William B. Long

Clinical indications for cervical spine radiographs in the traumatized patient

During a 4 1/2 year period, 4,941 trauma patients were admitted to a hospital, and details of their injuries and treatment were entered in a computerized trauma registry. Using that database, patients with cervical spine injury were studied. Of the 4,941 patients, 1,823 (38 percent) had radiographs of the cervical spine. Ninety-four patients (5 percent) of these patients had injuries of the cervical spine or spinal cord. Sixty five of the 94 patients with cervical spine injury were alert. All had either neck pain or neck tenderness. We do not recommend screening cervical spine radiographs for the alert trauma patient without neck pain; however, we do recommend screening for all patients with decreased levels of consciousness and an injury that could have conceivably injured the cervical spine, for all patients with neurologic deficits compatible with a cervical origin, and for all patients with neck pain or tenderness. Lateral cervical spine radiographs were obtained in all injured patients. They demonstrated cervical spine injury in 70 patients (74 percent) and missed the injury in the remaining 24, which resulted in an unacceptable false-negative rate of 26 percent. We believe that all patients at risk for cervical spine injuries must have complete radiographic examinations of the cervical spine. Computerized axial tomography was the most useful modality to confirm a cervical spine injury in those patients whose lateral cervical spines appeared normal radiographically, especially in patients with associated head injury requiring computerized axial tomography of the brain. Computerized axial tomography diagnosed the injury in 14 of the 24 patients requiring study beyond initial screening. Also presented herein is a radiologic screening algorithm for cervical spine injuries in trauma patients.

Prognostic factors in severe accidental hypothermia: experience from the Mt. Hood tragedy

The May 1986 Mt. Hood climbing disaster presented Portland area hospitals the opportunity to initiate a trial of extracorporeal rewarming using cardiopulmonary bypass in ten severely hypothermic patients (two survivors). The data from this experience as well as others previously reported can yield prognostic indicators of survival in cases of accidental hypothermia. These are demonstrated to include: the presence of underlying medical illness, duration of cold exposure, initial core temperature, mental status, the presence of spontaneous respirations, presenting cardiac rate and rhythm, and arterial oxygen tension. Profound hyperkalemia and markedly elevated serum ammonia levels indicate cell lysis; significant hypofibrinogenemia suggests intravascular thrombosis and each laboratory marker predicts a dire outcome. The treatment of choice for severe accidental hypothermia is felt to be rapid core rewarming on cardiopulmonary bypass.

Patterns of injury in helmeted and nonhelmeted motorcyclists

In the present study, the incidence of severe brain injury was 600 percent higher for patients riding without a helmet and the incidence of all brain injuries was nearly twice as high in the nonhelmeted riders. All surviving patients with severe brain injury sustained residual long-term disability. The incidence of injury and death was much higher for motorcyclists than for occupants of automobiles involved in accidents. Riding a motorcycle is dangerous and riding without a helmet is fool-hardy. Helmets also protect the face, as facial fractures were twice as common in the nonhelmeted riders. There were no significant differences between nonhelmeted and helmeted motorcyclists in terms of overall injury as measured by an injury severity score of 16 or greater. Orthopedic injuries, in this study, were so common that orthopedic surgeons performed more major operations than all other surgical specialists combined. Depth of orthopedic coverage is essential to treat significant numbers of injured motorcyclists. Neurosurgeons are key members of a trauma care team. Helmet laws would help us utilize our limited neurosurgical capacity more effectively by reducing the incidence of brain injury. Medical professionals must educate the public regarding the societal and personal cost of unhelmeted motorcycle riding. Legislation mandating helmet usage for motorcycle riders must be sought.

Extracorporeal cardiopulmonary life support with heparin-bonded circuitry in the resuscitation of massively injured trauma patients*

