- Email: [email protected]
Surgical treatment of tracheomediastinal fistula from recurrent hodgkin’s lymphoma
832
CASE REPORT TSE ET AL SURGERY OF TRACHEOMEDIASTINAL FISTULA
Ann Thorac Surg 1999;67:832– 4
before operation, which nicely depicts the course of the LAD within the epicardial fat [2]. Thus, an intramural course can be detected in advance and an open procedure scheduled if necessary. However, magnetic resonance imaging cannot prevent the surgeon from anastomosing the wrong vessel. Intraoperative and postoperative angiography to control graft patency are desirable strategies [3]. However, intraoperative imaging is not possible in many institutions, including our own. Moreover, postoperative angiography is an additional expense and adds a slight risk to the patient. Nevertheless, it may help to identify inadequate bypass procedures and allow percutaneous transluminal coronary angioplasty to alleviate recurrent angina [4]. Therefore, we routinely evaluate all our patients by angiography within 6 months after operation. In conclusion, minimally invasive coronary artery bypass graft operation certainly provides an important new tool for the cardiac surgeon. However, it entails specific difficulties and risks because patients may undergo perfect surgery to the wrong vessel. Fig 2. Postoperative angiogram with a technically perfect anastomosis to the first diagonal branch.
Comment The case demonstrates a pitfall of minimally invasive coronary artery bypass graft operation when using a mini-thoracotomy approach. The identification of the correct vessel can be rather difficult or sometimes even impossible through the small incision, especially when the patient is obese and the coronary artery has an intramural course. Therefore, the risk of operating on a wrong vessel is certainly fundamental. Nevertheless, the mistake may occur more often during the learning curve. Generally, we ask for magnetic resonance tomography
References 1. Shennib H, Mack MJ, Lee AGL. A survey on minimally invasive coronary artery bypass grafting. Ann Thorac Surg 1997;64:110–5. 2. Scheld HH, Schmid C. Cardiac surgery without the use of cardiopulmonary bypass: the challenges. Curr Opin Anaesthesiol 1998;11:5– 8. 3. Emery RW, Emery AM, Flavin TF, Nissen MD, Mooney MR, Arom KV. Revascularization using angioplasty and minimally invasive techniques documented by thermal imaging. Ann Thorac Surg 1996;62:591–3. 4. Angelini GD, Wilde P, Salerno T, Bosco G, Calafiore A. Integrated left small thoracotomy and angioplasty for multivessel coronary artery revascularization. Lancet 1996;347: 757– 8.
Surgical Treatment of Tracheomediastinal Fistula From Recurrent Hodgkin’s Lymphoma David G. Tse, MD, Adam Summers, MD, James R. Sanger, MD, and George B. Haasler, MD Divisions of Cardiothoracic and Plastic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
The role of surgery in the management of Hodgkin’s disease is usually diagnostic because chemotherapy and radiation are often curative. We report here the surgical treatment of a tracheomediastinal fistula from recurrent Hodgkin’s lymphoma. (Ann Thorac Surg 1999;67:832– 4) © 1999 by The Society of Thoracic Surgeons Accepted for publication Aug 14, 1998.
Fig 3. Postoperative angiogram after percutaneous transluminal coronary angioplasty and placement of a stent into the left anterior descending coronary artery. © 1999 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
Address reprint requests to Dr Haasler, Department of Cardiothoracic Surgery, Medical College of Wisconsin, 9200 W. Wisconsin Ave, Milwaukee, WI 53226; e-mail: [email protected].
