Lightning strike to the head: case report

A case is presented of a teen-aged athlete who sustained a direct lightning strike to the head while wearing a football helmet. The helmet, the presence of sweat, and aggressive resuscitation were instrumental in his survival and complete recovery. This appears to be the first documentation of a lightning strike to an individual wearing protective headgear.

Economic considerations

The costs to society of trauma care are huge. Multiple-injury patients in critical care units consume a vast percentage of the direct medical costs. This article examines the role that pre-existing diseases have on the length of stay in the critical care unit and the costs associated with this care.

Ethical considerations

The doctor's oath to serve the good of the patient requires the recognition that the patient's good consists of more than simply his or her biomedical health status. This article proposes a scheme for identifying the primary decision maker in clinical settings, particularly when the patient's own decision-making capacity is in question. A few of the many ethical controversies encountered in the practice of trauma medicine are examined and discussed.

Alkaline phosphatase levels in diagnostic peritoneal lavage fluid as a predictor of hollow visceral injury

Isolated injuries to hollow viscera may result in equivocal diagnostic peritoneal lavage (DPL) findings. Small bowel injuries cause alkaline phosphatase (AP) levels to increase in DPL effluent. The goal of this study was to better define the role of AP levels in the evaluation of the injured abdomen. We prospectively measured AP levels in 672 patients undergoing DPL. These were retrospectively compared with the clinical findings. All 12 patients with small bowel injuries and three of four with large bowel injuries had an AP level > 10 IU/L. There was one patient with an AP level > 10 IU/L without clinically significant intra-abdominal injury. An AP level > 10 IU/L in the DPL effluent predicted injury requiring laparotomy with a specificity of 99.8% and a sensitivity of 94.7%. We recommend using AP levels only in the management of patients with equivocal findings on DPL who would otherwise not undergo laparotomy. This selective use of AP levels will improve the probability of early diagnosis of bowel injury without increasing the cost of care.

Major hepatic trauma

The intraoperative management of complex liver injuries can be extremely challenging. During the past two decades, there have been some changes in philosophy regarding the optimal techniques for controlling hemorrhage and decreasing mortality and morbidity rates. An overview of these techniques is presented.

Prospective evaluation of surgeons' use of ultrasound in the evaluation of trauma patients

Ultrasound diagnostic imaging has been demonstrated to be a valuable investigative tool in the evaluation of trauma patients in Europe and Japan. In the United States, however, ultrasound has not been widely used by trauma surgeons because of its lack of availability in the trauma resuscitation area and the associated cost and lack of full-time availability of a technician. In this prospective study, four attending trauma surgeons, four trauma fellows (PGY 6 and 7), and 25 surgical residents (PGY 4) at a level I trauma center were trained in specific ultrasound techniques to identify fluid in trauma patients with thoracoabdominal injuries. Their ultrasound evaluations of 476 patients demonstrated that in 90 patients with clinically significant injuries, ultrasound imaging successfully detected injury in 71, for a 79% sensitivity. Specificity was 95.6%. We conclude that (1) surgeons can rapidly and accurately perform and interpret ultrasound examinations; and (2) ultrasound is a rapid, sensitive, specific diagnostic modality for detecting intraabdominal fluid and pericardial effusion.

A laboratory model for studying blast overpressure injury

Blast injury remains an important source of trauma in both civilian and military settings. We have studied a recently developed blast wave generator to evaluate its effectiveness for laboratory study of blast injury. In order to determine the reliability of the device and the pathology of the lesions caused by the short duration (0.5-1.0 msec), and high intensity (60-375 psi) pressure wave, laboratory rats were exposed to the pressure waves generated by the machine. The animals were divided into three groups: the first exposed to midthoracic blasts, the second to abdominal blasts, and a group of controls exposed to a gentle stream of gas. Group I showed gross and microscopic evidence of lung blast injury of "rib imprint" hemorrhages, intra-alveolar hemorrhage, marked increase in lung weight, prolonged apnea, and bradycardia. Group II showed typical blunt abdominal trauma at the closest ranges, but characteristic submucosal hemorrhages up to 4.0 cm from the blast nozzle. In both groups, a protective effect was seen in heavier animals. The blast wave generator permits reproducible blast injury in the laboratory that is safer and faster than current methods. The lung and bowel lesions induced are grossly and microscopically similar to injuries of blast exposure seen in clinical patients.

Focal motor seizures complicating carotid endarterectomy

We studied four patients with focal motor seizures complicating carotid endarterectomy and compared them with 14 other cases reported previously. Seventeen of the 18 patients had high-grade carotid stenoses. A severe unilateral headache usually preceded seizure activity, which was followed by prolonged Todd's paralysis. Eight patients had histories of ipsilateral stroke. There was no association with perioperative hypertension. Two patients who were receiving heparin sodium had intracerebral hemorrhages that caused one of the two postoperative deaths. The patency of all endarterectomized carotid arteries was recorded by arteriography or noninvasive studies. These data suggest that patients who have severe unilateral headaches following ipsilateral carotid endarterectomy for high-grade stenoses are at risk for focal motor seizures. The roles of antithrombotic agents and anti-seizure medication in this setting are unclear.

