Biomedical subjects
Publications and source records attributed to M J Parr.
A previously healthy female sustained bilateral subcapital femur fractures during an eclamptic seizure. This complication has not been previously described in association with eclampsia. Clinicians need to be aware of this potential complication and investigate postseizure hip pain appropriately.
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The fear of acquiring infectious diseases has resulted in reluctance among healthcare professionals and the lay public to perform mouth-to-mouth ventilation. However, the benefit of basic life support for a patient in cardiopulmonary or respiratory arrest greatly outweighs the risk for secondary infection in the rescuer or the patient. The distribution of ventilation volume between lungs and stomach in the unprotected airway depends on patient variables such as lower oesophageal sphincter pressure, airway resistance and respiratory system compliance, and the technique applied while performing basic or advanced airway support, such as head position, inflation flow rate and time, which determine upper airway pressure. The combination of these variables determines gas distribution between the lungs and the oesophagus and subsequently, the stomach. During bag-valve-mask ventilation of patients in respiratory or cardiac arrest with oxygen supplementation (> or = 40% oxygen), a tidal volume of 6-7 ml kg(-1) ( approximately 500 ml) given over 1-2 s until the chest rises is recommended. For bag-valve-mask ventilation with room-air, a tidal volume of 10 ml kg(-1) (700-1000 ml) in an adult given over 2 s until the chest rises clearly is recommended. During mouth-to-mouth ventilation, a breath over 2 s sufficient to make the chest rise clearly (a tidal volume of approximately 10 ml kg(-1) approximately 700-1000 ml in an adult) is recommended.
We reviewed the cause and timing of death of all the patients who died within hospital following multiple trauma and admission to a multidisciplinary intensive care unit (ICU) that also acts as a tertiary referral centre for neurosurgery. The ICU database identified 101 such patients in a 3-year period and their records were reviewed retrospectively. There were 40 (39%) deaths within 24 h of admission to the ICU, 38 of which resulted from severe brain injury and two from haemorrhagic shock (HS). A further 61 (60%) deaths occurred more than 24 h after the time of admission to ICU (mean 7 days; range 2-49 days), of which 46 (75%) were due to severe brain injury. While these findings do not question the promulgated tri-modal distribution of death following trauma, they are at variance with the view that the third peak of deaths is due mainly to multiple organ failure. When severe head injury accompanies multiple trauma, it is likely to be the major determinant of late mortality. If outcome from major trauma is to be improved, then a greater emphasis needs to be placed on the prevention and optimal management of severe brain injury.
OBJECTIVE: To describe the reasons for, and immediate outcome following Medical Emergency Team (MET) activation. METHODS: Retrospective analysis of MET calls in 1998. RESULTS: There were 713 MET calls to 559 in-patients. Of the 559 patients 252 (45%) were admitted to ICU and 49 (6.9%) died during the MET response. The three commonest criteria for calling the MET were a fall in GCS>2 (n=155); a systolic blood pressure<90 mmHg (n=142) and a respiratory rate>35 (n=109). Cardiac arrests accounted for 61 calls and had an immediate mortality of 59%. The most common MET criterion associated with admission to ICU was a respiratory rate >35. Of patients who received MET calls based only on the 'worried' criterion 16% were admitted to ICU. The MET felt that a not-for-resuscitation order would have been appropriate in 130 cases (23%). NFR orders were documented during 27 of the MET calls. CONCLUSIONS: The MET system provides objective and subjective criteria by which medical and nursing staff can identify patients who become acutely unwell. A high proportion of these patients will require admission to Intensive Care. The MET system also provides the opportunity to identify patients for whom an NFR order should be considered.
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Trauma is one of the major causes of death and disability in modern society, particularly for the young. Organized trauma systems reduce mortality and morbidity from trauma. An effective trauma system addresses all aspects of trauma care, from prevention to rehabilitation. Well-developed trauma systems are currently available only to a minority of the world's population. Trauma systems in developed nations have much potential for improvement.
A case of severe adult botulism with paralysis, respiratory failure and cranial nerve palsies is presented. The pathophysiology, clinical manifestations, diagnosis and treatment options for botulism are discussed.