0003-4975/99/$20.00 PII S0003-4975(98)01342-3
Ann Thorac Surg 1999;67:832– 4
CASE REPORT TSE ET AL SURGERY OF TRACHEOMEDIASTINAL FISTULA
833
T
he role of surgery in the management of Hodgkin’s disease is usually diagnostic because chemotherapy and radiation are often curative. Life-threatening problems may arise making an operation the only realistic approach. We report here the surgical treatment of a tracheomediastinal fistula from recurrent Hodgkin’s lymphoma. A 29-year-old man with a history of stage IIIB nodular sclerosing Hodgkin’s lymphoma treated 17 years earlier with MOPP (mechlorethamine, vincristine, procarbazine, and prednisone) and ABV (doxorubicin, bleomycin, and vinblastine) chemotherapy presented with progressive mediastinal fibrosis, an evolving large confluent mediastinal mass, and an enlarging fistula involving the left tracheobronchial angle communicating anteriorly into the overlying mediastinum. Previous biopsies of the mediastinum by means of cervical mediastinoscopy, partial upper median sternotomy, left anterior mediastinotomy, and right thoracotomy had shown only fibrotic tissue and reactive lymph nodes but no tumor. Main right pulmonary artery compression compromising lung perfusion was treated with a self-expanding 12-mm 3 40-mm endovascular coated Wallstent (Schneider, USA, Inc, Minneapolis, MN). Flexible fiberoptic bronchoscopy, with which a small anterior left mainstem bronchus ulcer had been previously noted, now revealed a large fistula. The resultant cavity walls included both main pulmonary arteries and measured 4 cm 3 3 cm 3 3 cm. The risk of massive hemorrhage into the airway mandated closure of this enlarging cavitary fistula (Fig 1). At surgery, flexible fiberoptic bronchoscopy through a right-sided double-lumen endotracheal tube identified a large irregular space with necrotic debris and pulsatile mediastinal structures through a defect in the anterior distal trachea and proximal left mainstem bronchus. Through a median sternotomy, the anterior mediastinum was noted to be completely encased by a fibrotic dense mass that enveloped the aortic root, superior vena cava, and presenting surface of the pericardium. An uninvolved pericardial patch was harvested. The fistula cavity was approached between the aorta and superior vena cava by careful division of the fibrous tissue guided by needle aspiration to avoid great vessel injury. After reaching the cavity, the right pulmonary stent was visualized, lacking overlying pulmonary artery tissue. Two defects from the anterior distal trachea to the proximal left mainstem bronchus that were separated by a 3-mm bridge of cartilage constituted the base of the cavity. Debridement and several biopsies were performed. Repair of the tracheobronchial defect was accomplished with autogenous pericardial patch after insertion of a 1-cm 3 4-cm coated Wallstent into the left main bronchus. Omental transposition into the area of repair obliterated the remaining cavity. Reinspection of the airways by bronchoscopy demonstrated good stent position with a nicely expanded proximal left main stem bronchus. Biopsies from the fibrous cavity and tracheal cartilage bridge (but not from the harvested pericardium) were positive for recurrent nodular sclerosing Hodgkin’s lymphoma. Residual soft tissue infection was treated with 6 weeks of intravenous antibiotics. The patient also re-
Fig 1. Computed tomographic scan showing tracheomediastinal fistula, large mediastinal mass, and compression of mediastinal structures.
quired insertion of a multisegment vascular Gianturco stent into the superior vena cava because of tumor encasement and incipient superior vena cava syndrome. Interval computed tomographic scans have since revealed celiac adenopathy. Postoperative chemotherapy and radiation treatments have been well tolerated. Diminution of the mediastinal mass, obliteration of the cavity, and incorporation of the pericardial patch with patent distal airways has been demonstrated on follow-up studies (Fig 2). He remains clinically stable at 4 months after operation.
Comment Mediastinal Hodgkin’s lymphoma presenting solely as an intrathoracic neoplasm occurs in approximately 50% of Hodgkin’s lymphomas. The incidence of relapse iso-
Fig 2. Computed tomographic scan 3 months after closure of tracheal bronchial fistula showing omental transposition filling anterior mediastinum and cavity, and a stent in the left main bronchus.