BACKGROUND Patients who have massive but potentially survivable injuries frequently die from complications of hypovolemia, hypoxemia, hypothermia, metabolic acidosis, and coagulopathy. Emergency cardiopulmonary bypass has been unsuccessful in preventing such deaths because it involves systemic anticoagulation that exacerbates coagulopathy. PATIENTS AND METHODS A simplified extracorporeal cardiopulmonary life support (ECLS) system was assembled consisting of a centrifugal pump head, heat exchanger, membranous oxygenator, percutaneous cannulas, and heparin-bonded circuitry. The entire system has heparin-bonded surfaces. Patients were resuscitated with the system after femoral vein-femoral artery cannulation. ECLS was used to resuscitate massively injured patients who were deteriorating despite maximal conventional therapy. RESULTS While receiving maximal conventional therapy, 6 patients developed hypothermia, metabolic acidosis, and coagulopathy causing pulmonary hemorrhaging and hypoxemia from severe underlying lung injuries. ECLS with heparin-bonded circuitry provided cardiopulmonary support and rewarming while physicians addressed coagulopathies and surgical bleeding and assessed survivability. Three patients survived. CONCLUSIONS ECLS with heparin-bonded circuitry offers supplemental capability in the resuscitation and cardiopulmonary support of selected massively injured patients while their primary injuries are being evaluated and treated.

MODERN CONCEPTS OF THE DIAGNOSIS AND TREATMENT OF NECROTIZING FASCIITIS

BACKGROUND Necrotizing fasciitis is a potentially fatal infection involving rapidly progressive, widespread necrosis of the superficial fascia. OBJECTIVES The purpose of this collective review is to review modern concepts of the treatment and diagnosis of necrotizing fasciitis. DISCUSSION Necrotizing fasciitis is characterized by widespread necrosis of the subcutaneous tissue and the fascia. Although the pathogenesis of necrotizing fasciitis is still open to speculation, the rapid and destructive clinical course of necrotizing fasciitis is thought to be due to multibacterial symbiosis. During the last two decades, scientists have found that the pathogenesis of necrotizing fasciitis is usually polymicrobial, rather than monomicrobial. Although there has been no published well-controlled, clinical trial comparing the efficacies of various diagnostic imaging modalities in the diagnosis of necrotizing infections, magnetic resonance imaging (MRI) is the preferred technique to detect soft tissue infection. MRI provides unsurpassed soft tissue contrast and spatial resolution, has high sensitivity in detecting soft tissue fluid, and has multiplanar capabilities. Percutaneous needle aspiration followed by prompt Grams staining and culture for a rapid bacteriologic diagnosis in soft tissue infections is recommended. Surgery complemented by antibiotics is the primary treatment of necrotizing fasciitis. CONCLUSION Wide, extensive debridement of all tissues that can be easily elevated off the fascia with gentle pressure should be undertaken. Successful use of intravenous immunoglobulin has been reported in the treatment of streptococcal toxic shock syndrome. The use of adjunctive therapies, such as hyperbaric oxygen therapy, for necrotizing fasciitis infection continues to receive much attention.

REVOLUTIONARY ADVANCES IN THE MANAGEMENT OF TRAUMATIC WOUNDS IN THE EMERGENCY DEPARTMENT DURING THE LAST 40 YEARS: PART I

BACKGROUND AND OBJECTIVES This report provides an overview of advances in wound repair devised by our research team during the last four decades. This collective review is presented in two parts. DISCUSSION The following components are included in Part I: 1) search and treat life-threatening trauma; 2) conduct a thorough history; 3) examine the wound using aseptic technique; 4) anesthetize the wound before cleansing; 5) hair removal, skin disinfection, hemostasis, surgical debridement, and mechanical cleansing; 6) antibiotics, drains, and open wound management. CONCLUSION On the basis of these comprehensive research studies, we have noted a marked reduction in the incidence of wound infection in traumatic wounds.

Adult refractory hypoxemic acute respiratory distress syndrome treated with extracorporeal membrane oxygenation: the role of a regional referral center

BACKGROUND The investigators present a series of adults with severe acute respiratory distress syndrome (ARDS) who were treated with extracorporeal membrane oxygenation (ECMO) at a regional referral center. METHODS Patients with refractory hypoxic ARDS received ECMO until they recovered lung function or demonstrated futility. ECMO was initiated at the referring facility if necessary, and aggressive critical care was maintained throughout. RESULTS ARDS due to multiple etiologies was managed with ECMO in 36 adults. The pre-ECMO ratio of partial pressure of oxygen to fraction of inspired oxygen was 48.3 ± 2.2. Regional facilities referred 89% of these patients, and 69% required ECMO for transport. The mean duration of ECMO was 7.1 ± .9 days for survivors, and the mean post-ECMO ratio of partial pressure of oxygen to fraction of inspired oxygen was 281.2 ± 11. ECMO was successfully weaned in 67% of patients, and 60% survived to discharge. CONCLUSIONS ECMO provides support that prevents ventilator-induced lung injury while the lungs heal. The investigators present a series of 36 adults with refractory hypoxemic ARDS (ratio of partial pressure of oxygen to fraction of inspired oxygen <50) from 17 different facilities who, treated with ECMO at a single referral center, had a 60% survival rate.

