Gauze packing as damage control for uncontrollable haemorrhage in severe thoracic trauma.

INTRODUCTION: The usefulness of thoracic damage control (DC) for trauma requiring a thoracotomy is not established. The aim of this study was to clarify the usefulness of thoracic packing as DC surgery. METHODS: This was a retrospective case series study of 12 patients with thoracic trauma suffering uncontrollable intrathoracic haemorrhage and shock who underwent intrathoracic packing. Our thoracic DC technique consisted of ligation and packing over the bleeding point or filling gauze in the bleeding spaces as well as packing for the thoracotomy wound. The success rates of intrathoracic haemostasis, changes in the circulation and the volume of discharge from the thoracic tubes were evaluated. RESULTS: Packing was undertaken for the thoracic wall in five patients, for the lung in four patients, for the vertebrae in two patients and for the descending thoracic aorta in one patient. Haemostasis was achieved successfully in seven cases. Of these, the volume of discharge from the thoracic tube exceeded 400 ml/hr within three hours after packing in three patients, decreased to less than 200 ml/hr within seven hours in six patients and decreased to 100ml/hr within eight hours in six patients. Systolic pressure could be maintained over 70 mmHg by seven hours after packing. CONCLUSIONS: Intrathoracic packing is useful for some patients, particularly in the space around the vertebrae, at the lung apex, and between the diaphragm and the thoracic wall. After packing, it is advisable to wait for three hours to see whether vital signs can be maintained and then to wait further to see if the discharge from the thoracic tube decreases to less than 200 ml/hr within five hours.

Correlating the severity of paraquat poisoning with specific hemodynamic and oxygen metabolism variables.

OBJECTIVE: To investigate the hemodynamics and oxygen metabolism of patients with varying degrees of severity of paraquat poisoning. DESIGN: Prospective, observational, clinical study. SETTING: Intensive care unit in a university hospital. PATIENTS: Forty-three consecutive patients with paraquat and/or diquat poisoning were classified into three groups by the severity index of paraquat poisoning (SIPP; hr/mg/L). INTERVENTIONS: Standard treatments included specific respiratory management, fluid resuscitation, and aggressive circulatory support. MEASUREMENTS AND MAIN RESULTS: Serum paraquat and diquat levels were measured at arrival, and SIPP was calculated. The cardiac index (CI), left ventricular stroke work index (LVSWI), systemic vascular resistance index (SVRI), oxygen delivery index (DO2I), oxygen consumption index (VO2I), and oxygen extraction ratio (O2ER) were measured at 6, 12, 24, 36, 48, 72, and 96 hrs postadmission. A significant inverse correlation between SIPP and survival time was found in 31 fatal cases (r = .85; p < .001). In the SIPP 10-50 group, CI, DO2I, VO2I, and O2ER were maintained at higher levels than in the SIPP group of <10 (p < .05), whereas SVRI decreased significantly (p < .05). In the SIPP group of >50, CI, LVSWI, SVRI, DO2I, and VO2I decreased, whereas O2ER had a tendency to increase progressively. There was a significant correlation between SVRI and SIPP, O2ER and SIPP, and O2ER and SVRI 24 hrs after admission, respectively (p < .001). CONCLUSIONS: Paraquat poisoning is characterized by high oxygen consumption with high oxygen extraction, with the degree of derangement based on the severity index. The development of a marked imbalance between increased oxygen demand and decreased oxygen supply because of myocardial depression might be a possible cause of death in circulatory failure.

Residual myocardial damage following electrical injuries.

It is unknown to what degree electrical injury causes cardiac muscle damage. We used standard clinical methods and varying combinations of 201Tl scintigraphy (TI), 123I-metaiodobenzylguanidine scintigraphy, echocardiography, 99mTc-RBC angiography, and coronary catheterization to evaluate five patients with high-tension electrical injuries for cardiac damage. The first follow-up examination was performed within 2 months of injury, and the second follow-up was performed more than 6 months after the first follow-up. Electrocardiographic abnormalities were observed in two patients in the acute stage, but no abnormality was detected in the follow-up period. Myocardial perfusion abnormalities were found in all cases with Tl. The degree of injury indicated by Tl was more severe than that indicated by 123I-metaiodobenzylguanidine scintigraphy. Moreover, Tl showed progression of injury in all cases. These preliminary findings must now be confirmed and verified in a larger group of patients.

Cranial defect and decrease in cerebral blood flow resulting from deep contact burn of the scalp in the neonatal period.

A case of cranial defect in the anterior fontanelle region is reported. The patient suffered a deep contact burn on the right parietofrontal region in the neonatal period. At age 3 years, a bone defect of 30 x 20 mm was observed in the right parietofrontal region, including the anterior fontanelle, and the pulsation of the brain was palpable. Moreover, scintigraphy of cerebral blood flow using SPECT with 99mTc-HMPAO demonstrated extensive decrease in blood flow in the right parietosquamosal region. Cranioplasty was performed at 3 years and 4 months using split ribs grafts and at age 5 years and 4 months using split-thickness calvarial bone grafts. After the cranioplasty, there was no bony defect and no region of reduced blood flow. The child is developing well.

Effective control of methicillin-resistant Staphylococcus aureus in a burn unit.

Methicillin-resistant Staph, aureus (MRSA) colonization and infection was studied in 231 patients who were admitted to our burn unit and remained for 3 days or more between 1986 and 1994 (patients with inhalation injury only and no burn wound were excluded). The study was divided into two periods: from 1988 to 1989 and from 1990 to 1994. MRSA was found in 80 patients. They increased from 1986 to 1988, slightly decreasing thereafter. In 1994 the incidence of MRSA was 4.3 per cent. The number of strains of MRSA isolated from burn wounds was significantly reduced in the later period. Comparing the two periods, isolation of patients from MRSA, prevention of contamination during care, and reduction in the number of patients initially given second- or third-generation cephem antibiotics were performed more strictly in the later period. The effectiveness of these measures was confirmed. Moreover, the first operation was carried out significantly earlier in the later period. Early excision and early closure of the wound was more effective in preventing and controlling MRSA colonization and infection.