Neurogenic pulmonary edema due to traumatic brain injury: evidence of cardiac dysfunction.

BACKGROUND: Acute neurogenic pulmonary edema, a common and underdiagnosed clinical entity, can occur after virtually any form of injury of the central nervous system and is a potential early contributor to pulmonary dysfunction in patients with head injuries. OBJECTIVE: To explore myocardial function in patients with evident neurogenic pulmonary edema after traumatic head injury. METHODS: During a 1-year period in a university hospital in Sfax, Tunisia, information was collected prospectively on patients admitted to the 22-bed intensive care unit because of isolated traumatic head injury who had neurogenic pulmonary edema. Data included demographic information, vital signs, neurological status, physiological status, and laboratory findings. All of the patients had computed tomography and plain radiography of the neck and determination of cardiac function. RESULTS: All 7 patients in the sample had cardiac dysfunction. Evidence of myocardial damage was confirmed by echocardiography in 3 patients, pulmonary artery catheterization in 3 patients, and/or postmortem myocardial biopsy in 4 patients. Echocardiography studies, repeated 7 days after the initial study in one patient and 90 days afterward in another, showed complete improvement in wall motion, with a left ventricular ejection fraction of 0.65. CONCLUSION: All patients who had neurogenic pulmonary edema due to traumatic head injury had myocardial dysfunction. The mechanisms of the dysfunction were multiple. The great improvement in wall motion seen in 2 patients indicated the presence of a stunned myocardium. Further studies are needed to understand the mechanisms of this cardiac dysfunction.     

Pulmonary diffusing capacity in adult cystic fibrosis: reduced positional changes are partially reversed by hyperoxia

In seated adult cystic fibrosis (CF) patients, vascular recruitment of the relatively normal regions of the pulmonary circulation could occur in response to vascular destruction or hypoxia elsewhere in the pulmonary vasculature, thus limiting overall reductions in the single breath CO diffusing capacity (DLcoSB) with advancing disease. The purpose of this study was to determine the extent to which pulmonary capillary recruitment limits reductions in DLcoSB in seated adult cystic fibrosis patients, to define the role of hypoxia, and to develop strategies to improve detection of diffusion abnormalities in this disease. In normal subjects and adult CF patients breathing room air, and in a subgroup, after breathing both 40% and 100% O2 for 20 min, we measured changes (compared to sitting) in the three equation DLcoSB by changing transvascular pressure either with 15 degrees head down position (15 degrees HD), or with high negative inspiratory pressure (HNIP). In CF patients breathing room air, the changes in DLcoSB with both 15 degrees HD and HNIP were significantly smaller (p less than 0.01) than in controls and the positional changes correlated with the degree of airway obstruction. Although CF patients had no significant positional changes in diffusional resistance (1/DLcoSB) breathing room air, the positional changes in 1/DLcoSB after breathing 100% O2 for 20 min were similar in magnitude to the positional changes in normal subjects. We conclude that compensatory pulmonary capillary recruitment occurs in the relatively normal regions of the pulmonary vasculature breathing room air in the resting seated position in CF patients, thus minimizing reductions in DLcoSB in the seated position. This accounts for reduced responses of DLcoSB to both position and HNIP. The improved positional changes in 1/DLcoSB breathing hyperoxic gas mixtures in CF patients suggests that the vascular recruitment breathing room air is partly due to hypoxic vasoconstriction rather than due solely to fixed pathological changes in the pulmonary vasculature.     

Venous thromboembolism after trauma

PURPOSE OF REVIEW: The trauma population is at increased risk of venous thromboembolic disease, a potentially preventable cause of mortality and morbidity. Although the association between trauma and venous thromboembolism has been recognized for more than a century, there is still great variability in the clinical practices with respect to prophylaxis. This thorough review of recent literature aims to clarify the incidence and risk factors for deep venous thrombosis and pulmonary embolism after trauma, review options and recommendations for detection of deep venous thrombosis and pulmonary embolism, and give evidence-based recommendations for prophylaxis. Special attention is paid to patients with spinal cord injury, patients with head injury, and pediatric trauma patients. RECENT FINDINGS: Highlights in this field during the past year include stratification of venous thromboembolism risk factors after trauma using a large national database, the expanded use of venous duplex ultrasound surveillance in the ICU and during rehabilitation, and investigations into the safety of low molecular weight heparins in patients with solid organ and traumatic brain injuries. Additionally, two new classes of anticoagulant drugs have been introduced for venous thromboembolism prophylaxis, and there are some preliminary studies on a temporary vena cava filter for the prevention of pulmonary embolism. SUMMARY: Venous thromboembolism remains an area of active clinical research focusing on evolving diagnostic techniques, newer methods of chemical and mechanical prophylaxis, and improved understanding of the etiologic factors of posttraumatic venous thromboembolism. These efforts will undoubtedly decrease the posttraumatic morbidity and mortality associated with venous thromboembolism.     

