Bronchoscopic guidance makes percutaneous tracheostomy a safe, cost-effective, and easy-to-teach procedure.

BACKGROUND: We wanted to assess the efficiency of instituting a modified technique of percutaneous tracheostomy (PET) with bronchoscopic guidance. METHODS: During a 10-month period 48 consecutive trauma patients requiring tracheostomy were divided between a standard tracheostomy control group (ST) and a PET group. All patients were followed prospectively. The hospital charges were reviewed retrospectively. RESULTS: Age, gender, body habitus, and principal diagnosis were similar in the 21 ST patients and the 27 PET patients. All STs and 15 of the PETs were performed in the operating room (OR), and the 12 remaining PETs were done in the intensive care unit (ICU). Four patients in the ST group and six in the PET group died. One of these deaths occurred in a patient in the PET group with severe adult respiratory distress syndrome. Procedure time was shorter for PET (16 versus 45 minutes, p < 0.0001). Junior residents performed more PETs than STs (33% versus 10%), and PET was considered "easier" to perform than ST (81% versus 47%). Hospital charges for PET in the ICU were $3400 less per patient compared with ST or PET in the OR. CONCLUSIONS: PET was performed easily and safely in the OR and at the ICU bedside. PET required one-third the time of ST. Bronchoscopic supervision of PET may have contributed to the small number of complications and the educational experience of junior residents. PET in the ICU can reduce hospital charges significantly and avoids transport of patients to the OR. PET is as safe as ST and should be considered the procedure of choice for an ICU patient requiring an elective tracheostomy.

Malignant pleural mesothelioma diagnosed after chest trauma.

Two patients who presented with persistent pulmonary symptoms after chest trauma and were diagnosed to have malignant pleural mesothelioma are described. The symptoms, more than expected from trauma, prompted earlier diagnosis of this underlying disease. The possibility of unknown preexisting diseases should always be considered in posttraumatic patients with unusual presentations.

Serious silver sulphadiazine and mafenide acetate dermatitis.

Infrequently reported, serious allergic reactions to topical antimicrobial agents used in the treatment of burn injuries are a potential source of confusion. To avoid misdirected therapy, an understanding of the manifestations of such reactions is important. Two recent cases of serious allergic reactions, one to silver sulphadiazine, one to mafenide acetate, are presented and the literature is reviewed.

Anhydrous ammonia burns: case presentation and literature review.

Anhydrous ammonia, a caustic compound commonly used in industry, can cause severe burns, even with brief contact. As with other alkali burns, early irrigation to remove the ammonia from burned areas is crucial to limit tissue damage. Two cases of identical exposure to industrial strength ammonia are presented. Each patient was exposed to ammonia liquid and vapors simultaneously when a tank containing this compound exploded. One patient showered at the scene immediately after exposure, whereas the other deferred irrigation until he arrived at the hospital. The first patient suffered minor burns with a 2-day, uncomplicated hospital stay. The second patient suffered 14% total body surface area burns and a significant inhalation injury. He required intubation, mechanical ventilation, and skin grafting during his 13-day hospitalization. Although much is written about the management of chemical burns, few articles address ammonia burns. Aggressive initial management significantly reduces morbidity of ammonia burns.

The use of a permanent dermal allograft in full-thickness burns of the hand and foot: a report of three cases.

The standard method of grafting deep, thermal hand-and-foot burns with either full-thickness sheet grafts or narrowly meshed, thick, split-thickness skin grafts not only leaves a deep donor site, but also becomes complicated by infection, hypertrophic scarring, blistering, and hyper- or hypopigmentation. The availability now of an acellular, immunologically inert dermal transplant (AlloDerm; LifeCell Corp., The Woodlands, Texas) allows the successful use of ultrathin autografts while maximizing the amount of dermis delivered to the wound site. These autografts leave thin donor sites that heal faster and with fewer complications. This case report describes the use of AlloDerm dermal grafts on three patients with full-thickness burns of the distal extremities. Grafts were applied to the hand in two cases and the dorsum of the foot in the third. Range of motion, grip strength, fine motor coordination, and functional performance were quantitatively evaluated. As demonstrated by these patients, cosmetic and functional results were considered good to excellent after the use of AlloDerm grafts with thin autografts.

Exercise-associated solar purpura in an atypical location.

Solar purpura localized to the malar region occurred in a 41-year-old jogger after a six mile run. This eruption is another example of the dermatoses experienced by athletes.

Jaggery: an avoidable cause of severe, deadly pediatric burns.

BACKGROUND: Jaggery is the non-industrial refinement of sugar cane into a sugar product. Sugar cane cultivation, harvest and refinement are central aspects of rural Indian life. METHODS: We present a retrospective review of pediatric burns at a single institution in Southern India, drawing special attention to scald burns incurred when young children fall into the cauldron of boiling jaggery. Descriptive statistics comparing children burned by jaggery and children burned by other mechanisms were performed. Multivariable logistic regression including burn size and mechanism of burn (jaggery and non-jaggery) was performed to determine the increased risk of death when burned by jaggery. RESULTS: Children burned by jaggery immersions are older, more likely male, and have larger burns. They have longer hospital stays, more operations, and are more likely to die. When controlling for age, gender, size of burn, and mechanism, jaggery exposure was associated with a higher mortality. DISCUSSION: Jaggery burns are deadly, devastating burns which could be prevented. While jaggery and sugar cane production can lead to economic independence for rural Indian villages, the cost it exacts from burns and death to the youngest and most vulnerable children must be addressed and prevented.

