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Background: Cervical spine clearance in the very young child is challenging. Radiographic imaging to diagnose cervical spine injuries (CSI) even in the absence of clinical findings is common, raising concerns about radiation exposure and imaging-related complications. We examined whether simple clinical criteria can be used to safely rule out CSI in patients younger than 3 years., Methods: The trauma registries from 22 level I or II trauma centers were reviewed for the 10-year period (January 1995 to January 2005). Blunt trauma patients younger than 3 years were identified. The measured outcome was CSI. Independent predictors of CSI were identified by univariate and multivariate analysis. A weighted score was calculated by assigning 1, 2, or 3 points to each independent predictor according to its magnitude of effect. The score was established on two thirds of the population and validated using the remaining one third., Results: Of 12,537 patients younger than 3 years, CSI was identified in 83 patients (0.66%), eight had spinal cord injury. Four independent predictors of CSI were identified: Glasgow Coma Score <14, GCSEYE = 1, motor vehicle crash, and age 2 years or older. A score of <2 had a negative predictive value of 99.93% in ruling out CSI. A total of 8,707 patients (69.5% of all patients) had a score of <2 and were eligible for cervical spine clearance without imaging. There were no missed CSI in this study., Conclusions: CSI in patients younger than 3 years is uncommon. Four simple clinical predictors can be used in conjunction to the physical examination to substantially reduce the use of radiographic imaging in this patient population.

Normal-appearing epithelium of cancer patients can harbor occult genetic abnormalities. Data comprehensively comparing gene expression between histologically normal breast epithelium of breast cancer patients and cancer-free controls are limited. The present study compares global gene expression between these groups. We performed microarrays using RNA from microdissected histologically normal terminal ductal-lobular units (TDLU) from 2 groups: (i) cancer normal (CN) (TDLUs adjacent to untreated ER+ breast cancers (n = 14)) and (ii) reduction mammoplasty (RM) (TDLUs of age-matched women without breast disease (n = 15)). Cyber-T identified differentially expressed genes. Quantitative RT-PCR (qRT-PCR), immunohistochemistry (IHC), and comparison to independent microarray data including 6 carcinomas in situ (CIS), validated the results. Gene ontology (GO), UniProt and published literature evaluated gene function. About 127 probesets, corresponding to 105 genes, were differentially expressed between CN and RM (p < 0.0009, corresponding to FDR <0.10). 104/127 (82%) probesets were also differentially expressed between CIS and RM, nearly always (102/104 (98%)) in the same direction as in CN vs. RM. Two-thirds of the 105 genes were implicated previously in carcinogenesis. Overrepresented functional groups included transcription, G-protein coupled and chemokine receptor activity, the MAPK cascade and immediate early genes. Most genes in these categories were under-expressed in CN vs. RM. We conclude that global gene expression abnormalities exist in normal epithelium of breast cancer patients and are also present in early cancers. Thus, cancer-related pathways may be perturbed in normal epithelium. These abnormalities could be markers of disease risk, occult disease, or the tissue's response to an existing tumor., ((c) 2007 Wiley-Liss, Inc.)

During wartime, abdominal and thoracic trauma constitutes approximately 20% of combat-related injuries. Rates of infection vary based upon organ of injury with the highest rates noted for trauma to the colon. This review focuses on the management and prevention of infections related to injuries of the thoracic and abdominal cavity. The evidence upon which these recommendations are based included military and civilian data from prior published guidelines, clinical trials, where available, reviews, and case reports. Areas of focus include antimicrobial therapy, irrigation and debridement, timing of surgical care, and wound closure. Overall, there are limited data available from the modern battlefield regarding the prevention or treatment of these infections and further efforts are needed to answer best treatment strategies.

