Riyad Karmy-Jones

Magnesium sulfate prophylaxis after cardiac operations

One hundred patients undergoing elective cardiac operations were randomized into placebo (n = 54) and magnesium (n = 46) groups. The magnesium group received six doses of 2.4 g (19.2 mEq) magnesium sulfate intravenously in the first 24 hours after the cardiac operation. The magnesium group had higher serum magnesium concentrations postoperatively (1.09 +/- 0.20 versus 0.75 +/- 0.13 mmol/L; p < 0.0001), postoperative day 1 (1.49 +/- 0.34 versus 0.70 +/- 0.12 mmol/L; p < 0.0001) and postoperative day 2 (0.96 +/- 0.19 versus 0.76 +/- 0.07 mmol/L; p < 0.0001). Patients in the magnesium group had a lower incidence of ventricular tachyarrythmias (VTs) (17.3% versus 51.9%; p = 0.0006), less need for treatment (6.5% versus 20.3%; p < 0.0001), fewer VT episodes/patient (0.3 +/- 0.8 versus 1.39 +/- 1.9; p < 0.0001), and a reduction in the severity of VTs as measured by the modified Lown grade (p = 0.0002). No differences were demonstrated with respect to supraventricular tachyarrythmias. The magnesium group had reduced absolute creatine kinase-MB levels (5.3 +/- 4.2 versus 28.4 +/- 28 IU/L; p = 0.001) as well as creatine kinase-MB fraction (0.01 +/- 0.02 versus 0.05 +/- 0.04; p = 0.001) on postoperative day 1. Serum magnesium concentrations were lower during VTs than during periods of sinus rhythm (0.75 +/- 0.75 versus 1.02 +/- 0.35 mmol/L; p < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Endovascular repair compared with operative repair of traumatic rupture of the thoracic aorta: a nonsystematic review and a plea for trauma-specific reporting guidelines.

BACKGROUNDnThoracic endovascular aortic repair (TEVAR) has become the preferred intervention for managing traumatic thoracic aortic injury. The literature suggests that TEVAR is associated with reduced mortality and paraplegia compared with open repair (OR). The lack of guidelines for reporting results and the paucity of patient follow-up make interpretation of the literature difficult.nnnMETHODSnA literature review of English language papers on thoracic aortic trauma published between 2005 and 2010 was performed. Papers were analyzed to determine how many commented on injury data known to affect outcome (age, hemodynamic stability, injury severity, degree of aortic injury, etc.).nnnRESULTSnSixty-two retrospective reviews and six meta-analysis papers were identified. Of the review papers, only 6.4% described aortic anatomy using standard criteria, only 25.8% reported the degree of aortic injury, only 19.4% defined early or emergent intervention, only 32.3% provided details regarding hemodynamic stability, and only 56.5% described injury severity by Injury Severity Score. In a subset analysis of papers containing trauma relevant data, comparing TEVAR with OR, the TEVAR population was older, whereas the OR group was more often unstable. TEVAR had a significantly lower mortality, a trend to reduction in paralysis, but a significantly increased stroke rate. Follow-up was minimal in both groups.nnnCONCLUSIONnThe lack of reporting guidelines coupled with a paucity of follow-up data weakens any recommendation regarding the optimal choice of intervention. To address these deficiencies, we recommend reporting guidelines specific to the trauma population that will allow better risk adjustment and improve the quality of the evidence base.

Surgical management of lung gangrene.

OBJECTIVEnTo review the outcomes of five cases of pulmonary resection for lung gangrene.nnnDESIGNnA retrospective chart review.nnnSETTINGnA tertiary referral centre.nnnPOPULATION STUDIEDnFive patients who underwent pulmonary resection for lung gangrene between April and December 1999.nnnMAIN RESULTSnPathological confirmation of lung gangrene was obtained in all cases. Three patients were ventilator dependent. All five patients had ongoing sepsis despite antibiotic therapy. Additional indications for resection included bronchopleural fistula (two patients), empyema (three patients) and hemoptysis (one patient). In two cases, there was evidence of bilateral, diffuse necrotizing pneumonia, while in three cases the process was localized to one side. Computed tomography revealed cavitation in four cases and the absence of blood supply to the affected lung in one case. Surgical resection included wedge resection (one patient), lobectomy (two patients), bilobectomy (one patient) and pneumonectomy (one patient). In all cases, the bronchial stump was reinforced with an intercostal flap. Postoperative empyema occurred in two cases, one treated by thoracoscopic decortication, the other by percutaneous drainage. There were no instances of stump leak and no deaths. One patient remains ventilator dependent.nnnCONCLUSIONSnResection for lung gangrene is possible even in the setting of diffuse parenchymal changes and ventilator dependency. A computed tomography scan of the chest is important to make the diagnosis of lung gangrene and to plan operative management. Reinforcement of the bronchial stump is critical.

