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Biomedical subjects

N Snow

Publications and source records attributed to N Snow.

At least 19 recordsLinked to original sources

Pulmonary venous drainage into the left atrial appendage facilitates transplantation of the left lung with difficult exposure.

Heterotopic implantation of the pulmonary venous confluence into the left atrial appendage during left lung transplantation is a reasonable alternative technique to reestablish venous drainage when exposure of the native left pulmonary veno-atrial connection may be problematic. We used this approach in a 39-year-old woman with chronic bronchiectasis who underwent bilateral sequential lung transplantation through a clam-shell approach. Dense hilar scarring and a small left atrial size made exposure of the native left pulmonary veno-atrial connection difficult.

Adult↗

The effect of fiberoptic bronchoscopy on cerebral hemodynamics in patients with severe head injury.

STUDY OBJECTIVE: Concerns exist about the effect of flexible fiberoptic bronchoscopy (FFB) on intracranial pressure (ICP). We studied the effect of FFB on cerebral hemodynamics in patients with severe head injury. DESIGN: Prior to FFB, patients were anesthetized and muscle relaxants were given as necessary to eliminate coughing. Comparisons were made of mean arterial pressure (MAP), ICP, and cerebral perfusion pressure (CPP) prior to, during, and after FFB, as well as comparisons of mean cerebral hemodynamic values in an 8-hour period before and after FFB. Observations were made of changes in neurologic status post-FFB. SETTING: Surgical intensive care unit of Level 1 Trauma Center. PATIENT POPULATION: Fifteen patients with severe head injury in whom ICP was monitored and who required FFB for diagnosis of nosocomial pneumonia or treatment of lobar collapse. RESULTS: Pre-FFB ICP averaged 14.3 mm Hg (range, 6 to 26 mm Hg). During FFB, patients experienced a mean increase in ICP of 13.5 mm Hg above basal values (p = 0.0001). At peak ICP, MAP increased from a baseline of 92.3 mm Hg (SD +/- 16.1) to 111.5 mm Hg (+/- 13.9). Mean CPP was 83.7 mm Hg at peak ICP (range, 52 to 121 mm Hg), a 14.0% increase over baseline. The ICP and MAP returned to basal levels following bronchoscopy. No patient had a clinically significant increase in ICP or demonstrated any deterioration in Glasgow Coma Scale score or neurologic examination findings post-FFB. CONCLUSIONS: Although FFB causes an increase in ICP in patients with severe head injury, MAP also rises, and an adequate CPP is maintained. The ICP returns to basal levels after the procedure. When properly performed, FFB does not adversely affect neurologic status in patients with severe head injury.

Acute Disease↗

Computed tomography for the evaluation of knife impalement injuries: case report.

A patient with a stab wound to the back with suspected major vascular injury was evaluated by computed tomography instead of arteriography. The computed tomographic (CT) scan demonstrated no injury to the aorta, inferior vena cava, or esophagus, which were adjacent to the blade, and excluded a hematoma. The information from the CT scan made possible a less extensive surgical procedure than might have otherwise been necessary.

Adult↗

Thoracic CT scanning in critically ill patients. Information obtained frequently alters management.

Conventional radiographic studies of the chest in the intensive care unit often fail to positively identify suspected intrathoracic pathology due to many patient- and equipment-related variables. Our experience has indicated that CT scanning of the chest improves diagnostic accuracy, precisely defines anatomic abnormalities, frequently affects treatment decisions, and has been performed safely in this fragile patient population. Examples of correctable lesions have included pneumothorax, empyema, lung abscess, mediastinal abscess and pleural effusion. Chest CT findings always occurred while the portable plane chest radiographs were nondiagnostic. CT-directed intervention often improved patient outcome.

Adult↗

Surgical cricothyrotomy in the field: experience of a helicopter transport team.

A retrospective analysis of 3,500 helicopter missions revealed 20 patients who required cricothyrotomy in the field for emergency airway access. Five patients who were in cardiopulmonary arrest succumbed despite cricothyrotomy, all with adequate airway control (Trauma Score, 2.8; ISS, 55.6). Seven of 12 patients with oral, maxillofacial, or cervical trauma survived (Trauma Score, 9.6; ISS, 48.25). There were no instances of bleeding, malposition, airway obstruction, or dysphonia after decannulation in the survivors. Autopsy revealed no serious airway pathology or compromise in those who expired. Surgical cricothyrotomy can successfully be performed in the field by a nurse/physician helicopter transport team. When conventional airway maneuvers are unsuccessful we recommend cricothyrotomy for emergency airway access.