834
CASE REPORT SCHULTZ ET AL COMPLEX TRACHEOBRONCHIAL INJURY
lated to the mediastinum is more remote (12% to 15%) and depends on both initial pathologic stage and treatment modality [1, 2]. Sequelae of mediastinal Hodgkin’s lymphoma have included encasement (superior vena cava syndrome, compression of main pulmonary arteries), bleeding, and perforation (tracheoesophageal fistula) [3–5]. Essential to treatment is obtaining a diagnosis, which is the usual role of surgery; thereafter, appropriate antineoplastic therapy can often cure difficult problems as illustrated in tracheoesophageal fistula secondary to Hodgkin’s lymphoma [5]. Fistulization between the trachea and anterovisceral mediastinum, an uncommon entity, and its surgical management have not been reported when arising from mediastinal Hodgkin’s lymphoma. This case highlights diagnosis and surgical treatment of a challenging, potentially disastrous problem. Repair of a tracheal defect with an autogenous pericardial patch in the presence of an infected cavity once infection was controlled appeared a viable option for separation of the great vessels from the tracheobronchial tree. Experimental studies of pericardial incorporation have pointed to reepithelialization and eventual stiffening [6]. Further stabilization was provided with endobronchial stenting. Elimination of the residual space after debridement and buttressing of major vascular structures was accomplished with viable vascular tissue, ie, omental transposition. Fortuitously, the concomitant mediastinal fibrosis and omental transplant may have decreased the risk of progressive mediastinitis and afforded better antibiotic penetration. Hodgkin’s disease appearing like sclerosing mediastinitis has been previously reported [7]. A diagnosis of recurrent Hodgkin’s disease was finally obtained from mediastinal and tracheal biopsies to direct definitive treatment as multiple previous surgical procedures had failed to establish this. Initial biopsy specimens were nonspecific, having features consistent with multiple etiologic processes such as Castleman’s disease and postinfectious mediastinal fibrosis. Lastly, the use of endovascular stents for management of major mediastinal great vessel compression is demonstrated here as an evolving alternative to surgical bypass. The coated right pulmonary artery stent undoubtedly prevented major hemorrhage from occurring before and during the surgical correction.
References 1. Roach M III, Brophy N, Cox R, et al. Prognostic factors for patients relapsing after radiotherapy for early Hodgkin’s disease. J Clin Oncol 1990;8:623–9. 2. Healey EA, Tarbel N, Kalish L, et al. Prognostic factors for patients with Hodgkin’s disease in first relapse. Cancer 1993; 71:2613–20. 3. Yellin A, Mandel M, Rechavi G, Newman Y, Ramot B, Lieberman Y. Superior vena cava syndrome associated with lymphoma. Am J Dis Child 1992;146:1060–3. 4. Shields JJ, Cho KJ, Geisinger KR. Pulmonary artery constriction by mediastinal lymphoma simulating pulmonary embolus. Am J Roentgenol 1980;135:147–50. 5. Greven KM, Evans LS. The occurrence and management of © 1999 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
Ann Thorac Surg 1999;67:834 – 6
esophageal fistulas resulting from Hodgkin’s disease. Cancer 1992;69:1031–3. 6. Bryant LR, Eiseman B. Replacement of tracheobronchial defects with autogenous pericardium. J Thorac Cardiovasc Surg 1964;48:733– 40. 7. Flannery MT, Espino M, Altus P, Messina J, Wallach PM. Hodgkin’s disease masquerading as sclerosing mediastinitis. South Med J 1994;87:921–3.
Surgical Management and Followup of a Complex Tracheobronchial Injury Scot C. Schultz, MD, John W. Hammon, Jr, MD, Charles S. Turner, MD, Will F. McGuirt, Jr, MD, and Jean M. Nelson, MD Departments of Cardiothoracic Surgery, Section of Pediatric Surgery, General Surgery, Otolaryngology, and Anesthesiology, Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina
Tracheobronchial trauma is an uncommon condition with potentially devastating consequences. Appropriate pre-, intra-, and postoperative management is mandatory for a satisfactory functional outcome. We report a case of extensive tracheobronchial injury secondary to blunt trauma, which was managed successfully with emergent surgical repair and careful endoscopic follow-up. We review the important management decisions made in this case. (Ann Thorac Surg 1999;67:834 – 6) © 1999 by The Society of Thoracic Surgeons
T
racheobronchial injury after blunt trauma may involve the trachea or bronchi from the level of the cricoid cartilage to the division of the lobar bronchi. It is a rare entity that is frequently lethal, particularly when there is a delay in diagnosis. We report the management and follow-up of a 4-year-old boy who was ejected from a vehicle and suffered an extremely complex tracheobronchial injury.
Case Report A 4-year-old boy, an unrestrained back seat passenger, was ejected from a vehicle after a head-on collision. He arrived at an outside emergency department with a Glasgow coma score of 3, hypotensive, and tachycardic.