Carcinoid crisis after biopsy of a bronchial carcinoid

Pulmonary carcinoids are rarely associated with carcinoid syndromes and even less commonly with carcinoid crisis. Somatostatin analogues can control carcinoid syndrome or crisis with tumors of gastrointestinal origin. We report the successful use of a somatostatin analogue in preventing carcinoid crisis at the time of resection of an active bronchial carcinoid tumor.

Cardiopulmonary bypass for resuscitation after penetrating cardiac trauma

Cardiopulmonary bypass is only occasionally required acutely in the management of penetrating cardiac injuries, usually to allow coronary grafting. We describe a case of penetrating trauma in which cardiopulmonary bypass was used to resuscitate a patient whose cardiac lacerations were controlled in the emergency department.

Esophageal-pericardial fistula with purulent pericarditis secondary to esophageal carcinoma presenting with tamponade

A case of esophago-pericardial fistula secondary to esophageal carcinoma causing pericardial effusion and tamponade is presented. Palliation can be achieved effectively by limited thoracotomy, pericardial resection and drainage, and in selected cases esophageal stenting.

Colobronchial fistula due to Crohn's disease

Enteropulmonary fistulas may present as recurrent localized pneumonia. A case of one such fistula originating from the colon in a patient with Crohns disease is discussed.

Chronic traumatic and congenital diaphragmatic hernias: presentation and surgical management.

BACKGROUNDnThe diagnosis of chronic diaphragmatic hernias, whether due to congenital defects or trauma, may be difficult to make and may rely on clinical suspicion in the setting of persistent nondiagnostic radiographic findings. Repair is indicated to avoid catastrophic cardiopulmonary compromise and/or incarceration of abdominal organs.nnnSTUDY OBJECTIVESnTo review the varied presentations and treatment of chronic diaphragmatic hernia.nnnDESIGNnRetrospective review.nnnSETTINGnUniversity of Washington and Harborview Medical Center, Seattle, Washington.nnnPATIENTSnBetween 1997 and 2001, nine patients presented with chronic diaphragmatic hernia (two congenital cases, seven post-traumatic cases). Four cases involved the right diaphragm. The following clinical features were noted: asymptomatic, chest radiograph showing bowel herniation (n=1); chest wall mass (n=1); asymptomatic with the chest radiograph showing marked elevation of hemidiaphragm (n=1); dyspnea with the chest radiograph showing marked elevation of hemidiaphragm (n=1); diarrhea and heartburn (n=1); generalized gastrointestinal upset (n=1); recurrent pneumonia (n=2); recurring effusions (n=4); and dyspnea on exertion (n=5).nnnINTERVENTIONSnDiagnosis was confirmed by chest radiograph in two patients, chest computed tomography scan in one patient, barium studies in three patients and thoracoscopy in three patients. All hernias were repaired via thoracotomy, and two hernias were repaired with artificial patch.nnnCONCLUSIONSnPatients with chronic diaphragmatic hernias present with a variety of symptoms and radiographic findings. When radiology or symptoms suggest bowel involvement, barium studies are appropriate. In other cases, chest computed tomography scans and/or thoracoscopy are useful. Repair is accomplished through the ipsilateral chest, with primary repair of the diaphragm preferred over patch repair.

Management of pulmonary embolism with rheolytic thrombectomy

BACKGROUNDnCatheter thrombectomy combining thrombus destruction with local thrombolysis has been used in patients with pulmonary embolism (PE) who are unstable or have significant right heart dysfunction, but have contraindications to systemic thrombolytic therapy.nnnOBJECTIVESnTo assess the outcomes of patients who underwent pulmonary embolectomy using a commercially available thrombectomy device.nnnMETHODSnA retrospective chart review of patients who underwent pulmonary embolectomy between March 2007 and August 2009 was performed. Patients were classified as having clinical massive or submassive PE, and moderate or severe right ventricular dysfunction. Data collected included pre- and postprocedure shock index (heart rate divided by systolic blood pressure) and mean pulmonary artery pressure.nnnRESULTSnSixteen patients with a mean (± SD) age of 54.4 ± 15.8 years underwent embolectomy. Five had clinical massive PE (two in cardiogenic shock) and three of 11 submassive cases had severe right ventricular dysfunction. All were deemed to have contraindications to systemic lysis. Both shock index (1.02 ± 33 preintervention versus 0.71 ± 0.2 postintervention [P=0.001]) and mean pulmonary artery pressure (34.5 ± 9.9 mmHg preintervention versus 27.1 ± 7.1 postintervention [P=0.01]) improved. In the massive PE group, one patient died and two survivors experienced retroperitoneal bleeding and transient renal failure. At follow-up (17.3 ± 7.8 months), two patients in the massive PE group demonstrated evidence of mild cor pulmonale.nnnCONCLUSIONnRheolytic thrombectomy is an effective strategy in managing massive PE, particularly in patients who have well-defined contraindications to systemic lytic therapy. The effectiveness of rheolytic thrombectomy for submassive PE is not as well defined, but warrants a comparison with systemic lytic therapy.