ICU重度颅脑损伤患者肺部感染临床特征分析

[目的]探讨ICU重度颅脑损伤患者并发肺部感染的危险因素.[方法]对53例重度颅脑损伤并发肺部感染患者的临床资料进行回顾性分析.[结果]同期共收治165例重度颅脑损伤患者,其中53例合并肺部感染,感染率为32.1%.经单因素分析发现,气管切开史、住院天数≥20 d、基础疾病史、休克史和呼吸机应用史是ICU重度颅脑损伤并发肺部感染的危险因素.主要致病菌以革兰阴性杆菌为主,占72.7%,其次是革兰阳性球菌,占22.7%,真菌占4.6%.[结论]ICU重度颅脑损伤并发肺部感染与多种临床因素密切相关,其预后差,病死率高.     

Air embolism in chest trauma

Abstract Air embolism is a recognized complication of penetrating chest trauma. A case of fatal air embolism is presented and the pathophysiology of both venous and arterial air embolism is described. Air embolism can be precipitated by positive intrathoracic pressure in the presence of open vascular injury and can present as unexpected cardiovascular collapse following intubation and positive pressure ventilation. Strategies for preventing air embolism include minimum airway pressures during ventilation, single lung ventilation via a double lumen tube and maintenance of adequate pulmonary venous pressure with intravenous fluids. Established air embolism is managed by patient positioning to direct air bubbles away from vital organs, aspiration of intravascular air, minimizing air bubble size and repairing the underlying injury.     

Unexpected complication during extracorporeal membrane oxygenation support: Ventilator associated systemic air embolism

Systemic air embolism through a bronchovenous fistula (BVF) has been described in patients undergoing positive-pressure ventilation. However, no report has mentioned the potential risks of systemic air embolism through a BVF in patients undergoing extracorporeal membrane oxygenation (ECMO). Positive-pressure ventilation and ECMO support in patients with lung injury can increase the risk of systemic air embolism through a BVF. Increased alveolar pressure, decreased pulmonary venous pressure, and anticoagulation are thought to be the factors that contribute to this complication. Here, we present a case of systemic air embolism in a patient with ECMO and mechanical ventilator support.     

Remaining Vigilant to Paradoxical Air Embolism in Patients Undergoing Hysteroscopic Surgery: A Case Report and Review of the Literature

The purpose of this case study and review was to understand the perianesthestic care of paradoxical air embolism (PAE) in patients undergoing hysteroscopic surgery. The perianesthestic management record of a patient undergoing hysteroscopic surgery was analyzed to study the characteristics of PAE, and the literature describing the perianesthestic care for PAE was reviewed. The first symptom of PAE in hysteroscopic surgery is often a decrease in end-tidal carbon dioxide (ETCO₂), and the complications include embolism of the pulmonary artery, coronary artery, and cerebral artery. The best monitoring method is continuous ETCO₂ monitoring, and intraoperative echocardiography is an excellent method to diagnose and guide the treatment of PAE. PAE is a rare but serious complication of hysteroscopic surgery that is associated with organ ischemia and hypoxia. Prevention and treatment of PAE requires the vigilance and cooperation of not only perianesthesia nurses and anesthesiologists but also the surgeons and operating room nurses. Early prevention, proper monitoring, and effective treatment are the keys to successful rescue for PAE.     

脑卒中吞咽功能障碍鼻饲照护者对患者鼻饲体位的认知现状

目的了解脑卒中吞咽功能障碍鼻饲照护者对患者鼻饲体位的认知现状。方法用方便抽样法选取43名鼻饲照护者,用自行设计的调查问卷进行调查。结果74．42％照护者了解鼻饲体位不当易诱发或加重肺部感染,41．86％照护者了解病情允许时鼻饲体位为抬高床头至少30°,27．91％照护者能正确安置患者鼻饲体位,9．30％照护者了解鼻饲后保持原体位至少30min。结论脑卒中吞咽功能障碍鼻饲照护者对鼻饲体位认知偏差,应对照护者进行强化教育。     

Cardiac,Respiratory and Postural Influences on Venous Return of Internal Jugular and Vertebral Veins

It is known from physiology that heartbeat and respiration influence venous return, but little is known regarding the extent to which these two factors affect flow. In this study, we estimated the prevalence of cardiac- and breathing-induced venous flow modulations in the internal jugular vein (IJV) and vertebral vein (VV) and the effects of posture. In 19 healthy patients, neck vein flow was examined with pulsed wave Doppler. Electrocardiogram and respiratory signals were simultaneously acquired. In supine position, heart contraction always influenced venous flow, whereas breathing influenced 68% of IJV and 34% of VV flow. In sitting position, heart contraction influenced 74% of IJV and 42% of VV flow; breathing influenced 68% of IJV and 61% of VV measures. Thus, cardiac influence is greatly present in supine position, whereas breathing influence prevails in the VV while sitting. This setup allowed us to observe that in some patients, expiration may cause an unexpected increase in venous flow.     