Purpose: To retrospectively evaluate the integration of pelvic computed tomographic (CT) angiography into the thoracoabdominal CT examination of blunt trauma by using 64-detector row CT to differentiate active arterial from active venous hemorrhage., Materials and Methods: This study was institutional review board approved and HIPAA compliant; the requirement for informed patient consent was waived. Fifty-three patients (30 male, 23 female; mean age, 42 years) with multiple blunt trauma underwent pelvic CT angiography with 64-detector row CT at admission. Arterial phase and portal venous phase pelvic CT angiograms were evaluated for evidence of vascular injury. In patients with active extravasation, the size of the hemorrhaging area was measured on arterial, portal venous, and delayed phase images. The Fisher exact test was used to correlate presence of vascular injury with subsequent clinical management. The Wilcoxon rank sum test was used to test the association between size of active hemorrhage during the vascular enhancement phases and subsequent clinical outcome. Finally, the Fisher exact test was used to correlate presence of vascular injury with severity of osseous injury., Results: At pelvic CT angiography, 21 of the 53 patients had evidence of vascular injury: 10 isolated active arterial extravasations, three isolated arterial occlusions, three cases of both arterial extravasation and occlusion, two cases of arterial and venous extravasations, and three isolated venous extravasations. Eleven of the 21 patients also underwent conventional angiography, with subsequent embolization performed in seven of these 11 patients. The remaining 10 patients were successfully treated conservatively. When the foci of active arterial extravasation were compared on arterial, portal venous, and delayed phase images, the mean areas of hemorrhage across all three phases were larger in patients who required conventional angiography than in those successfully treated with conservative management., Conclusion: With use of 64-detector row scanning, pelvic CT angiography was successfully integrated into the authors' CT protocols and enabled differentiation between active arterial and active venous hemorrhage, which may influence clinical management., ((c) RSNA, 2008.)

Background: Higher mortality in elderly drivers involved in motor vehicle collisions (MVCs) is a major concern in an aging population. We examined a spectrum of age-related differences in injury severity, outcome, and patterns of injuries using our institution's trauma registry and the National Trauma Data Bank., Methods: Injury severity scores (ISSs) and measures of outcome were compared among five age groups (<26, 26-39, 40-54, 55-69, 70+ years) using chi tests and analysis of variance. International Classification of Diseases-9th Revision (ICD-9) codes were used to compute the frequency of specific injuries across groups. We used stratified analysis and multiple logistic regression to control for confounding., Results: After the age of 25, injury severity, mortality, and length of stay (LOS) all increased progressively with age, whereas likelihood of discharge home decreased for each group (p < 0.001). Restraint use increased with age. However, age-related adverse outcomes were significantly increased even after adjusting for restraint use (p < 0.0001). Unrestrained elderly drivers had the highest mortality and morbidity (p < 0.001), and were least likely to be discharged home (p < 0.001). Abbreviated Injury Scale scores and ICD-9 codes indicated that poor outcomes with older age were driven primarily by head and chest injuries, especially intra-cranial hemorrhage, rib fractures, pneumothorax, and injury to the heart and lungs., Conclusions: Elderly drivers involved in MVCs have disproportionately poor outcomes primarily because of a greater incidence of head and chest injuries. Seat belt and airbag use in elderly drivers significantly reduce this trend but do not eliminate it. These observations should help establish clinical guidelines for the evaluation of traumatized elderly drivers, develop specific education programs, and safer vehicle design.

Endovascular therapeutic hypothermia has been shown to preserve neurological function and improve outcomes; however, its use and potential complications have not been fully described in patients with traumatic head injuries. We believe that the use of endovascular cooling leads to deep venous thrombosis (DVT) in this high-risk population. We performed a retrospective review of 11 patients with severe head injuries admitted to our Level I trauma center surgical intensive care unit who underwent intravascular cooling. Duplex sonograms were obtained after 4 days at catheter removal or with clinical symptoms that were suspicious for DVT. Patients had a mean age of 23.2 (range, 16-42) years and an Injury Severity Score of 31.9 (range, 25-43). The overall incidence of DVT was 50 per cent. The DVT rate was 33 per cent if catheters were removed in 4 days or less and 75 per cent if removed after 4 days (risk ratio = 2.25; odds ratio = 6; P = ns). An elevated international normalized ratio upon admission was protective against DVT (no DVT = 1.26 vs DVT = 1.09; P = 0.02). Inferior vena cava filters were placed in most patients with DVT. The use of endovascular cooling catheters is associated with increased risk of DVT in patients with traumatic head injuries. Therefore, we discourage the use of endovascular cooling devices in this patient population.

