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Byline: James W. Pate, Gayle Minard Author Affiliation: Elvis Presley Trauma Center Department of Surgery University of Tennessee Memphis, TN 38163

Aortic cross-clamping during surgery of the thoracic aorta may result in paraplegia or kidney failure. Difficulties associated with external shunts and bypasses have limited their use. Therefore we compared intraluminal shunting to the nonshunting method of repair in neonatal pigs. Blood flow to the spinal cord and viscera was measured with radiolabeled microspheres before, during, and after thoracic aortic cross-clamping or shunting. Two no-shunt groups were studied: One group was clamped distal to the left subclavian artery for 30 minutes and the other for 1 hour. In the intraluminal shunt group, a shunt was placed in the aorta just below the ligamentum arteriosum for 1 hour; it was then removed and the aorta repaired. In the no-shunt groups, there was virtually no blood flow to the lower cord and viscera during the cross-clamp period. Hyperemia of the lower thoracic and lumbar cord occurred in the no-shunt 30-minute group 15 minutes after clamp removal. In the no-shunt 60-minute group, flow initially returned to the lumbar cord but then declined; and after 1 hour of reperfusion it was significantly lower than baseline. Renal blood flow was even more severely affected in the no-shunt 60-minute group, with minimal recovery during the reperfusion period. In the intraluminal shunt group baseline spinal cord and visceral blood flow were maintained during thoracic aortic cross-clamping, without the problems associated with extracorporeal circulation.

Chest wall injuries range from relatively trivial to fatal flail chest or huge defects. Significant chest wall injury is present in about one third of patients admitted after severe trauma. In management, the principal areas to be considered are pain control, open wounds, pneumothorax, flail chest, and pulmonary contusion.

Tracheobronchial injury was considered rare until the last two decades but is becoming more common (or is being recognized more often). The author reviews diagnosis and the principles of management, among which infection prevention is stressed.

Arterial injuries at the base of the neck are associated with a high mortality from uncontrolled hemorrhage and cerebral ischemia and, in survivors, frequently result in permanent crippling due to vascular insufficiency.This report is an analyses of 21 patients with proven major arterial injuries at the base of the neck treated at the City of Memphis Hospitals in the last 12 years. ETIOLOGY. —The incidence of arterial involvement from lacerations in this area cannot be proven due to the fact that many neck and shoulder lacerations are sutured and the patient sent home without hospital admission or long-term follow-up. In any case, a statement of the incidence of such wounds would have little clinical meaning. It appears that the majority of the gunshot wounds between the first intercostal space and the cricoid cartilage do involve major vessels. Likewise, only one of these 21 cases sustained a simple lacerating injury—this

As more cardiac and great-vessel diseases are being surgically attacked, the need for accurate anatomical diagnosis becomes mandatory. While the classical history and physical examination remain the most important diagnostic tools available, they are frequently unable to give the high degree of anatomical exactness demanded by surgical intervention in central cardiovascular disease. Roentgenographic visualization of the contrast-filled heart and great vessels has proved to be one of the most useful of the special diagnostic procedures. Many methods have been described for arteriographic visualization of the aortic arch and its branches. In general, these methods may be divided into three groups: (1) angiocardiography, in which the dye passes through the heart and then into the aorta,10 with its modifications of right atrial catheterization23 and release of dye from an intra-atrial bulb9; (2) retrograde arterial catheterization via the carotid,5 the brachial,1 the radial,14 or the femoral

1.Measurements of the (forced) total and timed expiratory vital capacities and maximum expiratory flow rates have been made in 11 patients with obvious right ventricular failure and in 18 with left ventricular failure.2.Pulmonary ventilation studies were of limited value in right ventricular failure except in following the response to therapy. Arterial gas studies were more informative here.3.However, ventilation tests were a sensitive indicator of incipient or frank left ventricular failure and its response to therapy.4.Normal parameters obtained on pulmonary ventilation testing as described in this paper were helpful in differentiating acute left ventricular failure from other causes of dyspnea.

1.This is a report of 32 cases of bronchogenic carcinoma in which the correct diagnosis was never seriously considered before death. These errors occurred in 650 cases of bronchogenic carcinoma from among about 150,000 admissions.2.The presenting complaints were extremely variable. Joint pain, neurological and gastrointestinal symptoms were present in most cases. Respiratory symptoms were the presenting complaints in only two.3.Physical findings revealed neurological deficits in 13 and eight had abnormality on examination of the chest.4.Negative chest x-ray films were obtained from six. Soft infiltrations suggestive of tuberculosis or pneumonia were present in 13; five of these shadows disappeared during hospitalization. Bullous emphysema was the next most common finding on x-ray film.5.Half of the patients were considered to have tuberculosis and about a third had positive sputa.6.Metastases were usually extensive, involving the liver, adrenal, bone, brain, heart, spleen, gastrointestinal tract, kidney, thyroid and skin.7.Study of these errors in diagnosis indicates that spinal or brain compression, joint pain and pulmonary tuberculosis should make one cognizant of the possibility of coexisting bronchogenic carcinoma and that careful, repeated examinations should be made in patients with these conditions to prove or disprove the presence of cancer.