Showing papers by "Lincoln Hospital published in 1997"

Exaggerated lithotomy position-related rhabdomyolysis

Abstract: A case report and review of the exaggerated lithotomy position, in particular, and other position-related rhabdomyolysis is presented. The objective is to emphasize that the exaggerated lithotomy position, although providing good exposure for urethral and prostatic surgery, is associated with a low but definite risk of rhabdomyolysis and acute renal failure. Certain risk factors for the complication have been outlined. Close perioperative monitoring, including the use of pulmonary artery pressure and lower-extremity compartment pressure measurements in high-risk cases, is suggested for the prevention and the early detection of these cases. Prompt volume replacement and diuresis is the cornerstone of therapy in preventing acute renal failure in patients who develop rhabdomyolysis and myoglobinuria.

Extending the horizons of "damage control" in unstable trauma patients beyond the abdomen and gastrointestinal tract.

Abstract: "Damage control" has become an accepted technique for the treatment of patients with exsanguinating injuries to the abdomen. We describe a case where the damage control philosophy was applied outside the confines of the abdominal cavity, a gunshot wound to the groin, and in which a temporary intraluminal shunt was used to maintain distal perfusion while the acidosis and coagulopathy were corrected in the intensive care unit. Successful vascular reconstruction was later completed with polytetrafluoroethylene.

New-onset Bronchospasm or Recrudescence of Asthma Associated with Cocaine Abuse

Abstract: Objective: To determine whether the occurrence of new-onset bronchospasm or the recrudescence of asthma is associated with the use of cocaine. Methods: A consecutive sample of patients presenting to an inner-city adult ED with new-onset bronchospasm or recrudescence of bronchospasm after >5 years were prospectively enrolled in a case-control prevalence study. The bronchospasm patients were queried as to their exposure to illicit drugs, and urine was obtained to screen for cocaine and its metabolite, benzoylecgonine. An age- and sex-matched control group was composed of randomly chosen subjects without respiratory complaints or a history of asthma. The control group was also screened by urine toxicology for cocaine and its metabolite, benzoylecgonine. Results: In the asthma group, 21/59 (36%) had a urine toxicologic screen positive for cocaine metabolite (benzoylecgonine). Of the 21 with a positive screen for cocaine, 8 denied illicit drug abuse. Among the 13 patients reporting drug use, 10 said that they smoked crack and 3 snorted cocaine. In the control group, 8/53 (15%) were positive. Multivariate logistic regression analysis, with adjustment for age and sex, indicated that the use of cocaine was associated with a 3-fold higher prevalence of new-onset bronchospasm or recrudescence of asthma (OR = 3.28, 95% CI: 1.26 to 8.50). Conclusions: There appears to be an association between cocaine use and new-onset bronchospasm or recrudescence of asthma in this inner-city ED population. Further study is necessary to determine the basis for this association.

Inferior vena cava injuries: noninvasive follow-up of venorrhaphy.

Abstract: Background and Methods: Recent reports have documented a reduced mortality from injuries to the inferior vena cava (IVC). Few reports, however, have addressed the follow-up of the repaired IVC. From January of 1984 to December of 1995, we prospectively collected data on all patients with IVC injuries at Lincoln Medical and Mental Health Center, an urban Level I trauma center. Results: There were 81 patients with IVC injuries: 60 gunshot wounds, 17 stab wounds, and four blunt injuries. Overall, 45 patients survived (56%). Excluding those who arrived without vital signs and those who did not have emergency department thoracotomies, the survival was 68%. Of the survivors, 38 patients received lateral venorrhaphy, and seven patients underwent ligation. Of the 38 survivors with lateral venorrhaphy, 30 patients (79%) underwent noninvasive follow-up: 13 patients by sonography, 11 patients by computed tomographic scan, and six patients by both modalities. The IVC was visualized in 28 patients (93%) and was found to be patent in 24 (86%). There were four thromboses documented noninvasively, with three cases being confirmed by contrast venorrhaphy. All three resolved with systemic anticoagulation. Conclusions: We conclude that sonography and computed tomographic scan provide reliable noninvasive evaluation of the repaired IVC. We recommend that all patients with an IVC injury, which has been repaired, undergo evaluation for patency before discharge.

Efficacy of Atropine Sulfate in Combination with Albuterol in the Treatment for Acute Asthma

Abstract: Objective: To determine the efficacy of combination therapy using atropine sulfate and albuterol in the treatment for an acute exacerbation of asthma. Methods: A prospective, randomized double-blind, placebo-controlled study was performed in the ED of a large, inner-city, university-affiliated teaching hospital. Participants were a convenience sample of patients presenting to the ED between September 1993 and March 1994 with acute exacerbations of their asthma. Patients judged to be in extremis were excluded. All patients received 3 nebulized treatments with 2.5 mg of albuterol at 0, 30, and 60 minutes. Patients were randomized into 1 of 3 groups with the following added to their nebulizer solutions: 1) saline placebo during all 3 treatments; 2) 2.0 mg atropine sulfate added to the first nebulizer and saline in the second and third; or 3) 2.0 mg atropine to the first and third treatments (with saline in the second). No other medication was administered during the study period. At 90 minutes, the patients were evaluated for admission or release from the ED according to predetermined criteria, and additional medications were given as necessary. Vital signs, peak expiratory flow rate (PEFR), degree of wheezing, level of distress, and side effects were measured before and after each nebulizer treatment. Results: Of the 153 patients eligible for the study, 126 completed the entire study protocol. There was no significant difference between the 3 groups on any parameter studied, including improvement of PEFR, vital signs, or level of distress. There was no difference in the admission rate between the 3 groups, nor was there a difference in the incidence of side effects among the groups. Conclusion: In this study population, combination therapy with atropine sulfate and albuterol offered no significant benefit over the use of albuterol alone in the treatment for acute exacerbation of asthma.

Bioethical Aspects of HIV Infection in Children

Abstract: The care of HIV-infected children is fraught with many bioethical conflicts and dilemmas that require careful attention if care is to be provided appropriately. Understanding of the interplay of such general principles as autonomy, nonmaleficence, confidentiality, and veracity helps to clarify the nature of specific conflicts. This article addresses both general principles and their specific applications to pediatric patients with HIV infection. It addresses these matters from the points of view both of patients and parents. It shows why conflict is practically inevitable, and it points the way toward prevention and resolution of conflict. Practical guidelines are provided in relation to the critical problem of disclosure of diagnosis to the patient.

Unwillingness to lie supine? a sign of pericardial tamponade.

Abstract: The stable patient with an occult cardiac injury can represent a diagnostic dilemma. The trauma surgeon must maintain a high index of suspicion for cardiac injury with precordial penetrating trauma. Herein are reported two cases of stable patients with penetrating precordial trauma who refused to lie supine because of difficulty breathing, preferring to sit upright, who eventually had positive pericardial windows and sternotomies for repair of cardiac injuries. The presence of this clinical finding, unwillingness to lie supine, should make the trauma surgeon highly suspicious of a cardiac injury and to proceed quickly to echocardiography or, preferably, to subxiphoid pericardial window to rule out cardiac injury.