Purpose: To retrospectively evaluate delayed-phase computed tomography (CT) in the differentiation of active splenic hemorrhage requiring emergent treatment from contained vascular injuries (pseudoaneurysms or arteriovenous fistulas) that can be treated electively or managed conservatively., Materials and Methods: The institutional review board approved this HIPAA-compliant retrospective study; the informed consent requirement was waived. Forty-seven patients with blunt splenic injury diagnosed at CT after blunt abdominal trauma were evaluated. Abdominal and pelvic dual-phase CT was performed; images were obtained 60-70 seconds and 5 minutes after contrast material injection. Scans were reviewed in consensus by two radiologists. Splenic injuries were graded with the American Association for the Surgery of Trauma Splenic Injury Scale. Patients with intrasplenic hyperattenuating foci on portal venous phase images were classified as having active splenic hemorrhage (group 1) or a contained vascular injury (group 2) on the basis of delayed-phase imaging findings. Findings suggestive of active hemorrhage included areas that remained hyperattenuating or increased in size on delayed-phase images. The clinical outcome of these patients was determined by reviewing their medical records. Relationships between several factors were tested with the Fisher exact test, including (a) the presence or absence of hyperattenuating foci and management and (b) the presence of contained vascular injury or active extravasation and management., Results: Portal venous phase CT revealed a focal high-attenuation parenchymal contrast material collection in 19 patients: nine patients were classified as group 1 and 10 were classified as group 2. All patients in group 1 underwent emergent splenectomy, and all patients in group 2 were initially treated without surgery. Significant differences in management were noted on the basis of whether hyperattenuating foci were seen on portal venous phase images (P < .001) and whether hyperattenuating foci seen at portal venous phase imaging were further characterized as active splenic hemorrhage or a contained vascular injury at delayed-phase CT (P < .001)., Conclusion: In blunt splenic injury, delayed-phase CT helps differentiate patients with active splenic hemorrhage from those with contained vascular injuries.

Purpose: To retrospectively evaluate multi-detector row computed tomography (CT) without oral contrast material for depiction of bowel and mesenteric injuries that require surgical repair in patients with blunt abdominal trauma., Materials and Methods: The investigational review board approved the study. Informed consent was waived. CT reports for October 2001 to September 2003 were reviewed and 1082 patients were identified who had undergone abdominopelvic CT with a multi-detector row scanner and without oral contrast material. Findings were divided into four categories: negative, solid organ injury with or without hemoperitoneum, free fluid only, and suspected bowel or mesenteric injury. Sensitivity, specificity, positive predictive value, and negative predictive value were calculated by comparing CT findings with laparotomy reports and hospital course., Results: CT findings were no intraabdominal injury (n = 932), solid organ injury only (n = 102), free fluid only (n = 34), and suspected bowel or mesenteric injury (n = 14). CT findings in patients suspected of having bowel or mesenteric injury were pneumoperitoneum with other secondary findings (n = 4), mesenteric hematoma and bowel wall abnormality (n = 2), mesenteric hematoma only (n = 4), and bowel wall thickening only (n = 4). In 11 patients, bowel or mesenteric injury was proved surgically. Thus, the study included 1066 true-negative, nine true-positive, two false-negative, and five false-positive results. Based on these data, sensitivity was 82% (95% confidence interval [CI]: 52%, 95%), specificity was 99% (95% CI: 98%, 99%), positive predictive value was 64% (95% CI: 39%, 83%), and negative predictive value was 99% (95% CI: 98%, 99%) for depiction of bowel and mesenteric injuries., Conclusion: Multi-detector row CT without oral contrast material is adequate for depiction of bowel and mesenteric injuries that require surgical repair. Results are comparable with previously reported data for single-detector row helical CT with oral contrast material., ((c) RSNA, 2004.)

Background: During the past 25 years, there has been much debate about general surgical workforce supply and demand. In the late 1970s and early 1980s, concern was raised by the Study on Surgical Services for the United States and the Graduate Medical Education National Advisory Council that there would be a gross oversupply of total physicians and surgeons by the years 1990 and 2000., Data Sources: In a 1990 report sponsored by the Council on Graduate Medical Education, reevaluation of the workforce data showed no surplus at that time and instead predicted a deficit of surgeons by 2010. Studies by other investigators in the mid-1990s supported these conclusions. Furthermore, a new workforce model published in 2002 predicted a significant overall deficit of physicians by 2020. The discrepancies in the projected and the actual data have been explained by a variety of factors including an aging population with increased surgical needs, an increasing number of outpatient surgical procedures, subspecialization within the field of general surgery, and decreasing interest in the field by United States medical students., Conclusions: Although it is difficult to compare data among studies, and there are many confounding factors in the data, review of the workforce data does support a future deficit of surgeons, a prediction that warrants further investigation.