Management strategies for improving outcome following severe head injury

Severe head injury is a major cause of disability, death, and economic cost. Significant reductions in mortality and morbidity can be achieved in patients with severe head injury through the use of evidence-based protocols and guidelines. Although no set standard is available for the management of patients with severe head injury, improved outcomes following severe head injury are seen with complete and rapid physiologic resuscitation and specific strategies that decrease ICP.     

Relationship of Forward Head Posture and Cervical Backward Bending to Neck Pain

Abstract

The purpose of this study was to investigate the relationship of forward head posture and cervical backward bending to neck pain. The subjects were fifty-four volunteer office workers, who spent at least four hours of their work day at a computer terminal (17 males and 37 females). Since all subjects reported having pain, the subjects who reported pain in four areas or more were considered the case group and those who reported pain in three areas or less were considered the control group. Measurements of forward head posture and cervical backward bending in both the natural sitting position and the erect sitting position were recorded by the Cervical Range of Motion Instrument (CROM). The results showed that compared to the control group, the case group subjects had more pain over the past thirty days, visited medical professionals more frequently during the past twelve months, and when describing a typical day reported greater pain. Additionally, members of the case group had greater forward head posture and less cervical backward bending in the natural sitting position and the erect sitting position. The results of this study support the belief that a relationship of forward head posture and cervical backward bending to neck pain exists.     

120例重型颅脑外伤患者并发肺部感染的危险因素分析及护理方法

目的:探讨重型脑外伤患者并发肺部感染的发生率,分析危险因素和相应有效的护理方法。方法:回顾分析2015年1-12月我院IC U 120例重型颅脑外伤患者的临床资料,观察患者肺部感染的发生率,分析危险因素、探讨护理方法。结果: 肺部感染的发生率54.2%,年龄、误吸、手术、气管切开、机械通气时间、肺部原发疾病、激素使用时间与重型颅脑外伤并发肺部感染相关。结论：针对危险因素采取有效的护理措施,降低重型颅脑外伤患者肺部感染的发生。     

Tension pneumocephalus

Tension pneumocephalus occurs when intracranial air exists under pressure, resulting in neurologic deterioration. The syndrome is precluded by an extracranial-intracranial communication and a difference in extracranial-intracranial pressure with the latter being greater. Although most frequently associated with head trauma, a variety of situations, including an operative sitting position and use of nitrous oxide anesthesia, have been known to contribute to this potentially life-threatening complication. This article will address pathogenesis, assessment parameters, and medical and nursing approaches utilized to reduce and minimize further entrapment of air. A case report will be presented illustrating this condition.     

Adult respiratory distress syndrome precipitated by massive salicylate poisoning

Pulmonary oedema has been reported in severe cases of acetyl salicylic acid (ASA) poisoning. Liberal use of intravenous fluids, to establish a forced diuresis, is usually thought to be the precipitating cause. A case of severe ASA poisoning and respiratory failure was found to have increased pulmonary vascular resistance and signs of intravascular hypercoogulability. The patient recovered rapidly on mechanical ventilation with a posotive endexpiratory pressure of 18 cm H₂O and systemic steroids.Abbreviation ASA acetyl salicylic acid - ARDS adult respiratory distress syndrome - PaO₂ arterial oxygen pressure - PaCO₂ arterial carbon dioxide pressure - PEEP positive endexpiratory pressure - FiO₂ fraction of oxygen in inspired air - CVP central venous pressure - CI cardiac index - PASP pulmonary artery systolic pressure - PADP pulmonary artery diastolic pressure - PCWP pulmonary capillary wedge pressure     

重型颅脑损伤合并肺挫伤患者的护理干预

目的：探讨重型颅脑损伤合并肺挫伤患者的临床急救与护理方法,提高治愈率。方法：对40例重型颅脑损伤合并肺挫伤患者采取急救措施和护理干预,观察护理效果。结果：40例患者中,死亡4例,重残13例,轻残17例,生活基本自理6例。住院期间发生肺部感染28例。结-论：通过对重型颅脑损伤合并肺挫伤患者实施积极抢救和护理干预,有效减少并发症的发生,提高了抢救成功率,降低了死残率。     

