Iatrogenic cerebral gas embolism: analysis of the presentation, management and outcomes of patients referred to The Alfred Hospital Hyperbaric Unit.

INTRODUCTION: The aim of this study was to review patients with iatrogenic cerebral gas embolism (CGE) referred to The Alfred Hospital hyperbaric unit to determine whether hyperbaric oxygen treatment (HBOT) reduced morbidity and mortality. METHODS: This is a retrospective cohort study with a contemporaneous comparison group of patients referred between January 1998 and December 2014. The primary end point was good neurological outcome at the time of discharge from hospital or rehabilitation facility as assessed by the Glasgow Outcome Scale (GOS-E). RESULTS: Thirty-six patients were treated with HBOT for CGE and nine patients were diagnosed with CGE but did not receive HBOT. Thirty-two patients developed CGE from an arterial source and 13 from a venous source. The mean time from recognition of the event to institution of HBOT was 15 hours. Four of 45 patients (8.9%) died. Good neurological outcomes (defined as GOS-E 7 or 8) occurred in 27 patients and moderate disability in 13. The only independent factor that was associated with good neurological outcome was time to first HBOT (OR 0.94, 0.89-0.99; P = 0.05). Hemiplegia as the first presenting sign, however, was associated with poor outcome (OR 0.27, 0.06-1.08; P = 0.05). The source of embolus (arterial versus venous), hyperbaric treatment table used and patient age did not affect outcome. CONCLUSION: Appropriate treatment of CGE with hyperbaric oxygen was found to be impeded by delays in diagnosis and subsequent transfer of patients. Better neurological outcome was associated with HBOT within eight hours of CGE.

Management of spleen injuries: the current profile.

BACKGROUND: There has been a shift from operative to conservative management of splenic injuries in the last two decades, but the current practice in Australia is not known. This study aims to determine the profile of splenic injury in major trauma victims and the approach to treatment in Victoria for the last 2 years. METHODS: A review of prospectively collected data from the Victorian State Trauma Registry (VSTR) from July 2005 to June 2007 was conducted. Demographic data, details of the event, clinical observations, management and associated outcomes were extracted from the database. The patients were categorized into four groups according to management (conservative, splenectomy, embolization and repair) and were compared accordingly. Multivariate binary logistic regression was performed to identify predictors of treatment (conservative versus splenectomy) on arrival. RESULTS: Of the 318 major trauma patients with splenic injuries, 186 (59%) were treated conservatively, 103 (32%) with splenectomy, 17 (5%) with arterial embolization and 12 (4%) with repair. Of these, 14 (14%) splenectomy cases and 2 (12%) embolization cases did not receive their respective treatments within 24 h. The severity of the spleen injury (as measured by the Abbreviated Injury Scale (AIS)) and age were identified as significant independent predictors of the form of treatment provided. CONCLUSION: In Victoria, conservative management is the preferred approach in patients with minor (AIS = 2) to moderate (AIS = 3) splenic injuries. The low rates of embolization warrant further research into whether splenectomy is overused.