Delayed fatal hemothorax due to traumatic carotid dissection: a case report of a previously unreported cause of death

A unique case of delayed fatal hemothorax in a 12-year-old girl resulting from atypical dissection of a traumatic carotid aneurysm is reported, due to occult neck trauma received in a sledding accident which occurred one week prior to death. Aspects of traumatic carotid dissection and forensic implications of delayed presentation of such findings in the setting of occult trauma are discussed.

Commotio cordis in two amateur ice hockey players despite the use of commercial chest protectors: case reports

We describe two recent deaths in 15-year-old male ice hockey players. Both adolescents died of commotio cordis from chest impacts by ice hockey pucks despite their use of commercially designed and manufactured chest protectors. Commotio cordis is discussed as a preventable sports-related injury in the adolescent age group, and the need for improved chest protective equipment in preventing such injuries is also examined.

An unusual entrance wound associated with rimfire rifles

In many cases of self-inflicted contact wounds of the head with rimfire rifles, we have noted that the entrance wound appears unusual: in 50% of cases studied, a pencil-like extension or zone of blackened and seared skin extends downward from the entrance. The most probable cause for the appearance of this wound is a momentary break in contact between the muzzle and skin as the victim reaches for the trigger with resultant escape of a jet of hot sooty gas. Whereas not unique for rimfire rifles, such a wound from a handgun is uncommon.

Clinical considerations for the use of intravenous nicardipine in the treatment of postoperative hypertension

The incidence of postoperative hypertension after both cardiac and noncardiac surgery is a major concern. alpha-Adrenergic-blocking drugs, such as phentolamine, and direct-acting vasodilators, such as nitroglycerin and nitroprusside, are commonly used to treat hypertension. Nifedipine, a calcium channel blocker, may also be used, but because no intravenous preparation is available, its effects are not titratable. A new short-acting calcium channel blocker, nicardipine, is a potent vasodilator and produces more selective responses in the coronary versus the systemic vascular circulation. It is an effective cerebral vasodilator, increasing cerebral blood flow and oxygen delivery. Nicardipine can be administered as an intravenous loading infusion of 10 to 15 mg/hr for 25 minutes, followed by a maintenance infusion of 3 to 5 mg/hr. Nicardipine has a short duration factor, is easily titratable and is as effective as nitroglycerin or nitroprusside in the control of hypertension. In summary, nicardipine has many properties of an ideal drug for the treatment of postoperative hypertension.

Effects of doxacurium chloride on biventricular cardiac function in patients with cardiac disease

The effects of doxacurium chloride, a new long-acting non-depolarizing neuromuscular blocking drug, on cardiac performance were studied in 45 patients undergoing high-dose fentanyl-diazepam-oxygen anaesthesia for cardiac surgery. Data were collected at baseline (10 min after tracheal intubation), and at 2, 5 and 10 min after an i.v. bolus of doxacurium with a rapid-response thermistor pulmonary arterial catheter, using two-dimensional transoesophageal echocardiography, and direct arterial pressure measurement. The patients were allocated to four groups based on the type of surgery and dose of doxacurium (0.05 or 0.08 mg kg-1). No changes in left or right ventricular dimensions or contractility were detected in any group. Although significant changes (P less than 0.05) occurred in several groups, all these changes were clinically insignificant (less than 10% change from baseline values), and were similar to those seen in unstimulated anaesthetized patients. Doxacurium appears to be a safe drug for use in patients undergoing cardiac surgery, and is devoid of significant cardiovascular side effects in the doses tested.

Hemodynamic effects of verapamil during fentanyl-nitrous oxide anesthesia

The hemodynamic effects of a verapamil infusion were investigated in six dogs given fentanyl-nitrous oxide anesthesia. Verapamil, 0.2 mg/kg, was given followed by an infusion of 3, 6, and 9 micrograms/kg per minute, which produced plasma verapamil concentrations ranging from 98 to 204 ng/ml. Verapamil significantly reduced the systemic vascular resistance index and mean arterial pressure. The decrease in afterload led to an increase in cardiac index, since there was little change in myocardial contractility (LV dP/dt). Administration of calcium chloride, 20 mg/kg, did not reverse the hemodynamic effects of verapamil. The data indicate that in dogs verapamil can be given, even in high concentrations, during fentanyl-nitrous oxide anesthesia without serious adverse electrophysiologic or hemodynamic consequences.

Cardiovascular effects of a nifedipine infusion during fentanyl-nitrous oxide anesthesia in dogs

The hemodynamic effects of a nifedipine infusion were investigated in eight dogs given fentanyl/pancuronium/nitrous oxide/oxygen anesthesia. Nifedipine (20 micrograms/kg) was given intravenously over two minutes immediately prior to each 30-minute infusion at 2 micrograms/kg/min, 4 micrograms/kg/min, and 6 micrograms/kg/min. The range of plasma nifedipine levels obtained was 52.1 to 113.7 ng/mL. The predominant hemodynamic effects were significant reductions in systemic vascular resistance (SVR) and mean aortic pressure (MAP), accompanied by a rise in cardiac index and heart rate (HR). Administration of calcium chloride (20 mg/kg) after the nifedipine infusion had no effect on SVR or MAP, but HR was significantly reduced. Serum epinephrine and norepinephrine levels increased after the infusion of nifedipine and suggested that fentanyl did not completely overcome the sympathetic response to the profound vasodilatation. The resulting tachycardia in combination with diastolic hypotension from nifedipine could have a detrimental effect on the myocardial oxygen balance.

Comparative hemodynamic effects of labetalol and hydralazine in the treatment of postoperative hypertension

The antihypertensive efficacy and safety of IV labetalol were evaluated and compared with the efficacy and safety of IV hydralazine in the treatment of postoperative hypertension. Twenty patients undergoing major noncardiac surgery were entered into the study. Patients were randomized and treated for postoperative hypertension with either labetalol (n = 10) or hydralazine (n = 10). Labetalol and hydralazine both produced significant reductions in arterial blood pressure (p less than 0.001) within 10 minutes, which lasted at least 2 hours. In addition, labetalol produced a significant reduction in the heart rate and rate-pressure product without creating any adverse effects. In contrast, hydralazine produced significant sinus tachycardia requiring IV propranolol in three patients, two of whom developed transient ST segment depression. These results indicate that labetalol is safe and effective for the control of postoperative hypertension, especially in those patients who are least able to tolerate tachycardia.

Comparison of propofol and thiamylal for induction and maintenance of anaesthesia for outpatient surgery

In an open, randomized study we have compared the safety and efficacy of propofol with thiamylal for induction and maintenance of anaesthesia supplemented by nitrous oxide in elective termination of pregnancy. Induction of anaesthesia was achieved with either propofol 2.5 mg kg-1 or thiamylal 4.0 mg kg-1 followed by maintenance with 70% nitrous oxide in oxygen and repeat boluses of 25% of the induction dose i.v. as indicated clinically. Both drugs induced and maintained anaesthesia reliably, with some minor differences. Recovery from propofol was significantly more rapid. The patients in the propofol group were alert and orientated early in the postoperative period, with less nausea or vomiting. Propofol has properties that are of particular benefit in anaesthesia for ambulatory surgery.