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Studies have shown that severe daytime restriction of dietary protein improves the efficacy of L-dopa and reduces response fluctuations in some Parkinson's disease (PD) patients. This study investigated the nutritional adequacy of the daytime restricted-protein diet. Eleven free-living PD patients suffering from unpredictable response fluctuations to L-dopa were counseled to limit protein intake to approximately 10 g before 1700. Three sets of 6-d food records obtained during the 8-wk study showed that while on the test diet, mean intakes of most nutrients remained above the recommended nutrient intakes, although significant decreases occurred in protein, calcium, iron, phosphorus, riboflavin, and niacin intakes. The impact of the test diet on nutritional status as evaluated by changes in body weight and serum prealbumin was small. We conclude that healthy and highly motivated patients can maintain adequate intakes of most nutrients while restricting daytime protein intake. However, nutrient intakes might be compromised in patients whose regular diets are marginally adequate.

A significant number of elderly drivers present without discernible external cause for their road crash. We hypothesize that syncope may contribute to their crash etiology and prospectively evaluated drivers older than 60 years with unexplained crash, presenting to our trauma center during a 1-year period. Prehospital data and prior medical history were obtained on all, followed by a standard syncope work-up. Of 79 drivers ages 60-98, 58 (73%) were at fault in the crash. In 33 (57%), the crash etiology could not be determined. Thirteen had prior syncope history. Workup was negative in two patients, and six died or were transferred before evaluation. Twenty-five of 33 (76%) had positive workups for syncope: cardiac causes in 10; neurologic in seven; psychiatric in five, endocrine in two; one indeterminant. Ten of 18 who survived had license revocation for medical reasons. Syncopal episodes are a frequent contributor to unexplained crashes among elderly drivers and should be suspected whenever external causes are not apparent.

The ability of elderly citizens to drive safely has been the subject of ongoing debate. To identify the type of elderly driver who becomes involved in an injury-producing road crash, we profiled all drivers over 39 years of age admitted to our Level I Trauma Center over a 1-year period. Data were prospectively collected and drivers age 40-59 years were compared with those over 60 years. Eighty-four drivers ageor = 60 and 130 drivers age 40-59 were studied. Of the 84 elderly drivers, 67 were deemed at fault. Twenty-four of those crashes were due to driving errors, 12 due to syncopes, and in 20 no crash cause was determined. Fifty-three of the 67 at fault drivers had significant underlying medical problems, compared to 9 of 17 deemed not at fault. Only four were legally intoxicated. Of the 130 drivers in the comparison group, only 19 had significant underlying medical problems; in three syncope was suspected; 18 were legally intoxicated. We conclude from our data that underlying medical disorders occur frequently in elderly drivers and may contribute to their incidence of road crashes.

We reviewed the records of 253 patients with head injury who required serial computed tomographic (CT) scans; 123 (48.6%) developed delayed brain injury as evidenced by new or progressive lesions after a CT scan. An abnormality in the prothrombin time, partial thromboplastin time, or platelet count at admission was present in 55% of the patients who showed evidence of delayed injury, and only 9% of those whose subsequent CT scans were unchanged or improved from the time of admission (P less than 0.001). Among patients developing delayed injury, mean prothrombin time at admission was significantly longer (14.6 vs. 12.6 s, P less than 0.001) and partial thromboplastin time was significantly longer (36.9 vs. 29.2 s, P less than 0.001) than patients who did not have delayed injury. If coagulation studies at admission were normal, a patient with head injury had a 31% risk of developing delayed insults. This risk rose to almost 85% if at least one clotting test at admission was abnormal (P less than 0.001). We conclude that clotting studies at admission are of value in predicting the occurrence of delayed injury. If coagulopathy is discovered in the patient with head injury early follow-up CT scanning is advocated to discover progressive and new intracranial lesions that are likely to occur.

Central venous catheterization during resuscitation of trauma patients remains controversial. Such catheterizations performed at the UMDNJ-Robert Wood Johnson Medical School at Camden Cooper Hospital/University Medical Center (Camden, NJ) trauma center for the period January 1, 1988 to December 31, 1989 were retrospectively reviewed. Patients with underlying hemothorax, pneumothorax, or resuscitative thoracotomy were excluded. There were 269 catheters inserted using the Seldinger technique. Catheters were placed via the internal jugular or subclavian veins by attending traumatologists or emergency medicine and surgical house staff under direct attending supervision. Of 238 patients ages 6 to 90 years, 156 were men. Mean Trauma Score and Injury Severity Score were 9 and 30, respectively. Patients were divided into two groups: patients undergoing cardiopulmonary resuscitation or in shock (systolic bp less than 90) during resuscitation (Group 1: n - 161); and patients not in shock (Group 2: n - 77). Thirty patients (Group 1a) expired in the resuscitation area. The remainder (Group 1b) with 150 catheterizations had 12 complications (8%): pneumothorax (8), hemothorax (1), and malposition (3). Group 2, with 80 catheterizations, had 6 complications (7.5%): pneumothorax (4), hematoma (1), and malposition (1). The complication rate for patients surviving the resuscitation (230 catheterizations) was 7.8 per cent. There were no catheter-related deaths. In conclusion, emergency central venous catheterization during resuscitation of trauma patients carries a relatively low risk of serious complications when performed by experienced physicians.

