Supraglottic and subglottic airway injury due to deployment and rupture of an automobile airbag.

A 46-year-old white female with underlying interstitial lung disease and asthma was driving a pickup truck when it was struck broadside. The airbag inflated and then ruptured, forcing inhalation of its contents. This produced facial desquamation, productive cough, wheezing, and headache. Chest radiograph showed bilateral interstitial fibrosis. Pulmonary function tests demonstrated small airway obstruction, hyperinflation, and impaired diffusion. Computerized tomography showed extensive sinusitis. She improved following treatment with inhaled steroids, bronchodilators, and oral antibiotics. Inhalation of the airbag contents produced supraglottic and subglottic airway inflammation, resulting in sinusitis and exacerbation of her underlying asthma.

Subclavian venous catheterization: greater success rate for less experienced operators using ultrasound guidance.

OBJECTIVE: To determine if ultrasound guidance can be safely performed and improve success rates for subclavian venous catheterization performed by less experienced operators. DESIGN: Prospective, randomized study. SETTING: Twenty-bed trauma-surgical-medical intensive care unit in a 524-bed, community, tertiary care, teaching hospital. PATIENTS: After the decision for central venous cannulation was made, informed consent was obtained, and less experienced operators then attempted to insert subclavian catheters in 33 critical care patients. INTERVENTIONS: Catheter placements were attempted, either by landmark technique, ultrasound technique, or by landmark attempts with ultrasound salvage. Catheterization techniques to be used were randomized using a random number table. MEASUREMENTS AND MAIN RESULTS: Fifty-three placement procedures were attempted in 33 patients. One procedure was excluded from data analysis. Successful catheterizations, occurrence rates of complications, number of attempts, and number of catheter kits used were recorded. In the analysis, 52 catheterization procedures were studied. Twelve (44%) catheters were successfully placed from 27 attempts using the landmark technique vs. 23 (92%) successful catheterizations during 25 ultrasound procedures (p = .0003). Fifteen failed landmark technique attempts had ultrasound salvage attempted, with 12 (80%) catheters successfully inserted. Eleven complications (minor) occurred in 27 attempts of subclavian venous catheterization using conventional landmark technique vs. one complication (minor) in 25 attempts of subclavian venous catheterization with ultrasound guidance (p = .002). There were no major complications in either group. The landmark group required an average of 2.5 venipunctures and 1.4 catheter kits per attempted catheterization. The ultrasound group required an average of 1.4 venipuncture attempts and 1.0 insertion kit. The statistical significance in differences in groups for the average number of venipunctures was p = .0007 and average number of kits used was p = .0003. CONCLUSIONS: Ultrasound guidance improves the success rate of subclavian venous catheterization performed by less experienced operators. There were no major complications in either group. Ultrasound guidance is usually successful in allowing performance of subclavian venous catheterizations when landmark techniques fail.

Intravenous lorazepam as an amnestic and anxiolytic agent in the intensive care unit: a prospective study.

OBJECTIVE: To assess the efficacy and hemodynamic safety of intravenous lorazepam as an amnestic and anxiolytic agent in patients undergoing critical care procedures. DESIGN: Prospective study. SETTING: Trauma/intensive care unit and coronary care unit of a 524-bed, tertiary, teaching community hospital. SUBJECTS: Ten patients undergoing critical care procedures. INTERVENTIONS: Intravenous lorazepam was administered at an initial dose of 2 mg, 15 to 20 mins before the critical care procedure (procedures included both invasive and noninvasive techniques) was performed. Anxiety level and memory assessment were evaluated at baseline and at various points following lorazepam administration. Changes in hemodynamic status were evaluated regularly throughout the study. MEASUREMENTS AND MAIN RESULTS: No significant changes in hemodynamic measurements were observed after administration of intravenous lorazepam. Significant differences were seen in anxiety scores and amnestic effects from preprocedure/pre-lorazepam to post-lorazepam evaluations (all p values were < .03). CONCLUSIONS: This study confirms the beneficial anxiolytic and amnestic effects of lorazepam in a subgroup of patients undergoing critical care procedures. The study also substantiates the safety of this drug in this patient population.

Octreotide-induced hyperkalemia.

A 68-year-old woman was admitted with numerous injuries after being hit by an automobile. On day 16 of hospitalization octreotide was started for treatment of a pancreatic fistula, and within 2 days the patient's serum potassium increased. By the third and fourth days of octreotide therapy the level had increased to the point at which it required treatment. The patient was asymptomatic, however, and had normal renal function. Octreotide was discontinued on the fifth day of the course, with a subsequent decrease in serum potassium. Two days later, one dose of the drug was given; serial serum potassium levels were measured before and after the dose, and increased after the rechallenge. Octreotide was not administered for the remainder of the patient's hospitalization, and hyperkalemia did not recur.

The efficacy of barbiturate coma in the management of uncontrolled intracranial hypertension following neurosurgical trauma.

The purpose of this study was to evaluate the role of barbiturate therapy as an adjunctive treatment for control of intracranial hypertension when conventional methods failed. To this end, a retrospective chart review was conducted on 21 neurosurgical trauma patients with uncontrolled intracranial pressure (ICP) admitted to a trauma/intensive care unit. In this patient population, the overall mortality was 48%. Control of ICP was achieved in 67% of patients. The survival of patients experiencing ICP control with barbiturate coma was better than those patients who failed therapy (71% vs 14%, p = 0.021). Thus, in a subgroup of neurosurgical trauma patients who are refractory to conventional management of elevated ICP, barbiturates appear to improve survival, suggesting that this therapy has an important role in the management of neurotrauma patients.