Accepted for publication Aug 13, 1998. Address reprint requests to Dr Hammon, Jr, Department of Cardiothoracic Surgery, Wake Forest University Medical Center, Medical Center Blvd, Winston-Salem, NC 27157-1096.
0003-4975/99/$20.00 PII S0003-4975(98)01206-5
CASE REPORT TSE ET AL SURGERY OF TRACHEOMEDIASTINAL FISTULA
Ann Thorac Surg 1999;67:832– 4
before operation, which nicely depicts the course of the LAD within the epicardial fat [2]. Thus, an intramural course can be detected in advance and an open procedure scheduled if necessary. However, magnetic resonance imaging cannot prevent the surgeon from anastomosing the wrong vessel. Intraoperative and postoperative angiography to control graft patency are desirable strategies [3]. However, intraoperative imaging is not possible in many institutions, including our own. Moreover, postoperative angiography is an additional expense and adds a slight risk to the patient. Nevertheless, it may help to identify inadequate bypass procedures and allow percutaneous transluminal coronary angioplasty to alleviate recurrent angina [4]. Therefore, we routinely evaluate all our patients by angiography within 6 months after operation. In conclusion, minimally invasive coronary artery bypass graft operation certainly provides an important new tool for the cardiac surgeon. However, it entails specific difficulties and risks because patients may undergo perfect surgery to the wrong vessel. Fig 2. Postoperative angiogram with a technically perfect anastomosis to the first diagonal branch.
Comment The case demonstrates a pitfall of minimally invasive coronary artery bypass graft operation when using a mini-thoracotomy approach. The identification of the correct vessel can be rather difficult or sometimes even impossible through the small incision, especially when the patient is obese and the coronary artery has an intramural course. Therefore, the risk of operating on a wrong vessel is certainly fundamental. Nevertheless, the mistake may occur more often during the learning curve. Generally, we ask for magnetic resonance tomography
References 1. Shennib H, Mack MJ, Lee AGL. A survey on minimally invasive coronary artery bypass grafting. Ann Thorac Surg 1997;64:110–5. 2. Scheld HH, Schmid C. Cardiac surgery without the use of cardiopulmonary bypass: the challenges. Curr Opin Anaesthesiol 1998;11:5– 8. 3. Emery RW, Emery AM, Flavin TF, Nissen MD, Mooney MR, Arom KV. Revascularization using angioplasty and minimally invasive techniques documented by thermal imaging. Ann Thorac Surg 1996;62:591–3. 4. Angelini GD, Wilde P, Salerno T, Bosco G, Calafiore A. Integrated left small thoracotomy and angioplasty for multivessel coronary artery revascularization. Lancet 1996;347: 757– 8.
Surgical Treatment of Tracheomediastinal Fistula From Recurrent Hodgkin’s Lymphoma David G. Tse, MD, Adam Summers, MD, James R. Sanger, MD, and George B. Haasler, MD Divisions of Cardiothoracic and Plastic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
The role of surgery in the management of Hodgkin’s disease is usually diagnostic because chemotherapy and radiation are often curative. We report here the surgical treatment of a tracheomediastinal fistula from recurrent Hodgkin’s lymphoma. (Ann Thorac Surg 1999;67:832– 4) © 1999 by The Society of Thoracic Surgeons Accepted for publication Aug 14, 1998.
Fig 3. Postoperative angiogram after percutaneous transluminal coronary angioplasty and placement of a stent into the left anterior descending coronary artery. © 1999 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
Address reprint requests to Dr Haasler, Department of Cardiothoracic Surgery, Medical College of Wisconsin, 9200 W. Wisconsin Ave, Milwaukee, WI 53226; e-mail: [email protected].
