The initial pulmonary evaluation of the immunocompromised patient

Practical approaches to the initial evaluation of solid organ transplant patients, BMT patients, and HIV-infected patients with pulmonary disease are summarized in Figures 2, 3, and 4. These algorithms are meant to be used as guidelines for the clinician. The clinical setting will ultimately determine the extent and speed of the evaluation. Patients who are recipients of solid organ transplants and have pulmonary symptoms may have focal or diffuse changes or may have normal chest radiographs. In all these groups, sputum is obtained by expectation. If a pathogen is found in any of the groups, it is treated. When no pathogen is found on sputum examination in patients with focal disease, empiric antibiotic therapy is given. If the patients do not improve on the empiric antibiotics, then bronchoscopy is performed. Some centers proceed directly to bronchoscopy before antibiotics are started in the hope of directing antibiotic therapy. Patients who have a normal CXR or diffuse infiltrates and no identified pathogen on examination of sputum undergo bronchoscopy, and the protocol is followed until a diagnosis is made (see Fig. 2). Patients who have received a BMT and who present with pulmonary symptoms are treated as shown in Figure 3. The CXR will reveal if the infiltrate is focal or diffuse. Those with focal infiltrates are treated with broad-spectrum antibiotics for 48 to 72 hours. If the symptoms and signs do not show some resolution, then bronchoscopy is usually performed. The effect of diffuse infiltrates in BMT patients depends to a large extent how far along in recovery from the transplant the patient is when they develop the infiltrates. During the first 30 days posttransplant, pulmonary edema commonly occurs, and the infiltrates may resolve with diuresis. If the patient is not clinically fluid overloaded or they do not respond to the diuretic therapy, then bronchoscopy with BAL is indicated. Finally, many HIV-infected patients may present with pulmonary symptoms. They may have a normal CXR or a diffuse or focal pattern (Fig. 4). All patients are subjected to sputum induction to identify a pathogen. If one is identified, it is treated. Should the patient not respond to treatment adequately or a pulmonary pathogen is not found, then bronchoscopy with BAL, protected specimen brush, or a transbronchial biopsy is attempted. The above schema is a general guideline to the initial evaluation of pulmonary disorders in the ICP. The respiratory abnormality is found in most of the cases if these algorithms are closely followed. If the patient does not improve or deteriorates further, additional diagnostic procedures such as video-assisted thorascopic lung biopsy or CT-directed transthoracic needle biopsy may be needed.     

The multiple injured patient with bladder trauma

Trauma of the bladder from external force is associated with severe multiple injuries and the resulting mortality rate is substantial. The major associated injury was fracture of the pelvic bones which was present in 346 (83%) of the 417 patients with bladder trauma. Contusion of the bladder was present in 280 (67%), intraperitoneal rupture in 53 (13%), extraperitoneal rupture in 76 (18%), and both intra- and extraperitoneal rupture in eight (2%). Radiologic evaluation of the bladder by a retrograde cystogram using 400 ml of dye is recommended to diagnose the type of bladder injury. Nonoperative (catheter) management of extraperitoneal rupture of the bladder was used in 18 patients and resulted in complications in four of the 18.     

Nutritional support of the multiple trauma patient

This report presents a brief review of currently relevant aspects of the parenteral nutritional support of the multiple trauma patient in intensive care. The decisive factors governing selection and application of an individually devised program of parenteral nutrition are the multiple trauma patient's energy turnover and nitrogen losses on the one hand, and the tolerance limits and viability of the traumatized organism on the other. It is possible nowadays to provide situation-adapted nutritional support corresponding to the individual requirements of a seriously injured patient. However, further detailed studies are still necessary to come up with more definite answers to questions regarding requirement levels, turnover, and tolerance of the substrates applied in critical metabolic situations. This aside, adequate nutritional therapy at present represents without a doubt an integral feature of any long-term post-trauma therapeutic program.     

Laryngeal fracture in the multiple trauma patient

The Cincinnati General Hospital experience with early diagnosis and repair of laryngeal fractures in the multiple trauma patient is presented. The results demonstrate the feasibility and value of early laryngeal diagnosis and repair in these severely traumatized patients.     

Management of the unstable patient with multiple trauma

The management of the patient with multiple trauma in unstable condition must be adapted to the means available (or unavailable) on site, i.e., trained personnel, material means, and the possibility of evacuation to a trauma center. This may require a multi-stage surgical strategy based on clinical examination and available imaging resources. Patients with multiple trauma in unstable condition should be brought to the operating room promptly for life-saving or stabilizing interventions (Extreme Urgency). The patient may then undergo further stabilization of vascular volume, coagulation, and metabolic deficits while simultaneously undergoing a more detailed clinical and radiologic evaluation; he may then return to the operating room within six hours for more definitive repair of urgent lesions (First Urgency). Once the patient is stable enough for evacuation, he should be transferred to a trauma center for definitive surgical care.     

Renal trauma in the multiple injured patient.

Immediate radiological evaluation of renal injuries by a large dose or infusion excretory urogram resulted in a definitive diagnosis in 87% of the cases. Further radiological evaluation or exploration was required to make a definitive diagnosis in the remaining 13%. Blunt external trauma was responsible for 94% of the renal injuries. Less morbidity and a sharp reduction in delayed renal operation followed the introduction of immediate surgical management with the more severe types of renal injury. Clamping of the renal vessels prior to opening Gerota's fascia prevents reactivation of hemorrhage and allows for a deliverate operation with conservation of undamaged renal tissue. Associated injuries were present in 73% of the patients, including intra-abdominal injuries in 42%. The over-all nephrectomy rate of 5% in this study compares favorably to the nephrectomy rate in studies reporting the expectant management of renal injuries.     