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A 41-year old primigravida underwent caesarean section because of foetal distress following prostin induction of labour. Intraoperative coagulopathy, haemorrhage and hypotension necessitated a hysterectomy. Subsequently, she developed respiratory and renal failure, requiring mechanical ventilation and haemodialysis. She made a full recovery. The likely diagnosis was amniotic fluid embolism (AFE), a rare complication of pregnancy with a variable presentation, ranging from cardiac arrest and death through to mild degrees of organ system dysfunction with or without coagulopathy. The differential diagnosis includes pre-eclamptic toxaemia/pregnancy-induced hypertension, anaphylaxis and pulmonary embolism. There is no diagnostic test for AFE; the finding of foetal elements in the maternal circulation is non-specific. Historically, AFE was thought to induce cardiovascular collapse by mechanical obstruction of the pulmonary circulation. It is now thought that a combination of left ventricular dysfunction and acute lung injury occur, with activation of several of the clotting factors. An immunological basis for these effects is postulated. There is no specific therapy and treatment is supportive. The mortality of the condition remains high.
A tumor model designed to assess liposome-mediated drug delivery to liver has been used in an attempt to better understand the mechanism of activity of liposomal mitoxantrone, a liposomal anticancer drug formulation that appears to be uniquely effective in treating this tumor model. Reductions in liposomal mitoxantrone accumulation in the liver were achieved either by use of poly(ethylene)glycol (PEG)-modified lipids or by methods designed to deplete liver phagocytes, a method referred to as hepatic mononuclear phagocytic system (MPS) blockade. A 2-fold reduction in mitoxantrone delivery to the liver was obtained using a mitoxantrone formulation with PEG-modified lipids, and a 3-fold reduction was obtained when liposomal mitoxantrone was given to animals pretreated to induce hepatic MPS blockade. Results demonstrate that the liposomal mitoxantrone formulation prepared with PEG-modified lipids was significantly less active than the formulations that did not contain PEG lipids, with median survival times of 17 days and 100% 60-day survival, respectively. In contrast, hepatic MPS blockade had no effect on the therapeutic activity of 1,2-dimyristoyl phosphatidylcholine/cholesterol (DMPC/Chol) mitoxantrone (100% 60-day survival). These data suggest that the hepatic MPS does not play a role in mediating the therapeutic activity of DMPC/Chol mitoxantrone in the treatment of liver localized disease. Results with formulations prepared with a PEG-stabilized surface, however, suggest that nonspecific methods to decrease liposome cell interactions inhibit the therapeutic activity of DMPC/Chol mitoxantrone.
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The incidence and origin of contamination of the vocal cords in 53 trauma patients was studied when tracheal intubation was performed before hospital admission. Eighteen patients (34%) had gross contamination which was blood in 15 patients and gastric contents in three patients. This has implications for prehospital airway management and particularly for use of the laryngeal mask airway.
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The use of the intubating laryngeal mask in three patients is described. In two patients for whom tracheal intubation using traditional techniques had failed, the intubating laryngeal mask was used to achieve successful tracheal intubation. The trachea of one of these patients was subsequently re-intubated for a second procedure using the same technique. A third patient with a cervical spine fracture whose trachea was electively intubated using the intubating laryngeal mask is also presented.
A multicentre trial of the use of the intubating laryngeal mask was carried out at seven centres in the United Kingdom using the same agreed protocol. Lung ventilation followed by blind tracheal intubation through the intubating laryngeal mask was attempted on 500 ASA grade 1 and 2 patients. It was possible to insert the intubating laryngeal mask in all 500 cases. Ventilation via the intubating laryngeal mask was described as satisfactory in 475 (95%) cases, difficult in 20 (4%) cases and unsatisfactory in 5 (1%) cases. Blind tracheal intubation through the intubating laryngeal mask was possible in 481 (96.2%) cases within three attempts. Intubation was successful at the first attempt in 399 (79.8%) cases, at the second attempt in 62 (12.4%) cases and at the third attempt in 20 (4%) cases. The tracheas of 19 (3.8%) patients were not successfully intubated within the three attempts. Ventilation via the intubating laryngeal mask was described as unsatisfactory during two of these cases but oxygenation remained satisfactory in spite of this. Seventeen of the 19 failures occurred during the individual operator's first 20 attempts. The intubating laryngeal mask provides a successful method for blind tracheal intubation in a large proportion of cases and appears to be superior to the standard laryngeal mask airway for this purpose. The intubating laryngeal mask may be of use when tracheal intubation has failed using conventional methods.
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