Injury patterns in elderly patients are different from those in younger patients. With recent emphasis on osteoporosis and its effects, we looked at a continuous series of patients from one Level 1 trauma center regarding injury patterns by gender. For all patients older than 65 years, and including all mechanisms, older women were more likely to sustain forearm and wrist fractures than were older men. For the individual mechanism of motor vehicle collision there was a significant increase in the extremity Abbreviated Injury Scores in older women compared with older men. Similarly, older women were more likely to sustain lower leg fractures and distal upper extremity fractures than were older men. This raises the possibility that increased bone loss, as seen in older women, may be reflected in the injury patterns they sustained given the same mechanism. More work is warranted in this region to potentially diminish these effects.

Background: Adenosine nucleotides provide energy for many essential cellular functions. Liver and intestinal ATP and energy charge are known to decrease during hemorrhagic shock, and the ability to regenerate high-energy phosphates may have important implications for recovery. We measured organ-specific changes in energy charge after hemorrhagic shock and after shock followed by resuscitation., Study Design: Anesthetized Sprague-Dawley rats were bled and maintained at a mean arterial pressure (MAP) of 40 mmHg for 1, 2, 3, or 4 hours. Some animals were resuscitated with normal saline and shed blood (1:1) to a mean arterial pressure of 80 to 90 mmHg for 1 hour. Control animals were anesthetized, but not hemorrhaged. At the conclusion, blood gases and adenine nucleotides were measured., Results: Arterial pO2 and pCO2 were normal in all groups. Unresuscitated hemorrhage caused metabolic acidosis, but bicarbonate was normal in controls and after hemorrhage followed by resuscitation. Energy charge (EC) in the gastrocnemius was unaffected by hemorrhage or resuscitation. Liver EC decreased after hemorrhage (p = 0.0001), but recovered partially after resuscitation. Kidney EC was decreased after only 3 hours of hemorrhage and 1 hour of resuscitation (p = 0.005), but not with shorter periods of hemorrhage. Lung EC decreased with shock, but was substantially worse after resuscitation (p < 0.05)., Conclusions: After hemorrhage and resuscitation, EC decreased in lung, liver, kidney, and intestine, but the time course, extent of decline, and ability to recover after resuscitation varied from organ to organ. Inability to regenerate high-energy phosphates after hemorrhagic shock may be a marker for more severe cellular damage.

Background: Reflectance near-infrared spectroscopy (600-2200 nm) can noninvasively probe deep into tissues. Blood is the predominant absorber of near-infrared light in biological tissues. We investigated the feasibility of using reflectance near-infrared spectroscopy to measure blood pH in vitro., Methods: Reflectance near-infrared spectra (600-2200 nm) were obtained with a fiberoptic probe immersed in diluted human packed red blood cells maintained at 37 degrees C. Changes in pH (6.800-7.600) were induced by: (1) varying the partial pressure of carbon dioxide by the bubbling of mixtures of humidified carbon dioxide and nitrogen gas through the blood; and (2) adding 1 N HCl/NaOH. Humidified oxygen gas was bubbled through the blood to generate variations in oxygen saturation. After each titration of pH, the spectrum was recorded and blood was sampled for the measurement of: pH, pCO(2), and pO(2) using blood gas analysis; and hemoglobin concentration and oxygen saturation using co-oximetry. Samples from three separate pH titrations were combined (120 total samples) and analyzed using partial least-squares analysis to generate a mathematical model relating spectral changes to pH (calibration set). This model was then used to predict the pH of a set of 36 pH titrations (prediction set)., Results: Quantitative and qualitiative analyses of the spectra in the calibration set found that spectral changes in the wavelength range, 650-1050 nm, were directly related to changes in pH. First-derivative-treated spectra from the calibration set, analyzed using partial least-squares analysis, generated a mathematical model with a cross-validated r(2) of 0.939 and a standard error of calibration of 0.046 pH unit. When this model was applied to the prediction set, with an offset correction, the r(2) was 0.936 with a standard error of prediction of 0.050 pH unit., Conclusion: Blood pH can be predicted in vitro with clinical significance using reflectance near-infrared spectroscopy (650-1050 nm) within a standard error of 0.050 pH unit.