Adolescent↗

Coverage of the open sternotomy wound with Biobrane dressing.

Massive edema accumulated after prolonged cardiopulmonary bypass for coronary grafting such that neither the sternum nor the presternal skin could be closed after insertion of a left ventricular assist device. To protect the mediastinum from infection, we applied Biobrane synthetic temporary wound dressing and placed a moist gauze dressing over it. When the dressing was removed 4 days later, the wound was pink, granulating, free from infection, and suitable for closure. Use of Biobrane biologic dressing should be considered when the mediastinum must remain exposed after median sternotomy.

Bandages↗

Correlation between needle biopsy of lung tumors and histopathologic analysis of resected specimens.

Needle aspiration of a pulmonary mass may accurately delineate malignant from nonmalignant pulmonary lesions; however, needle aspiration may be unable to identify a specific cell type. Therefore, a retrospective review of patients undergoing needle aspiration of pulmonary masses was carried out for the years, 1979 through September 1984. A Lee needle was used, which produces a sample of tissue 1-mm in diameter suitable for histopathologic analysis as well as a cytologic specimen. A total of 87 needle biopsies were carried out, but only 46 patients later underwent resection. Five patients (6 percent) sustained a pneumothorax, and four required a chest tube. Minimal hemoptysis occurred in three patients (3 percent). Eight patients were subsequently found to have benign lesions, and there were 38 malignant tumors. Seven needle biopsies (18 percent; 7/38) were nondiagnostic and subsequently proved to be malignant. Thirty-one needle biopsies were diagnostic of malignant neoplasms (82 percent; 31/38). Twenty specimens showed the same cell type as the needle biopsy (65 percent 20/31). Eleven resected specimens disagreed with the cell type from the needle biopsy (35 percent; 11/31). In these 11 patients a change in management was indicated because of the delineation of a different cell type in only four (11 percent of all 38 patients with cancer). Mixed tumors and small cell carcinoma provide the area of most concern. Our conclusions are that needle biopsy accurately indicated a malignant neoplasm in 82 percent of the patients undergoing later resection and that the specimens from Lee needle biopsy accurately predicted the cell type in 65 percent of the specimens. The inaccurate histologic diagnosis was important clinically in only 11 percent of the patients. Overall, the needle biopsy of pulmonary lesions provided a correct decision on management in 87 percent of the cases in which biopsy provided diagnosis of a malignant neoplasm (31 patients).

Biopsy, Needle↗

Thoracic surgical content of an undergraduate surgical curriculum.

The surgical services have long been an excellent training ground for teaching clinical skills common to all physicians. The thoracic surgical service provides an additional opportunity to offer experience in trauma, resuscitation, and the management of many emergency situations common to all medical and surgical illness. With the use of a methodology previously reported by the Association for Surgical Education, a survey was developed and circulated among surgical department chairmen, directors of thoracic surgical training programs, and the medical school classes of 1978 who had completed 5 postgraduate years of training and/or practice. A modified Delphi technique was used to assess the information, and the rank order of mean scores for knowledge and skills was constructed for the various categories within the thoracic surgery curriculum. The Pearson product-moment correlation for the rank order of knowledge and skills demonstrated a high degree of correlation between directors and students (0.904 and 0.917, respectively), directors and chairmen (0.948 and 0.982, respectively), and between students and chairmen (0.900 and 0.952, respectively) for knowledge and skills. The most important knowledge categories were critical care and resuscitation (rank order 2.15), hemodynamic measurements and analysis (2.10), pulmonary embolus (2.06), and assessment of pulmonary function (1.92). The most important skills listed were thoracentesis (1.92), endotracheal intubation (1.86), and central vein cannulation (1.69). Analysis of data such as these permits construction of a surgery curriculum responsive to the goals and objectives of the faculty and implements the viewpoints of many individuals representing multiple backgrounds to formulate the most appropriate content for undergraduate surgical education.

Clinical Competence↗

Physician presence on a helicopter emergency medical service: necessary or desirable?

Helicopter emergency medical services may be served by a variety of medical and paramedical crew mixes. Analysis of 395 flights performed by Metro Life Flight in Cleveland, OH indicates that a physician is necessary 25% of the time, is not necessary 39.7% of the time, and may be necessary 34.7% of the time. The patients in the latter group could only be analyzed retrospectively and were of sufficient severity that the possible benefit of the physician was real but unpredictable. Physician presence was necessary for judgement, skill, or both.

Aerospace Medicine↗