The immediate transfusion of uncrossmatched type O blood in the initial resuscitation of the trauma victim remains controversial. To examine difficulties in crossmatching blood for later transfusions after use of uncrossmatched type O blood, we undertook a prospective 23-month study at a level I trauma center. One hundred thirty-five severely injured patients received uncrossmatched type O blood during the study period. Sixty-one patients (45%) died and 76 patients (56%) underwent emergent operation. There were no major transfusion reactions. Six patients had blood antigen-antibodies present on admission, and such antibodies developed in three patients during hospitalization. We conclude that uncrossmatched type O blood may be used safely in the exsanguinating patient, but blood antigen-antibodies, which may complicate later crossmatching, can develop after its use.

Outcome after traumatic brain injury, defined by the Glasgow Outcome Scale (GOS) and length of stay in acute rehabilitation, was measured in 59 patients admitted to an intensive rehabilitation program to examine the effects of severity of the initial brain injury, severity of multiple trauma, and length of stay in the acute care hospital. Severity of initial brain injury, best measured by length of coma, was the most significant predictor of GOS outcome. Length of acute hospitalization was a small, but significant, predictor of GOS. Severity of initial brain injury, length of acute hospitalization, and gender emerged as predictors of length of rehabilitation hospital stay. Although length of acute hospitalization is apparently affected by severity of brain injury, it adds significantly--more than severity of brain injury--to the prediction of length of rehabilitation.

Of 27 patients admitted to our level I trauma center with acute disruption of the thoracic aorta, two patients died of exsanguination before aortic repair. One patient had massive leakage from the aneurysm after aortography and died during surgery. All patients suffered from multiple injuries. Eighty-three percent of the patients had major operations in addition to the aortic repair. "Clamp and sew" technique was used in 18 patients (75%), two of whom had multiple tears of the aortic arch. Heparin-coated shunts were used in five patients (20.8%), and a cardiopulmonary bypass was performed in one patient who had multiple tears. Three postoperative deaths were related to polytrauma, cardiogenic shock, and sepsis. Paraplegia developed in three patients, two of whom had multiple aortic lesions necessitating longer ischemia time during the repair. Only one patient had complete neurologic deficit at the 1-year follow-up. In our series, neither surgical procedure proved superior. We conclude that the "clamp and sew" technique for repair of the disrupted thoracic aorta may allow for a more favorable outcome.

Subdiaphragmatic exsanguination is a major cause of death in civilian trauma. In a 1-year review of 867 consecutive admissions to a Level I Trauma Center, a 4.3 per cent incidence (37 patients) of infradiaphragmatic exsanguination was found. Eleven per cent of all abdominal injuries and 35 per cent of pelvic fractures sustained massive hemorrhage. A treatment protocol incorporating immediate airway control, MAST device, super-large bore venous access, warming rapid infusors, immediate type O blood transfusion, emergency department thoracotomy, and emergent operation as required, produced an overall mortality of 54 per cent. Mortality was higher for pelvic fracture (59%) than abdominal injury (43%). No patient survived ED thoracotomy. Continued developments in resuscitation techniques, as well as prehospital, and operative care are required to reduce mortality from exsanguinating hemorrhage.

Blunt chest trauma occurs in up to 50 per cent of all fatal motor vehicle accidents and is the primary cause of death in 12-25 per cent; yet only 15 per cent of patients with chest trauma arriving alive to the emergency department require early thoracotomy. Pulmonary artery disruption from blunt trauma is extremely rare. Two patients both women, older and obese with multiple rib fractures and little pulmonary parenchymal damage are reported. Neither had injury to the aorta, heart or intra-abdominal organs. One patient survived after lateral repair of the left main pulmonary artery and the other exsanguinated from a laceration of the right main pulmonary artery. Intrapericardial exposure of the proximal pulmonary arteries may be necessary for control of hemorrhage. Trauma surgeons should be familiar with this technique. Indications for immediate thoracotomy should include: massive hemothorax (greater than 1000 ml), continued bleeding greater than 300 ml in the first hour, bleeding greater than 200 ml/hr for 5 hours, or increasing hemothorax in spite of tube thoracostomy. Close adherence to these guidelines would have allowed both patients to be explored earlier.