Optimizing nutritional delivery in the intensive care unit (ICU) continues to be a challenge. Nutritional guidelines were developed at a metropolitan Level I trauma center as an institutional response to ensure the timeliness of patient evaluation, initiation of therapy, and attainment of goal therapy. A post-implementation review of 525 consecutive ICU patients revealed that the guidelines enabled the staff to evaluate 86% of all ICU patients and initiate appropriate therapy in 68% of them within 48 hours of admission. Goal therapy was achieved in more than 90% of patients within 72 hours. The establishment of nutritional guidelines is an integral step to improving nutritional therapy in the ICU.

Clinical pathways are similar to the production algorithms developed by industry. They are being adapted for use in healthcare to reduce resource utilization, decrease variability, and control expenditures. At Boston Medical Center we identified four trauma diagnoses that we believed to be amenable to the design and implementation of clinical pathways: closed head injury, penetrating wound to the abdomen, penetrating wound to the chest, and penetrating wound to an extremity. Upon implementation of these pathways, appropriate nonoperative, single-system, short-stay trauma patients were enrolled in them. This article details the process by which the four diagnoses were identified and the pathways designed, implemented, and evaluated. Preliminary data demonstrate a significant decrease in resource utilization following implementation of the pathways, without an adverse impact on readmission rates, length of stay, or mortality.

Introduction: Penetrating thoracic trauma in the pediatric population is increasing at an alarming rate. We sought to describe this population and to define prognostic factors that might be of benefit in the management of these patients., Methods: We retrospectively reviewed the charts and trauma registry records of 65 patients 18 years of age and younger admitted to an urban level I trauma center with the diagnosis of penetrating thoracic trauma., Results: The majority of the patients were adolescent boys. Injury severity score greater than 25 and a corrected admission pH less than 7.3 were associated with higher mortality and increased need for surgical intervention. Isolated thoracic injury was found to be associated with a high mortality rate. Autotransfused blood was used in 9 of the 65 patients., Conclusions: Injury severity score and corrected admission pH are independent predictors of mortality and need for operation in the pediatric population with penetrating chest injuries. Penetrating thoracic wounds demand special attention by the trauma team. The use of autotransfusion may be beneficial in pediatric trauma victims.

Leiomyoma is the most uncommon benign neoplasm of the breast. We report a case of a middle-aged woman with a palpable breast mass who underwent excisional biopsy. Pathologic examination revealed a leiomyoma. The clinical characteristics, pathologic findings, and proper management of this lesion are discussed. The tumor is thought to arise from the smooth muscle of the endothelium and can be managed similarly to leiomyomas occurring elsewhere. The possible effects of tamoxifen on uterine leiomyomas may be of theoretical concern with breast leiomyomas. The recognition of this entity and an understanding of the management of this rare lesion are necessary by all surgeons who perform breast surgery.

Unlabelled: A medical partnership program between Boston University School of Medicine and the the Emergency Hospital, of Yerevan, Armenia, has been developed to improve the care of the injured in that city. The Emergency Hospital, a trauma center, was site-visited by experts from a Level I trauma center who evaluated prehospital and hospital-based emergency and trauma services and made system-wide recommendations. Recognizing local limitations, the hospital was found to have the leadership commitment, staff complement, and basic infrastructure to meet the American College of Surgeons' criteria for Level II trauma centers. The goal of integration of the academic, clinical, and research roles of a medical center consistent with Level I-type trauma centers was formulated. After 36 months, several issues raised in the assessment are being addressed notwithstanding political and economic turbulence. The Emergency Hospital has established an accredited residency program in emergency medicine; implemented programs for postgraduate medical education of its staff; begun to develop medical information systems; expanded the scope of its activities to other institutions; and restructured the emergency admissions area. Management systems remain largely undeveloped as the discipline lacks recognition as an analytic tool for institutional improvement., Conclusions: The use of existing published resources for assessment and improvement of health services in dissimilar health-care systems has been validated as a systematic approach. For system advances to be well-founded, a combination of education, management, and clinical approaches needs to be addressed. Of these, our experience is that management issues are the most resistant to change.

