Pulmonary artery disruption from blunt thoracic trauma

Blunt chest trauma occurs in up to 50 per cent of all fatal motor vehicle accidents and is the primary cause of death in 12-25 per cent; yet only 15 per cent of patients with chest trauma arriving alive to the emergency department require early thoracotomy. Pulmonary artery disruption from blunt trauma is extremely rare. Two patients both women, older and obese with multiple rib fractures and little pulmonary parenchymal damage are reported. Neither had injury to the aorta, heart or intra-abdominal organs. One patient survived after lateral repair of the left main pulmonary artery and the other exsanguinated from a laceration of the right main pulmonary artery. Intrapericardial exposure of the proximal pulmonary arteries may be necessary for control of hemorrhage. Trauma surgeons should be familiar with this technique. Indications for immediate thoracotomy should include: massive hemothorax (greater than 1000 ml), continued bleeding greater than 300 ml in the first hour, bleeding greater than 200 ml/hr for 5 hours, or increasing hemothorax in spite of tube thoracostomy. Close adherence to these guidelines would have allowed both patients to be explored earlier.

Protein co-isolated with human tissue factor impairs recovery of activity

Preparations of human tissue factor isolated by immunoaffinity chromatography contain variable amounts of 47,000 mol wt, 55,000 mol wt, and multimeric tissue factor when analyzed without reduction on polyacrylamide gels in sodium dodecyl sulfate (SDS). When analyzed after reduction, the 47,000 mol wt tissue factor apoprotein and a protein of about 12,000 mol wt are observed. Elution of tissue factor from polyacrylamide gel slices, followed by reassociation with lipids, restored proportionately much greater tissue factor activity with the 47,000-mol wt protein than with the 55,000-mol wt form. Cyanogen bromide cleavage at the single tissue factor methionine revealed that the 12,000-mol wt protein is associated with the carboxyl-terminal peptide derived from the 47,000-mol wt protein. These results reveal that association of the 12,000-mol wt protein with the cytoplasmic domain of tissue factor can modulate its activity in vitro.

Fatigue fracture of the interlocking nail in the treatment of fractures of the distal part of the femoral shaft

The clinical and mechanical factors predisposing to a fatigue fracture of an interlocking nail were studied in seven patients who were treated for a fracture of the distal part of the femur. In all patients, the fracture of the femur was five centimeters or less from the more proximal of the two distal screw-holes. Finite-element analysis revealed that the stress on the nail exceeded its fatigue endurance limit and that the femur had to regain 50 per cent of its original stiffness through healing to accommodate weight-bearing without the risk of fatigue failure of the nail. The risk of fatigue failure may be minimized by using nails that have a larger diameter and by avoiding early weight-bearing.

Clearing the cervical spine: initial radiologic evaluation

The identification of unstable cervical spine injury (UCSI) in blunt high-energy transfer injury (BHETI) patients is critical to management. In a prospective study of BHETI patients identified to be at high risk for UCSI, the use of lateral cervical spine view (LCV), three-view cervical spine series (FCS), and limited computerized tomography (CT) in the initial evaluation of these patients was analyzed. Thirteen of 204 patients sustained UCSI. Sensitivity of the LCV alone was 0.85 and the predictive value of the negative test was 0.97. Sensitivity and predictive value of a negative study were maximized by the use of FCS combined with CT when plain X-rays were inadequate. We conclude that technically adequate, normal FCS can be safely used to eliminate the presence of UCSI. If these studies are technically inadequate, the addition of a limited CT can be used to "clear" the spine.

Major trauma in an urban New Zealand setting: resource requirements

Patients with severe injuries, place significant demands on an institution's facilities and staff if these patients are to be treated adequately. In the USA, requirements for institutions managing patients with major injuries have been outlined and 'trauma centres' designated. In New Zealand, the requirements for care of patients with severe injuries have not been documented. One hundred and fourteen patients who presented to the Accident and Emergency Department at Auckland Hospital over a 6 month period were prospectively evaluated. All patients had Injury Severity Scores greater than or equal to 16 and the majority were young males. The greatest number of patients presented at night and during the weekend. Radiographic studies and resuscitation room procedures were commonly required and 54% of patients required surgery within the first 24 h after presentation. Management of patients required involvement by a large variety of specialties with general surgery, intensive care, anaesthetics, neurosurgery and orthopaedics more commonly involved. Sixty per cent of patients required intensive care admission and the overall group had a 30% mortality rate. This study confirms that major trauma in New Zealand patients places similar demands on resources to that experienced in the USA. Although health resources are currently limited, appropriate allocation of these resources must be considered to best treat patients suffering severe injuries.