Dangers of cornstarch powder on medical gloves: seeking a solution.

This article reviews information on the hazards of cornstarch powder on medical gloves. Dusting powders were first applied to latex gloves to facilitate donning. After 1980, manufacturers devised innovative techniques without dusting powder. It has been well documented that these powders on gloves present a health hazard to patients and health care workers by 5 different mechanisms. First, the glove cornstarch has documented detrimental effects on wound closure techniques. Second, this powder potentiates wound infection. Third, cornstarch induces peritoneal adhesion formation and granulomatous peritonitis. Finally, these powders serve as carriers as latex allergen and they precipitate a life-threatening allergic reaction in sensitized patients. These well-documented hazards of glove powder have caused the United Kingdom and Germany to ban cornstarch powder on medical gloves over 10 years ago.

Aprotinin use in patients with dialysis-dependent renal failure undergoing cardiac operations ☆ ☆☆ ★ ★★ ♢ ♢♢

closure technique. Histologically, it was proved in these patients that the cancer affected only the external layer of the aortic wall. CT was a feasible means of judging whether malignant tumor had invaded the aorta by observing the motion of the tumors along the aortic wall. This method could be used for either purpose-to discriminate T4 tumors from others as a contraindication for resection or to devise a strategy for concomitant resection of the aorta. Provided an invaded portion of the aorta, which is in contact with the immobile surface of a tumor, has been revealed clearly before the operation, a circulatory bypass and prosthesis required for resection and replacement of the wall can be arranged appropriately. In our seven cases, we took advantage of the new imaging modality in this way. In our series, one tumor in contact with the distal arch was erroneously judged to be invasive. The most likely reason for this misdiagnosis was that the tumor was located on the distal arch near the pulmonary hilus and thus showed barely detectable upward and downward motion during breathing. For the same reason, a noninvasive tumor located on the diaphragm near the pulmonary ligament might be judged invasive by mistake. To avoid such misdiagnoses of pulmonary tumors located on the distal arch or diaphragm, the investigator should use the heartbeat mode as well as the breathing mode for more accurate evaluation, rather than using the breathing mode alone. It is still difficult to discriminate between invasion and fibrous adhesion. We believe that cine CT should reveal malignant adhesion distinctly, because such invasion shows tougher attachment with less mobility than simple fibrous adhesion. A study including more patients will be required to address this issue.

Citizen's Petition to Food and Drug Administration to ban cornstarch powder on medical gloves: Maltese cross birefringence

BACKGROUND During the last 25 years, scientific experimental and clinical studies have documented the dangers of cornstarch powder on examination and surgical gloves because the cornstarch promotes wound infection, causes serious peritoneal adhesions and granulomatous peritonitis, and is a well-documented vector of the latex allergy epidemic in the world. Realizing the dangers of cornstarch on examination and surgical gloves, Germanys regulations of personal protective equipment banned the use of surgical glove powder cornstarch in 1997. In 2000, the Purchasing and Supply agency for the United Kingdom ceased to purchase any gloves lubricated with cornstarch. DISCUSSION Realizing the dangers of cornstarch-powdered gloves, many hospitals and clinics in the United States have banned the use of cornstarch-powdered examination and surgical gloves. Hospitals that have banned cornstarch in their examination and surgical gloves have noted a marked reduction in the latex allergy epidemic in their facilities. Realizing the dangers of cornstarch-powdered examination and surgical gloves, Dr Sheila A. Murphey, branch chief, Infection Control Devices Branch, Division of Anesthesiology, General Hospital, Infection Control, and Dental Devices Office of Device Evaluation, Center for Devices and Radiological Health of the Food and Drug Administration (FDA), recommended that a Citizens Petition be filed to the FDA to ban cornstarch on surgical and examination gloves. CONCLUSION The 12 authors of this report have attached the enclosed petition to the FDA to ban the use of cornstarch on all synthetic and latex examination and surgical gloves used in the United States.