Smoke inhalation injury.

Smoke inhalation injuries are the leading cause of fatalities from burn injury. The major forms of inhalation injuries are carbon monoxide toxicity, injury to the upper airway, and pulmonary parenchymal damage. The compromised airway is protected by tracheal intubation, and respiratory failure is treated with assisted ventilation. Maintenance of good pulmonary hygiene, optomized fluid resuscitation, and routine invasive hemodynamic monitoring are the mainstays of therapy. The development of acute pulmonary insufficiency, pulmonary edema, or bronchopneumonia requires a comprehensive approach to all aspects of the illness. Acute pathophysiologic responses to inhalation injury are complex. Future therapies will target improved ventilatory strategies and the redundant host inflammatory response.

Bilateral gluteal compartment syndrome.

Gluteal compartment syndrome is uncommon but potentially devastating. Bilateral gluteal compartment syndrome occurs far more infrequently, with only three previous cases reported to date. This report reviews a case of bilateral gluteal compartment syndrome, the relevant anatomy of the gluteal region, and the etiology, pathophysiology, diagnosis, and treatment of this phenomenon.

Improved outcome with early fixation of skeletally unstable pelvic fractures.

Thirty-seven consecutive patients with unstable pelvic fractures were divided into two groups: Group 1 (July 1981 to December 1984; n = 18), when early fixation was not routinely used, and Group 2 (January 1985 to March 1988; n = 19), when early fixation was performed unless contraindicated. Hospital stay decreased by 37.8% in Group 2 (p = 0.04). Of Group 1 patients, 60% were disabled for at least 6 months versus 15.7% in Group 2 (p = 0.001), and 45% were discharged to a rehabilitation facility versus 26.4% in Group 2. Group 1 had more complications, 1.3 per patient, versus 1.0. Patients in Group 2 (undergoing early fixation) required 27.2% fewer units of blood than those in Group 1 in whom fracture surgery was delayed. Survival was better in Group 2, 100% versus 83.3% (p = 0.06). Early pelvic fracture fixation reduces hospital stay, long-term disability, and may result in fewer complications, decreased blood loss, and better survival.

'Damage control': an approach for improved survival in exsanguinating penetrating abdominal injury.

Definitive laparotomy (DL) for penetrating abdominal wounding with combined vascular and visceral injury is a difficult surgical challenge. Physiologic derangements such as dilutional coagulopathy, hypothermia, and acidosis often preclude completion of the procedure. "Damage control" (DC), defined as initial control of hemorrhage and contamination followed by intraperitoneal packing and rapid closure, allows for resuscitation to normal physiology in the intensive care unit and subsequent definitive re-exploration. The purpose of the study was to compare the damage control technique with definitive laparotomy. Over a 3 1/2-year period, 46 patients with penetrating abdominal injuries required laparotomy and urgent transfusion of greater than 10 units packed red blood cells for exsanguination. Medical records were retrospectively reviewed for degree and pattern of injury, probability of survival, actual survival, transfusion requirements for the preoperative and postoperative phases, resuscitation and operative times, lowest perioperative temperature, pH, and HCO3. No significant differences were identified between 22 DL and 24 DC patients and actual survival rates were similar (55% DC vs. 58% DL). However, in a subset of 22 patients with major vascular injury and two or more visceral injuries (maximum injury subset), otherwise similar to the overall group, survival was markedly improved in patients treated with damage control (10 of 13, 77%*) vs. DLM (1 of 9, 11%) (Fisher's exact test, * p < 0.02). In preparation for return to the operating room, DC survivors averaged 8.4 units of packed red blood cells transfused and 10.3 units fresh frozen plasma over a mean ICU stay of 31.7 hours. Resolution of coagulopathy (mean prothrombin time/partial thromboplastin time 19.5/70.4 to 13.3/34.9), normalization of acid-base balance (mean pH/HCO3 7.37/20.6 to 7.42/24.2), and core rewarming (mean 33.2 degrees C to 37.7 degrees C) were achieved. All patients had gastrointestinal procedures at reoperation (mean operative time, 4.3 hours). We conclude that damage control is a promising approach for increased survival in exsanguinating patients with major vascular and multiple visceral penetrating abdominal injuries.

Nonoperative management of blunt hepatic injuries: safe at any grade?

Nonoperative management of blunt hepatic injury (BHI) has become more widely accepted. A prospective trial was undertaken to test the belief that clinical state could identify the patients with BHI confirmed by computed tomography (CT) who could be safely managed without a surgical operation. Patients were excluded from nonoperative management only if they manifested hemodynamic instability, the presence or suspicion of any other injury requiring laparotomy, or would be unavailable for controlled monitoring. Of 60 patients treated for BHI, 30 were managed nonoperatively. The 30 who had laparotomies served as a comparative group. The groups were statistically similar in age, sex, and Injury Severity Score (ISS). The group managed nonoperatively had significantly more severe BHI. There were no deaths or delayed laparotomies in the nonoperative management group. The groups had similar ICU and total hospital stays when analyzed as independent variables or with control for BHI grade and ISS. Transfusion requirements were significantly lower for the nonoperative management group when analyzed independently or when controlled for BHI grade, ISS, and the number of non-abdominal injuries. Nineteen (63%) patients managed nonoperatively were followed until their CT scans showed complete resolution. None had complications. We conclude that nonoperative management of BHI is a safe and effective technique applicable to hemodynamically stable patients who lack other indications for laparotomy and who can be adequately monitored.