Tracheobronchial disruption: postoperative management with jet ventilation to minimize airway pressures.

The case of a 17-year-old male victim of blunt trauma with complex tracheobronchial injury identified by flexible bronchoscopy is discussed. The paper also describes the surgical treatment used and good results obtained.

Intra-aortic balloon pump for combined myocardial contusion and thoracic aortic rupture.

The coexistence of myocardial contusion and thoracic aortic injury is probably more common than recognized following rapid deceleration multisystem trauma. This report describes the successful application of intra-aortic balloon counterpulsation in a critically injured patient requiring emergent repair of a thoracic aortic tear complicated by ventricular failure due to cardiac contusion.

Bronchial anomaly of the right upper lobe.

This case report presents a rare anomaly of right upper lobe bronchial anatomy. During routine right upper lobe resection for carcinoma, a common right upper and middle lobe bronchus was found. The resection was completed as a right upper and middle bilobectomy.

Reversal of protamine-induced catastrophic pulmonary vasoconstriction by prostaglandin E1.

A case of catastrophic pulmonary vasoconstriction occurring after cardiopulmonary bypass after protamine reversal of heparin treated successfully with intravenous prostaglandin E1 is reported. Systemic hypotension was counteracted by epinephrine given through the left atrium. Protamine-heparin reactions are reviewed and a pathophysiological mechanism for the beneficial effect seen with prostaglandin E1 is proposed.

The role of early limited thoracotomy in the treatment of empyema.

On the basis of clinical experience with 80 patients at Denver General Hospital from 1979 through 1984, we devised a three-part classification of empyema. Class I empyema (n = 12) is pleural effusion with pH less than 7.2 and with no bacteria.

Long-term follow-up of a patient with quadruple valve replacement.

A 60-year-old woman who had suffered from rheumatic fever as a child required replacement of the aortic, mitral, and pulmonary valves. Subsequently, because of severe regurgitation, the tricuspid valve was also replaced. This case proves that, with satisfactory intraoperative cardiac protection, quadruple valve replacement can produce a good long-term functional result.

A practical approach to prosthetic valve endocarditis.

Prosthetic valve endocarditis (PVE) is an infrequent but dread complication, occurring in 1 to 2% of patients both early (less than 60 days) and late postoperatively. Diagnosis is always (99%) possible by two sets of blood cultures, but occasional exogenous causes of bacteremia may cloud the diagnosis, as will culture-negative cases of PVE and skin contaminants. With obvious exogenous sources of bacteremia, achieving sterile blood cultures after eradication of the noncardiac source permits discontinuation of antibiotics after two weeks.

Pericardial tamponade: a critical determinant for survival following penetrating cardiac wounds.

Previous studies have emphasized injury mechanism, wound site, and presenting vital signs as critical determinants for survival following penetrating cardiac injury. Our experience suggests pericardial tamponade is another crucial factor and is the basis for this study. Prognostic features were reviewed in 100 consecutive, unselected patients with acute cardiac injuries.

Aortocardiac fistula with aortic valve injury from penetrating trauma.

A patient with a delayed aorto-right ventricular fistula and aortic valve injury after penetrating trauma is reported, and 17 similar additional cases from the literature reviewed. By examining the aortic root of adults with normal cardiac anatomy at autopsy, we defined the target area for these injuries as a 2 X 2 cm contact surface between the aorta above the right coronary cusp and the right ventricular outflow tract below the pulmonary valve. Five of the 18 patients required emergency exploration due to hemodynamic instability.

Delayed presentation of traumatic diaphragmatic hernia.

More than 111 patients with traumatic diaphragmatic hernia (TDH) were treated in a 5 1/2-year period; eight (7.2%) were first recognized more than 30 days postinjury. All were men, and their average age was 33.

Temporary cardiac pacing in traumatic arrest victims.

Temporary ventricular pacing was successfully employed in two patients suffering refractory bradycardia following traumatic cardiac arrest. The hemodynamic response to pacing was dramatic and both patients eventually recovered fully from an apparent moribund state. Cardiac pacing may be an effective adjuvant in the early resuscitation of the massively injured patient.

Critical aortic coarctation: patch aortoplasty in infants less than age 3 months.

Twenty-three infants less than age 3 months (mean age 31 days) underwent patch aortoplasty for relief of coarctation of the aorta. All had intractable congestive heart failure, despite aggressive medical therapy. Each infant had other cardiac anomalies, including patent ductus arteriosus (83 percent) and ventricular septal defect (74 percent).

Isolated gonococcal pulmonary valve endocarditis: diagnosis by echocardiography.

The perplexing clinical course of a 23-year-old black male with isolated gonococcal pulmonary valvular endocarditis is presented. M-mode echocardiography provided the first clue to the presence of pulmonary valvular vegetations and the proper diagnosis. Since Neisseria gonorrhea appears to have a particular affinity for the pulmonary valve, the presence of isolated pulmonary valvular endocarditis should raise the strong possibility that Neisseria gonorrhea is the offending organism.

Late complications following surgical repair of total anomalous pulmonary venous return below the diaphragm.

Between May, 1975, and June, 1977, we surgically repaired an infracardiac total anomalous pulmonary venous return in 4 infants under deep hypothermic cardiac arrest. All patients had pulmonary hypertension and a patent ductus arteriosus. All survived operation and required positive end-expiratory pressure with mechanical ventilation.

Evaluation of technetium scanning for myocardial contusion.

Myocardial contusion is a serious problem not easily diagnosed. Laboratory and clinical studies carried out on myocardial infarction suggested that Technetium scanning might clarify this diagnostic dilemma. Radionuclide imaging with Technetium was carried out in 29 patients suspected of having myocardial contusion.

Thoracic traction for median sternotomy dehiscence.

Standard management of median sternotomy dehiscence sometimes fails to achieve lasting reduction and fixation of the sternal halves. An effective method of external thoracic traction that augments internal fixation of the sternal fracture is presented.

Tension pneumomediastinum.

Tension pneumomediastinum is an infrequently diagnosed but potentially fatal condition. The collection of air under pressure in the mediastinum compromises venous return to the heart and compresses major bronchi, leading to sudden and profound cardiovascular collapse. Although its mechanism was elucidated in the 1940's, when tension pneumomediastinum was most commonly a complication of tuberculosis, the same mechanism explains its formation in neonates with respiratory distress and in patients ventilated with volume respirators.

Three unusual complications resulting from attempted repair of partial anomalous pulmonary venous drainage.

The correction of shunts resulting from partial anomalous pulmonary venous drainage has become an accepted surgical procedure. Surgical complications, other than those that were purely postoperative, have been rare. The present report details the case histories of three patients with unusual complications resulting from this type of surgery.

Bronchial adenoma.

Thirty-three patients with bronchial adenoma have been treated in U.S. Army hospitals.