Oculocephalic Sympathetic Dysfunction in Posttraumatic Headaches

Oculocephalic sympathetic functions were assessed in five patients with posttraumatic headaches using the thermoregulatory sweat test and biochemical pupillary responses. Four patients demonstrated bilateral sympathetic dysfunction following whiplash injury, and one patient demonstrated unilateral sympathetic dysfunction following forehead injury. Bio-chemical pupillary responses were diagnostic in the early posttraumatic period, while the thermoregulatory sweat test was abnormal up to 56 months following the injury. This study documents serious injury to the cervical sympathetic nerves in patients with posttraumatic headaches following whiplash injury, and shows the reliability of the thermoregulatory sweat test in identifying patients with long-term oculocephalic sympathetic dysfunction. It also shows dissociated postganglionic cranial sympathetic dysfunction. Our experience and a review of the pertinent literature shows no convincing clinical or experimental evidence to establish oculocephalic sympathetic dysfunction as a direct cause of head pain, but it may exert an effect on cephalic pain through the trigeminovascular system.     

Venous thromboembolism prophylaxis and treatment in patients with acute stroke and traumatic brain injury

PURPOSE OF REVIEW: Patients with acute stroke and traumatic brain injury are at risk to develop venous thromboembolism. This review analyzes the available literature to propose guidelines for the prevention and treatment of venous thromboembolism in these groups of patients. RECENT FINDINGS: In acute ischemic stroke, low-dose low-molecular-weight heparin has the best benefit-risk ratio to prevent venous thromboembolism. Patients with primary intracerebral hemorrhage and traumatic brain injury should receive intermittent pneumatic compression, followed by low-dose low-molecular-weight heparin or unfractioned heparin 3-4 days after stroke onset or 24 h after injury or surgery, respectively, and after cessation of bleeding. Concerning treatment, in patients with deep-vein thrombosis lower doses of heparin are indicated to prevent pulmonary embolism, and a vena cava filter should be considered. In patients with pulmonary embolism, treatment could be more aggressive, because of a high mortality risk. SUMMARY: Adequate prevention of venous thromboembolism with intermittent pneumatic compression or pharmacological prophylaxis is important. The best treatment of venous thromboembolism remains unclear. In case of pulmonary embolism, more aggressive treatment is warranted.     

Associated sagittal spinal movements in performance of head pro- and retraction in healthy women: a kinematic analysis

Sagittal head excursions are frequently used as diagnostic and treatment tools by physiotherapists. Retractions are performed to promote good head-on-body orientation. This study examined the regional contribution of spinal movements to head pro- and retraction in addition to the effect of a more or less restrained sitting position in healthy women. Fourteen healthy women performed seven sagittal head excursions in a more or less restrained sitting position, during which time their kinematic response was measured with an optoelectronic system. Total anterior/posterior head excursion was smaller (P=0.005) in the more restrained sitting position. In both sitting positions, approximately 60% of the total anterior/posterior head excursion originated from the cervical spine, almost 30% from the cervicothoracic spine C7-T4, and approximately 10% from thoracic regions down to T12. Middle thoracic vertical displacement was smaller (p=0.005) in the more restrained sitting position. A high correlation was found between total head excursion and the cervicothoracic unit displacements in both sitting positions (r=0.79, r=0.85, respectively). In each sitting position, the craniovertebral angle, and the tragus-C7-horizontal line decreased in protraction. Movements in the thoracic region contributed to the total head excursion. Therefore, clinicians should recognize the thoracic contribution to sagittal head excursion when using pro- and retraction as a diagnostic and treatment tool.     

神经外科全麻坐位手术中静脉空气栓塞42例回顾性分析

[目的]回顾性分析本院神经外科坐位全身麻醉手术过程中静脉空气栓塞（VAE）的监测、发生、预防及处理.[方法]搜集本院神经外科2011年3月至2013年5月的215例坐位全身麻醉下行手术的患者的临床资料,以术中呼气末二氧化碳分压（PETCO2）出现急性地、持续性地、原因不明地下降≥5 mmHg为VAE的诊断标准.相关的数据从医疗记录资料中提取并分别予以比较,统计手术过程中VAE的监测、发生、预防及处理等情况.[结果]术中VAE总发生率为19.5％（42/215）,经积极的处理后,患者的各项生命体征恢复正常,术后均恢复自主呼吸并正常苏醒,无明显后遗症,也未出现VAE相关的致残或致死病例.[结论]在无更敏感监测手段下行神经外科坐位全身麻醉手术,PETCO2监测能够为有经验的麻醉医生对预防VAE的发生提供参考.     

Venous air embolism

This case report describes a new radiologic finding, that of an air-fluid level in the pulmonary artery. This is pathognomonic of venous air embolism when the patient has a chest film made in the upright position.