Thoracic trauma and critical care

Section 1: Underlying Principles. 1.1. Trauma Scores: Recent Advances S.M. Fakhry, N.A. Khan. 1.2. Care of the Multiple Injured Patient with Thoracic Trauma F.N. Obeid, et al. 1.3. Assessing Adequacy of Resuscitation R. Nirula, L.M. Gentilello. 1.4. Reperfusion Injury T.H. Pohlman. Section 2: Thoracostomy, Thorascopy and Thoracotomy. 2.1. Tube Thoracostomy J. Cuschieri. 2.2. Incisions and Approaches for Thoracic Trauma M.S. Farber, F.N. Obeid. 2.3. Emergency Department Thoracotomy: Indications and Outcomes A. Goldin, et al. 2.4. Urgent Thoracotomy M. Rosengart, R. Karmy-Jones. 2.5. Abbreviated Thoracotomy: The Evolving Role of Damage Control in Thoracic Trauma D.J. DiBardino, S.I. Brundage. 2.6. Transmediastinal Gunshot Wounds D.V. Shatz, R.J. Serurola Jr. 2.7. The Role of Thoracoscopy in Chest Trauma J. Monson, R. Karmy-Jones. 2.8. Management of Retained Hemothorax D. Gourlay. 2.9. Open Chest Human Cardiopulmonary Resuscitation M.E. Boczar, E.P. Rivers. Section 3: Pulmonary and Airway Emergencies. 3.1. Penetrating Lung Injuries K. Kralovich. 3.2. Tracheobroncial Injuries D. Wood. 3.3. Traumatic Asphyxia J. Cushieri. 3.4. Primary Pulmonary Blast Injury R. DuBose, R. Karmy-Jones. 3.5. Inhalation Injury G.J. Bauer, et al. 3.6. Thoracic Missile Emboli and Retained Bullets J.B. Kortbeek, et al. 3.7. Imaging of Blunt and Penetrating Trauma to the Pulmonary Parenchyma. 3.8. Surgical Management of Airway Obstruction D.E. Wood. 3.9. Complications of Lung Transplantation M.S. Mulligan. 3.10. Air Ambolism D. Oxorn. 3.11. Massive Hemoptysis C.J. McNamee, et al. 3.12. Tracheo-Inominate Artery Fistula B. Achen, et al. 3.13. PA Catheter Induced Hemoptysis C.J. McNamee, et al. 3.14. Re-expansion Pulmonary Edema K. Wagner, G.D. Trachiotis. 3.15. Postpneumonectomy Pulmonary Edema J. Urschel. 3.16. The Sonographic Detection of Pneumothoraces A.W. Kirkpatrick, S. Nicolaou. Section 4: Chest Wall Trauma. 4.1. Pulmonary Contusion S. Sattler, R.V. Maier. 4.2. Reconstruction of Complex Chest Wall Defects C.A. White, F.F. Isik. 4.3. Burns of the Chest Wall N. Gibran. 4.4. Traumatic Lung Hernia L.S. Kao. 4.5. Diaphragmatic Injuries V.J. Sorenson. Section 5: Esophageal Emergencies. 5.1. Caustic Injury of the Esophagus T. Eubanks. 5.2. Esophageal Perforation and Injury L. Kao, R. Karmy-Jones. Section 6: Cardiovascular Emergencies. 6.1. Blunt Cardiac Injury W.L. Biffl, E.E. Moore. 6.2. Blunt Cerebrovascular Trauma L.A. Nelson, et al. 6.3. Penetrating Cardiac Injuries S. Worrell, R. Karmy-Jones. 6.4. Management of Great Vessel Injuries S.C. Nicholls. 6.5. Blunt Thoracic Aortic Injuries: Diagnosis J. Borsa. 6.6. Operative Management of Blunt Thoracic Aortic Injuries