Maintenance of aerobic metabolism during global ischemia with perfluorocarbon cardioplegia improves myocardial preservation

We used phosphorus-31 nuclear magnetic resonance to test the ability of a perfluorocarbon blood substitute that has been shown in previous studies to improve oxygen delivery to hypothermic myocardium to maintain aerobic high-energy phosphate metabolism during total global ischemia. Twenty-three isolated perfused rabbit hearts were subjected to 180 min of hypothermic (23 degrees C) global ischemia followed by 45 min of normothermic reperfusion. Hearts received multiple doses of a cardioplegic solution that contained either oxygenated perfluorocarbon (Fluosol O2), nonoxygenated perfluorocarbon (Fluosol N2), or standard crystalloid hyperkalemic cardioplegic solution (STD-KCl) at 30 min intervals. Recovery of isovolumic left ventricular developed pressure (LVDP) was used to assess preservation of contractile function. Recovery of LVDP was 84 +/- 19% of preischemic control values with Fluosol O2, 68 +/- 16% with Fluosol N2, and 67 +/- 17% with STD-KCl (p = .058 vs Fluosol N2 and p = .056 vs STD-KCl). During 3 hr of ischemia intracellular pH (pHi) fell to 6.68 +/- 0.20 with STD-KCl and to 6.71 +/- 0.14 with Fluosol N2 but remained above 7.00 throughout the ischemic period with Fluosol O2 (p less than .0001 vs Fluosol N2 or STD-KCl). Myocardial ATP content was better preserved at 107 +/- 14% of control values with Fluosol O2 compared to 60 +/- 18% of control with Fluosol N2 and 75 +/- 21% of control with STD-KCl (p less than .001 vs Fluosol N2, p = .002 vs STD-KCl). Phosphocreatine (PCr) was also better preserved with Fluosol O2.(ABSTRACT TRUNCATED AT 250 WORDS)

Vascular trauma secondary to diagnostic and therapeutic procedures: 1974 through 1982. A comparative review

One-hundred nineteen patients with 125 iatrogenic vascular injuries requiring surgical intervention were treated at Walter Reed Army Medical Center from 1974 through 1982. This experience was compared with that from 1966 through 1973 [1]. A decrease in the proportion of cases resulting from cardiac catheterization was partially offset by an increase in injuries from invasive monitoring and injuries from percutaneous transluminal dilation procedures. A threefold increase in cases resulting from urologic surgery was related to the evolution of an aggressive approach toward retroperitoneal metastatic tumor. Over half of the arterial injuries are now iliofemoral in location because of the routine use of the femoral approach for angiographic and cardiac catheterization procedures. The need for complex reconstruction in addition to thrombectomy increased fourfold. Delayed surgical intervention was a factor in 9 of the 12 patients with permanent disability. There was no death attributable to vascular reconstruction.

Superiority of perfluorocarbon cardioplegia over blood or crystalloid cardioplegia

Oxygenated Fluosol-43 cardioplegia (CP), a perfluorocarbon with high oxygen solubility, was compared with crystalloid and oxygenated blood cardioplegia. Potassium in each CP was 25 mEq/l. Thirty perfused rabbit hearts in three groups of 10 hearts each underwent 100 minutes of global ischemia at 20 degrees C, followed by 45 minutes of reperfusion at 37 degrees C. During ischemia, CP was given every 20 minutes. With each CP injection, increases in myocardial oxygen tension were recorded using mass spectrometry and oxygen consumption (MVO2) was calculated. Left ventricular function was assessed before and after ischemia by measuring isovolumic developed pressure and dP/dt with an intraventricular balloon. Intramyocardial PO2 increased by 19.6 +/- 1.8 mm Hg in the Fluosol CP group, 0.4 +/- 0.1 mm Hg in the crystalloid CP group and 1.5 +/- 0.3 mm Hg in the blood CP group (p less than 0.001, Fluosol CP vs crystalloid CP and blood CP). MVO2 with each CP injection, expressed as ml O2/100 g dry weight, was 203.8 +/- 7.0 for Fluosol CP, 20.4 +/- 1.2 for crystalloid CP and 39.2 +/- 4.3 for blood CP (p less than 0.001 Fluosol CP vs crystalloid CP and blood CP). Recovery of maximal dP/dt after 45 minutes of reperfusion, expressed as a percentage of preischemic control, was 75.6 +/- 4.0% for Fluosol CP, 60.9 +/- 5.5% for crystalloid CP and 53.4 +/- 3.7% for blood CP (p less than 0.02 Fluosol CP vs blood CP and crystalloid CP). These data clearly show that the use of Fluosol cardioplegic solution enhanced oxygen delivery and use compared with blood and crystalloid cardioplegic solutions. The marked increase in intramyocardial oxygen and MVO2 with each injection of Fluosol CP shows that there is effective aerobic metabolic activity during ischemia, which may explain the improved functional recovery. The failure of blood CP to afford similar protection can be explained by a decreased oxygen release from hemoglobin due to the leftward shift of the oxygen-hemoglobin dissociation curve with hypothermia.