Neuroleptic malignant syndrome in the multiple trauma patient

A 25-year-old multiply traumatized patient developed neuroleptic malignant syndrome (NMS) secondary to the use of Haldol. The diagnosis was delayed due to poor recognition of the syndrome, risking a fatal outcome. The signs and symptoms of the syndrome are presented along with the pathophysiology and the available treatments for NMS.     

A prospective study comparing nuclear scintigraphy and computerized axial tomography in the initial evaluation of the trauma patient

Eighty-five consecutive patients admitted for trauma evaluation and fulfilling criteria suggesting the possibility of intra-abdominal injury underwent both immediate computerized axial tomography of the abdomen and a nuclear medicine evaluation, including a liver-spleen scan with or without a renal scan, in order to delineate their injuries and direct management. The limitations, advantages, and complementary use of each modality in the initial evaluation of the trauma patient is described. Overall, nuclear scintigraphy excelled in instances of contusion, in the evaluation of the restless or uncooperative patient, and in children. With computerized tomography, the retroperitoneal structures were well defined and multiple abdominal injuries could be seen. Neither modality demonstrated the presence of intra-abdominal fluid consistently. No patient with assumed isolated liver, spleen, or renal injury on the basis of the above studies, who was managed nonoperatively, required subsequent laparotomy.     

Management of open fractures in the multiple trauma patient

The management of open fractures in the multiple trauma patient is discussed. It is concluded that operative stabilization of the open fracture both enhances the survival of these patients and reduces the complications of the fracture while enhancing extremity function. This procedure must be conducted so as to avoid devascularization of more tissue and especially bone fragments and so that adequate stability is provided. In general, all open fractures are left open with the degree of openness depending upon the magnitude of the soft tissue trauma. In grade I and II open fractures, stabilization can usually be achieved by internal fixation or by a combination of minimal internal fixation (usually lag screws) and external fixation. In grade III open fractures, stabilization is usually best achieved by external fixation. However, the external fixation must be carefully designed to allow the subsequent soft tissue coverage operations which are usually required in third degree open fractures. In general, the external fixator should be viewed as a device to gain sufficient stability for patient mobilization and soft tissue management and not as definitive fracture care. For this reason, in the tibia unilateral frames are usually best and bilateral or trilateral frames should be reserved for segmental defects and severe zonal comminution. Definitive fracture care is then administered after soft tissue healing by cast or internal fixation.     

Erythropoietin in a patient following multiple trauma

We report on a Jehovah's Witness who had severe blood loss following major trauma. The problems of her management without blood transfusion, and with the use of recombinant human erythropoietin therapy for severe anaemia, are described.     

Initial evaluation of the patient with blunt abdominal trauma

Unrecognized abdominal injury remains a distressingly frequent cause of preventable death following blunt trauma. Peritoneal signs are often subtle, overshadowed by pain from associated injury, and masked by head trauma or intoxicants. The initial management of the patient with blunt abdominal trauma should parallel the primary survey of airway, breathing, and circulation. Diagnostic peritoneal lavage remains the cornerstone of triage in patients with life-threatening blunt abdominal trauma. The only absolute contraindication to the procedure is an existing indication for laparotomy. Computed tomography is useful as a complementary diagnostic tool in selected patients, and it is the critical test for guiding nonoperative management of known intraperitoneal trauma. Routine ancillary tests for potentially occult injuries include nasogastric-tube placement for ruptures of the left diaphragm, Gastrografin contrast study for duodenum perforation, and pyelography for urologic injury. Ultrasonography may become a valuable tool in the initial assessment of the injured abdomen. Ultimately, the most important principle in the management of blunt abdominal trauma is repeat physical examination by an experienced surgeon.     

Neuroleptic malignant syndrome in a multiple trauma patient

Neuroleptic malignant syndrome is a little-known adverse reaction to neuroleptic administration characterized by hyperpyrexia, leukocytosis, creatine kinase elevations, muscular rigidity, autonomic dysfunction, and alterations in level of consciousness. Neuroleptic malignant syndrome has an associated 20% mortality but can be reversed when treated with neuroleptic discontinuation and administration of bromocriptine and dantrolene. Early diagnosis in the trauma unit may prevent an extensive workup for presumed sepsis. To our knowledge, neuroleptic malignant syndrome has not previously been reported in a multiple trauma patients.     

Successful management of an elderly patient with multiple trauma

An elderly female patient with multiple trauma and flail chest received thoracic and lumbar epidural analgesia and anesthesia, respectively, in the surgical ICU and the operating room. This technique provided segmental analgesia with minimal amounts of narcotics. This allowed for the very important early ambulation and absence of respiratory complications, the main cause of increased morbidity in this age group.     

Computed tomography in the initial evaluation of patients with blunt trauma.

Two hundred sixty-six of 374 consecutive blunt trauma patients underwent emergency computed tomographic (CT) scanning during evaluation at a level I trauma center. The purpose of this study was to develop guidelines for use of CT scanning in the initial evaluation of blunt trauma patients. Of the 131 CT scans of the head obtained, 20 (15%) had positive results. Seven patients whose initial neurologic examinations were normal had abnormal results on head CT scans; none required emergent treatment of their head injury. This suggests that, in the presence of a normal neurologic examination, head CT scans can safely be delayed until other more serious injuries are addressed. Twenty-six CT scans of the chest were performed and ten (38%) were interpreted as abnormal. Chest CT scans provided information about the extent of the injury but did not alter the initial management of any patient and therefore are rarely indicated in the acute evaluation of trauma patients. A total of 110 abdominopelvic CT scans were performed and 20 (19%) were interpreted as positive. Seventy-five percent of those patients with positive CT scans were treated successfully in a nonsurgical fashion.