Robert R. Simon

Position and Diaphoresis in Acute Asthma

Presence of pulsus paradoxus, PCO2, sternocleidomastoid retraction, and flow rates have been used at the bedside to assess the severity of acute asthma. In our study of 49 adult patients, pulse rate, respiratory rate and pulsus paradoxus were shown to be significantly higher in patients assuming the upright position on admission to the emergency center; arterial pH, PO2, and peak expiratory flow rate were significantly lower in the upright patients. All upright patients had sternocleidomastoid retraction. Peak expiratory flow rate was 73.3 +/- 5 liters per minute in diaphoretic patients, 134 +/- 21 liters per minute in non-diaphoretic, upright patients, and 225 +/- 7.5 liters per minute in recumbent patients (p less than 0.02). No recumbent patient had a peak expiratory flow rate of less than 150 liters per minute or a PCO2 of greater than 44 mm Hg. The index of Fischl, signifying a need for admission to the hospital if greater than 4, was 4 or higher in 70 percent of upright patients and in 88 percent of diaphoretic patients. Only 7 percent of recumbent patients had Fischi indexes of greater than 4.

Subungual hematoma: Association with occult laceration requiring repair

Subungual hematomas are one of the most common injuries involving the hand. On conducting a literature search, we were unable to find any studies that investigated the association between subungual hematomas, fractures, and the presence of an occult laceration of the nail bed requiring repair. Forty-seven consecutive patients who presented to the emergency department with subungual hematoma involving more than one fourth of the nail bed were included in this study. In these cases, radiographs were taken, and the nail was lifted to look for a laceration. In the subgroup of patients who had subungual hematoma associated with a fracture, all of them had a laceration requiring repair. Patients with a subungual hematoma greater than one half of the size of the nail bed had a 60% incidence of a laceration requiring repair. The authors believe that patients presenting with a subungual hematoma involving greater than one half of the nail surface and a fracture of the distal phalanx should have the nail lifted and the nail bed explored and repaired.

Management of Salicylate Intoxication

SummarySalicylate intoxication is common. It results in impaired generation of adenosine triphosphate and produces a primary respiratory alkalosis. In adults the clinical manifestations may closely simulate a cerebrovascular event or alcoholic ketoacidosis. Central nervous system dysfunction, fever, glycosuria, ketonuria, respiratory alkalosis with an elevated anion gap, tinnitus, dehydration, hypokalemia and haemostatic defects are common. The diagnosis may be made rapidly by the ferric chloride test or Phenistix® test.Standard therapy includes gastric emptying, activated charcoal and alkalinisation of the urine. Osmotic diuresis is a controversial measure. Haemodialysis is indicated for patients with serum salicylate levels more than 100 mg/100ml, severe acid-base disturbance, or deterioration despite optimum therapy.

Moisture-vapour-permeable film as an outpatient burn dressing

This study compares a moisture-vapour-permeable film (MVPF) with silver sulphadiazine in a randomized prospective manner for the treatment of outpatient burns. The two treatment groups were closely matched in age, sex, per cent of BSA burned, and in burn severity and locations. The MVPF group demonstrated a 39.0 per cent greater reduction in pain after application of the dressing over the silver sulphadiazine group. Patients in the MVPF film group also reported significantly less difficulty in wound care and in dressing interference with their daily functions. The clinical infection rate and time to healing were similar in both groups. In the management of outpatient burns, MVPF was found to be superior to silver sulphadiazine.

A new technique for securing a chest tube

Most techniques described for securing a chest tube in position do not discuss closing the orifice in the chest wall after removal of the tube. An air tight closure of the chest wall and good approximation of the wound edges after removal of the chest tube must be done to prevent complications and obtain a cosmetically good scar. A technique for securing a chest tube is described that permits excellent approximation of the wound edges upon removal.

Cephalic vein cutdown at the wrist: Comparison to the standard saphenous vein ankle cutdown

We first developed a technique for cutdown of the cephalic vein at the wrist. We then conducted a prospective cross-over cadaver study comparing the ability of medical students to perform this technique with that of the standard saphenous vein cutdown at the ankle. All students had a previous course in anatomy but had never performed a cutdown. Before testing, the students were given written material and a ten-minute lecture describing both approaches. Seventeen students performed 34 cutdowns; nine students attempted the cephalic cutdown followed by the saphenous cutdown; the remaining eight used the reverse order. The mean time (+/- SD) to isolation of the cephalic vein was 85 +/- 70 seconds; for the saphenous vein, mean time was 70 +/- 89 seconds (P = NS). There was one failure (inability to isolate the vein within five minutes) in 17 attempts at the cephalic vein and two failures in 17 attempts at the saphenous (P = NS). There were no complications (nerve, artery, or tendon injury) with either technique. The mean external vein diameter (+/- SD) of the cephalic vein and the saphenous vein were 3.2 +/- 1.0 mm and 3.6 +/- 0.7 mm, respectively (P = NS). We conclude that relatively inexperienced providers can learn to perform the cephalic vein cutdown at the wrist on fresh cadavers with similar speed and success as that for the saphenous vein cutdown at the ankle. Cutdown at this site may provide a useful alternative to the saphenous cutdown in certain clinical situations.

Surgical Theatre in Rural Afghanistan

We discuss the establishment of underground surgical theatres in resistance-held, rural Afghanistan by the IMC. The limitations of working in facilities without electricity or modern surgical equipment or even adequate suction are discussed, and the methods we have implemented to deal with these limitations are presented.

Logistics of medical care in rural Afghanistan

The logistics of maintaining and supplying underground clinics located in war-torn rural Afghanistan are presented. Medical supplies are transported by pack animals over mountainous terrain, and must be specially packaged for the rigorous journey. Twenty percent of supplies are lost en route due to attacks or accidents. Medical and surgical equipment, some of which had to be specially designed, must be lightweight and durable. The system of monitoring clinic efficacy is also discussed.

Radiographic comparison of plain films in second- and third-degree ankle sprains

A literature search failed to demonstrate any investigations of the plain films of the ankle to determine whether there were any measurable differences in the ankle mortise, which would differentiate between a second and a third degree ankle sprain, thus obviating the need for stress views. In this study, the authors independently measured the distances between the talus and tibia at eight predetermined sites on the lateral and mortise views. This was done blindly so that neither author knew which cases were second- or third-degree ankle sprains. Only definite third-degree ankle sprains, as defined by a positive anterior drawer sign and/or a positive inversion stress test result on clinical evaluation, were included. The authors found there was severe interobserver variability. The authors thus feel that there is no clinically significant measurement on plain films of the ankle that can be used to differentiate accurately between second and third degree ankle sprains, and current reliance on clinical findings and subsequent stress x-ray films is appropriate and must remain the non-operative standard for evaluation of this problem.

Emergency cricothyroidotomy in the patient with massive neck swelling. Part 2: Clinical aspects.

A technique has been described for emergency tracheotomy in a patient with massive neck swelling which utilizes the hyoid bone to permit localization of the midline of the neck and manual surgical traction of the larynx. The method for localizing the hyoid bone in a patient with massive neck swelling requires only one measurement to be taken: from the angle of the mandible to the mental protuberance. From this measurement, one can locate the hyoid bone with ease. This procedure has been performed in 5 cadavers and 7 patients with excellent results, providing rapid access to the airway within less than 2 min. The authors believe that the procedure permits rapid access to the airway in patients with massive neck swelling in whom emergency tracheotomy or cricothyroidotomy is difficult and time consuming.