Objective: To investigate the effect of apneumic retraction on intracranial pressure (ICP) using a live porcine model., Design: Five 25- to 30-kg pigs had a fiber-optic ICP bolt inserted under general endotracheal anesthesia and were monitored for ICP, mean arterial pressure, arterial blood gas measurements, and intra-abdominal pressure before, during, and after pneumoperitoneum, with each period 30 minutes long. These series of measurements were repeated after artificially raising ICP with an epidural balloon to create a head-injured model. The mean (+/- SE) ICP in the noninjured model at baseline was 13.46 +/- 1.01 mm Hg; during pneumoperitoneum, 18.72 +/- 1.50 mm Hg (P = .0001). Similarly, in the head-injured model, ICP was raised artificially to a new baseline of 22 +/- 1.75 mm Hg with an epidural balloon, and pneumoperitoneum increased ICP to 27.40 +/- 0.93 mm Hg (P = .0001). Pneumoperitoneum was then released, and an apneumic retractor was inserted while maintaining the inflated epidural balloon., Main Outcome Measure: Changes in ICP., Results: Applying anterior wall retraction equivalent to 20 mm Hg was not associated with changes in ICP. These observations were independent of any changes in arterial PCO2 or arterial pH. Following the release of pneumoperitoneum, abdominal wall retraction, and epidural balloon, all measurements reverted to baseline., Conclusion: Pneumoperitoneum adversely affects ICP, while apneumic retraction may not affect animals with raised ICP. These findings suggest that pneumoperitoneum should be used with caution in patients with raised ICP, and apneumic retraction may be a safer alternative for laparoscopic evaluation in this population.

Objective: To determine if pH measured at the time of hospital admission and corrected for PCO2 was an independent predictor of trauma survival., Design: Phase 1 was a retrospective case-control analysis of 1708 patients, followed by multivariate multiple logistic regression analysis of a subset of 919 patients for whom the Revised Trauma Score (RTS), Injury Severity Score (ISS), and pH were available. Phase 2 was a prospective comparison of a mathematical model of survival derived in phase 1 (pH-TRISS) with the TRISS method in 508 of 1325 subsequently admitted trauma patients., Setting: Urban level 1 trauma center., Patients: All patients admitted with blunt or penetrating trauma during the study period., Main Outcome Measures: Survival vs mortality., Results: In phase 1, factors significantly associated with mortality by t test and chi 2 analysis included the RTS, ISS< Glasgow Coma Scale, corrected pH (CpH), and sum of the head, chest, and abdominal components of the Abbreviated Injury Scale-85 (AIS85) (HCAISS) (for all, P < .0001). The TRISS statistic was also a significant predictor of survival (P < .004). Age, sex, and the extremity and soft tissue components of the AIS85 were not associated with mortality. In a multivariate analysis of the RTS, HCAISS, and CpH, all were significant predictors of mortality. Even when controlling for RTS and HCAISS, CpH remained a significant predictor of mortality (P < .008). In phase 2, when pH-TRISS was tested prospectively against TRISS in a new group of patients, the new statistic appeared to provide a more accurate prediction of survival., Conclusions: The arterial pH measurement obtained on hospital arrival and corrected for PCO2 is a significant independent predictor of survival and adds to the predictive accuracy of the TRISS survival statistic. Age, sex, and the extremity and soft tissue components of the AIS85 did not contribute to the accuracy of the TRISS statistic in this patient population.

Previous studies have demonstrated that laser Doppler (LD) flowmetry is a useful technique for following changes in blood flow in a tissue bed, but the potential role of LD flowmetry in management of the critically ill patient is unclear. This study sought to establish the sensitivity of LD flowmetry compared to changes in centrally measured hemodynamic parameters in response to a mild hemorrhagic episode. In order to establish the correlation between LD flow and actual blood flow, livers from Sprague-Dawley rats were isolated and perfused via the portal vein with citrate anti-coagulated rat blood. Changes in LD flow were recorded while changing blood flow via the perfusion pump. There was a strong correlation between pump flow and LD flow (for N = 5 livers, r > 0.9; P < 0.05). This relationship was stable at hematocrits > 20. The second part of this study tested the sensitivity of LD flowmetry in anesthesized baboons. An LD probe was placed on the surface of the gracilis muscle of the adult male baboons. LD flow and hemodynamic parameters were measured following two episodes of bleeding and reinfusing 250 cc of blood. During the first bleed there were significant changes in heart rate (97 + 8 to 159 + 12), mean arterial pressure (125 + 6 to 105 + 9), and LD flow (20.6 + 4.6 to 11.9 + 3.6); these parameters returned to normal after reinfusion of blood. During the second bleed, the only parameters that showed significant changes were heart rate (118 + 5 to 135 + 12) and LD flow (17.5 + 8 to 10.7 + 3.4).(ABSTRACT TRUNCATED AT 250 WORDS)