An inhibitory monoclonal antibody against human tissue factor

We obtained a hybridoma using immune spleen cells from a mouse injected with human brain tissue factor that had been purified on a factor VII-agarose affinity column. This monoclonal IgG1, HTF1-7B8, inhibits tissue factor procoagulant activity. The concentration of HTF1-7B8 producing half-maximal inhibition is influenced by the concentration of factor VIIa, suggesting that the antibody and enzyme compete for the cofactor. The antibody was successfully used to detect both human and bovine tissue factor on nitrocellulose dot blots, indicating that the epitope recognized by this antibody is conserved in both species. This antibody clearly reveals tissue factor on a Western blot. An HTF1-7B8 affinity column was used to purify tissue factor from both human brain and placenta. The electrophoretic mobilities in polyacrylamide gels in the presence of sodium dodecyl sulfate (SDS) and the amino acid compositions of the purified tissue factor from brain and placenta are indistinguishable, as are their specific procoagulant activities in reconstituted systems. This antibody will be useful for immunopurification and characterization of tissue factor structure and mechanism.

Urgent and emergent re-laparotomy in trauma. A preventable cause of increased mortality?

In a 2-year period, 96 patients required laparotomy for trauma at the University of Kansas Medical Center. Fifteen patients required a total of 25 emergent and urgent reexplorations. Six patients required reoperation for bleeding, eight for intra-abdominal sepsis, and 3 for inadequate initial operation or missed injury. Forty per cent of patients undergoing multiple laparotomies died, versus 16 per cent for single operations. Factors predisposing to complications requiring re-laparotomy include multi-system trauma, blunt abdominal injury, and inadequate or delayed initial resuscitation and operation. Recognition of these factors and resuscitation and operation by personnel experienced in trauma care should lead to lower reoperation rates, and decreased morbidity and mortality when reoperation is necessary.

Rapid chromatographic purification of apolipoproteins A-I and A-II from human plasma

Rapid, large-scale isolation of human apolipoproteins A-I and A-II has been accomplished using two chromatographic procedures. The apolipoproteins adsorbed from plasma onto a column of phenyl-Sepharose are eluted with increasing propylene glycol concentrations. Apolipoproteins A-I and A-II can be resolved by elution with a linear 0 to 80% propylene glycol gradient. Homogeneous preparations of apo A-I and A-II are obtained following gel filtration in 3M guanidinium chloride.

Nonspecific lymphocyte responses in F344 and LEW rats: susceptibility to murine respiratory mycoplasmosis and examination of cellular basis for strain differences

Mycoplasma pulmonis produces a mitogen which may play a role in the pathogenesis of murine respiratory mycoplasmosis in rats. Since LEW rats are more susceptible to this disease than F344 rats are, these two strains were used to examine a possible association between disease severity and the level of nonspecific lymphocyte stimulation by mitogens, including M. pulmonis membrane preparations. F344 and LEW spleen, lung, blood, and lymph node lymphocytes were exposed to various mitogens. LEW lymphocytes gave a significantly higher response to mitogenic stimulation, regardless of their anatomical source. These differences in lymphocyte responsiveness were primarily due to differences within the nonadherent cell population. Significantly higher numbers of W3/25+ (T helper) cells were found in LEW lymphoid populations, whereas no difference was found in MRC OX-8+ (T suppressor/cytotoxic) cells. These data suggest an association between disease severity and host responsiveness to nonspecific stimuli.

The management of venous injuries in blunt extremity trauma

Data on venous injury in blunt extremity trauma are scarce. The nature of injury and results of therapy in 22 patients presenting with blunt venous extremity injury at MIEMSS and KUMC in a 10-year period are presented. Comparisons of the outcome with venous ligation and repair, the use of anticoagulants, and the use of fasciotomy, led to the development of guidelines for the therapy of blunt venous injury in both upper and lower extremity trauma.

Building a hospital nursing research department

The value of research to the practice of nursing has been well documented. The difficult question today is how to establish a formal research component into the nursing division when funding sources are scarce or nonexistent. The process that one large tertiary-care hospital used to accomplish this goal is analyzed. The authors discuss design, resources, implementation, financing, and program maintenance.