Use of ondansetron for control of projectile vomiting in patients with neurosurgical trauma: two case reports.

OBJECTIVE: To describe two cases of projectile vomiting that were treated successfully with ondansetron in patients with neurosurgical trauma. Causes and pharmacologic treatments for nausea and emesis are also discussed. DATA SOURCES: Patient data and literature citations from published case reports, review articles, and clinical research reports as identified by MEDLINE. DATA SYNTHESIS: Ondansetron, a potent and highly selective antagonist of serotonin at the 5-HT3 (subtype 3)-receptor, possesses potent antiemetic effects. It has not been associated with the extrapyramidal adverse effects seen with traditional antiemetics. The occurrence of extrapyramidal reactions may limit the usefulness of conventional antiemetics in neurosurgical patients because such agents interfere with serial mental status examinations and lower the seizure threshold. Therefore, ondansetron may be preferable in this patient population. Two patients with head trauma and projectile vomiting were treated successfully with ondansetron following treatment failure with prochlorperazine. These represent the first reported cases of efficacious treatment with ondansetron in neurosurgical trauma patients. CONCLUSIONS: Ondansetron may be the preferred agent for controlling nausea and vomiting in patients with neurosurgical trauma. Controlled clinical trials are needed to evaluate its safety and efficacy in this patient population.

Incidence of colonization, nosocomial pneumonia, and mortality in critically ill patients using a Trach Care closed-suction system versus an open-suction system: prospective, randomized study.

Eighty-four intubated, mechanically ventilated patients were prospectively evaluated for incidences of colonization and nosocomial pneumonias dependent on whether they received endotracheal suctioning by an "open" suction method vs. "closed" suction (Trach Care Closed Suction System) method. Results show that closed suctioning is associated with a significant (67% vs. 39% p less than .02) increase in colonization compared with open suctioning. However, difference in the incidence of nosocomial pneumonia was not significantly (26% vs. 29%) different between closed and open suctioning. Differences in severity of illness (Acute Physiology and Chronic Health Evaluation II and Therapeutic Intervention Scoring System), age, sex, presence of NG tubes, use of H2 antagonists or antacids, use of antibiotics, and history of smoking were all nonsignificant. Survival analysis demonstrated that the probability of survival without developing nosocomial pneumonia was greater among closed-suctioning patients vs. open-suctioned patients (p less than .03). This study shows that suctioning performed via the Trach Care closed-suction system increases the incidence of colonization but not the incidence of nosocomial pneumonia, and may actually decrease mortality when compared with open-suction systems.

A comparison of the effects of suxamethonium, atracurium and vecuronium on intracranial haemodynamics in swine.

Sixteen Yorkshire swine weighing 15-20 kg were studied to compare the effects of suxamethonium, atracurium and vecuronium on intracranial pressure (ICP), heart rate (HR), arterial blood pressure (BP), and cerebral perfusion pressure (CPP) in swine with normal or elevated ICP. In each animal an intracranial pressure-volume curve was produced by the inflation of an epidural balloon. The baseline ICP (Po), the ICP at the inflection point (Pi) and on the steep portion (Pmax) of the pressure-volume curve were identified and the balloon volumes recorded. The animals were assigned to receive either suxamethonium 1.0 mg/kg, atracurium 0.6 mg/kg, vecuronium 0.2 mg/kg, or saline placebo intravenously at three conditions: First, with the epidural balloon deflated Po, next at Pi, then at Pmax. Neither atracurium, vecuronium, nor placebo produced any statistically significant effect on HR, BP, ICP, or CPP at any baseline level of ICP. Suxamethonium produced an early fall in ICP (0.8 +/- 0.3, 2.6 +/- 1.0 and 3.5 +/- 1.3 mmHg at Po, Pi and Pmax respectively: P = .0005) followed by a rapid rise above the pre-infusion level (1.8 +/- 0.6, 2.8 +/- 0.6 mmHg, and 2.2 +/- 0.5 mmHg at Po, Pi and Pmax respectively: P = .0005). A fall in BP coupled with the rise in ICP resulted in a fall in CPP (5.8 +/- 2.3, 6.1 +/- 1.2, and 6.3 +/- 1.8 mmHg at Po, Pi and Pmax respectively: P = .0005). Although the fall in CPP was not large, in the presence of elevated ICP, where CPP already is marginal, such a decrease may compromise cerebral blood flow.(ABSTRACT TRUNCATED AT 250 WORDS)

Nifedipine-induced hypotension and mesenteric ischemia.

We have presented a case in which nifedipine-induced hypotension in a patient receiving beta blocker and nitrate therapy precipitated mesenteric angina, leading to emergency exploratory celiotomy. Although paradoxic angina is an unusual complication of this antianginal therapy, it should be considered in any patient who has acute abdominal pain and hypotension while receiving this therapeutic regimen.

Continuous thoracic epidural analgesia for the control of pain associated with pleural sclerosis.

Successful use of nonnarcotic, thoracic epidural analgesia for the control of pain associated with pleural sclerosis was accomplished in three gynecologic oncology patients with severe respiratory compromise due to malignant pleural effusions. Excellent analgesia was obtained with no observed anesthetic complications.