There are numerous reports in the literature concerning the use of laparoscopy for evaluation of abdominal trauma victims. The safety of laparoscopic evaluation in trauma patients with potentially severe intracranial injuries has not yet been analyzed. This study investigates the effect of pneumoperitoneum on intracranial pressure (ICP) and cerebral perfusion pressure. Five 30-kg pigs were monitored for ICP, mean arterial pressure (MAP), arterial blood gases (ABGs), and intra-abdominal pressure (IAP) for 30 minutes before, during, and after pneumoperitoneum. These series of measurements were repeated after artificially elevating the ICP with an epidural balloon. The mean ICP at baseline was 13.46 +/- 1.01 mm Hg. The mean ICP during pneumoperitoneum was 18.72 +/- 1.50 mm Hg (p = 0.0001). The ICP increased to 27.40 +/- 0.93 mm Hg (p = 0.0001) after the ICP was raised artificially to a new baseline of 22 +/- 1.75 mm Hg with the epidural balloon. These increases were independent of changes in arterial PCO2 or arterial pH. Pneumoperitoneum during laparoscopy may increase ICP and must be used cautiously in evaluating patients with severe head injuries.

Objective: To test the hypothesis that a supply of frozen red blood cells and a system for processing pyrogen-free crystalloid solution would meet the needs of an echelon 3 medical treatment facility in the U.S. military, caring for casualties during the initial phase of a military medical operation., Data Sources: Blood requirements for potential combat casualties were estimated from transfusion data on: (1) patients admitted to Boston City Hospital following trauma, utilizing a computerized data base, (2) patients admitted to the Naval Support Hospital-Da Nang during the Vietnam War, from 1966 to 1970, from published and unpublished material, and (3) casualties estimated by Department of Defense expert panels for specific conflicts. The procedure for processing frozen red blood cells was evaluated at the Naval Blood Research Laboratory. Estimates of wounded in action were provided by the Department of Defense., Data Synthesis: Computer modeling using standard spreadsheet software on a personal computer., Conclusions: Under military conditions, a frozen red blood cell bank and a system for processing pyrogen-free resuscitative fluid could be used to prepare 96 units of red cells and 960 1 of crystalloid solution per day. This would be adequate to treat approximately 180 casualties, the number projected for a 5-day battle with heavy casualties (6 wounded in action/1,000 soldiers/day). It was concluded that a frozen blood bank system and system for processing pyrogen-free resuscitative fluid could successfully meet the needs of an echelon 3 medical facility in the initial phase of a military medical operation.

On rare occasions, thoracic injuries require resuscitative efforts including emergent thoracotomy that result in edematous changes to the lungs and heart. Hemodynamic compromise occurs when these organs are placed in their anatomic position and closure of the thoracotomy is attempted. Adaptation of a temporary abdominal closure to a thoracic injury is described.

The combination of conventional traumatic injuries and radiation exposure has synergistic consequences, the full extent of which may take days to weeks to become apparent. Our understanding of such is derived from a variety of laboratory and clinical scenarios involving both therapeutic and accidental exposures. When presented with such an individual one must discern whether the victim has been bodily contaminated versus exposed to a source or both. The former will necessitate decontamination procedures which may be as simple as declothing and showering the individual. Simply removing the victim from the source will suffice to halt further radiation induced injury. In the vast majority of cases basic life support and other emergency medical procedures should be expeditiously instituted as warranted and without fear of personal hazard for health care teams. Following stabilization, further medical/surgical support must be predicated upon the extent of the radiation injury with the circulating absolute lymphocyte count serving as both a reliable and readily accessible indicator of the degree of underlying radiation injury. As radiation has profound consequences on immune and wound healing systems, therapies must be tempered by an understanding of the impact of radiation upon these systems. Overall, the consequences of irradiation injury will be the potential for an exacerbation of the effects of conventional traumatic injuries with a higher than expected morbidity and mortality.

Most injuries to the lung can be managed nonoperatively and rarely require resection. A case of bilateral hilar injuries requiring bilateral pulmonary lower lobectomies is presented. The resulting pulmonary hypertension, right ventricular failure, and cardiogenic shock explain the high mortality following extensive pulmonary resection in thoracic trauma and support the concept of a conservative approach.