in temperature versus the reduction in metabolic rate yielded a statistically significant correlation (p less than 0.01) with a slope of 13.6% reduction in metabolic rate per degree centigrade reduction in the 72-hour average rectal temperature. These results support the hypothesis that ibuprofen attenuates the hypermetabolic response to thermal injury by blunting the temperature elevation that is usually seen.

Manipulation of the inflammatory response to burn injury

BACKGROUND Burn injury is characterized by hypermetabolism and protein catabolism. Endotoxin, derived from either wound or gut, may participate in this response. METHODS Eleven seriously burned patients were treated with the endotoxin-binding agent polymyxin B and underwent partitional calorimetry and nitrogen balance studies. The data from theses patients were compared with data from 28 contemporary, similarly burned patients who did not receive polymyxin B. RESULTS Elevated levels of circulating endotoxin were not consistently detected in either group. Interleukin-6 was elevated and correlated with rectal temperature and nitrogen excretion in both groups. Administration of polymyxin B produced no change in metabolic rate but produced a significantly more positive nitrogen balance and was associated with a prompt reduction in interleukin-6 levels. CONCLUSIONS These data support the hypothesis that endotoxin plays a role in the postburn protein catabolism but not in the hypermetabolic response. This protein catabolic response is statistically associated with circulating interleukin-6 levels, suggesting a possible role for interleukin-6 in postinjury protein wasting.