0003-4975/99/$20.00 PII S0003-4975(98)01342-3
Ann Thorac Surg 1999;67:832– 4
CASE REPORT TSE ET AL SURGERY OF TRACHEOMEDIASTINAL FISTULA
833
T
he role of surgery in the management of Hodgkin’s disease is usually diagnostic because chemotherapy and radiation are often curative. Life-threatening problems may arise making an operation the only realistic approach. We report here the surgical treatment of a tracheomediastinal fistula from recurrent Hodgkin’s lymphoma. A 29-year-old man with a history of stage IIIB nodular sclerosing Hodgkin’s lymphoma treated 17 years earlier with MOPP (mechlorethamine, vincristine, procarbazine, and prednisone) and ABV (doxorubicin, bleomycin, and vinblastine) chemotherapy presented with progressive mediastinal fibrosis, an evolving large confluent mediastinal mass, and an enlarging fistula involving the left tracheobronchial angle communicating anteriorly into the overlying mediastinum. Previous biopsies of the mediastinum by means of cervical mediastinoscopy, partial upper median sternotomy, left anterior mediastinotomy, and right thoracotomy had shown only fibrotic tissue and reactive lymph nodes but no tumor. Main right pulmonary artery compression compromising lung perfusion was treated with a self-expanding 12-mm 3 40-mm endovascular coated Wallstent (Schneider, USA, Inc, Minneapolis, MN). Flexible fiberoptic bronchoscopy, with which a small anterior left mainstem bronchus ulcer had been previously noted, now revealed a large fistula. The resultant cavity walls included both main pulmonary arteries and measured 4 cm 3 3 cm 3 3 cm. The risk of massive hemorrhage into the airway mandated closure of this enlarging cavitary fistula (Fig 1). At surgery, flexible fiberoptic bronchoscopy through a right-sided double-lumen endotracheal tube identified a large irregular space with necrotic debris and pulsatile mediastinal structures through a defect in the anterior distal trachea and proximal left mainstem bronchus. Through a median sternotomy, the anterior mediastinum was noted to be completely encased by a fibrotic dense mass that enveloped the aortic root, superior vena cava, and presenting surface of the pericardium. An uninvolved pericardial patch was harvested. The fistula cavity was approached between the aorta and superior vena cava by careful division of the fibrous tissue guided by needle aspiration to avoid great vessel injury. After reaching the cavity, the right pulmonary stent was visualized, lacking overlying pulmonary artery tissue. Two defects from the anterior distal trachea to the proximal left mainstem bronchus that were separated by a 3-mm bridge of cartilage constituted the base of the cavity. Debridement and several biopsies were performed. Repair of the tracheobronchial defect was accomplished with autogenous pericardial patch after insertion of a 1-cm 3 4-cm coated Wallstent into the left main bronchus. Omental transposition into the area of repair obliterated the remaining cavity. Reinspection of the airways by bronchoscopy demonstrated good stent position with a nicely expanded proximal left main stem bronchus. Biopsies from the fibrous cavity and tracheal cartilage bridge (but not from the harvested pericardium) were positive for recurrent nodular sclerosing Hodgkin’s lymphoma. Residual soft tissue infection was treated with 6 weeks of intravenous antibiotics. The patient also re-
Fig 1. Computed tomographic scan showing tracheomediastinal fistula, large mediastinal mass, and compression of mediastinal structures.
quired insertion of a multisegment vascular Gianturco stent into the superior vena cava because of tumor encasement and incipient superior vena cava syndrome. Interval computed tomographic scans have since revealed celiac adenopathy. Postoperative chemotherapy and radiation treatments have been well tolerated. Diminution of the mediastinal mass, obliteration of the cavity, and incorporation of the pericardial patch with patent distal airways has been demonstrated on follow-up studies (Fig 2). He remains clinically stable at 4 months after operation.
Comment Mediastinal Hodgkin’s lymphoma presenting solely as an intrathoracic neoplasm occurs in approximately 50% of Hodgkin’s lymphomas. The incidence of relapse iso-
Fig 2. Computed tomographic scan 3 months after closure of tracheal bronchial fistula showing omental transposition filling anterior mediastinum and cavity, and a stent in the left main bronchus.
834
CASE REPORT SCHULTZ ET AL COMPLEX TRACHEOBRONCHIAL INJURY
lated to the mediastinum is more remote (12% to 15%) and depends on both initial pathologic stage and treatment modality [1, 2]. Sequelae of mediastinal Hodgkin’s lymphoma have included encasement (superior vena cava syndrome, compression of main pulmonary arteries), bleeding, and perforation (tracheoesophageal fistula) [3–5]. Essential to treatment is obtaining a diagnosis, which is the usual role of surgery; thereafter, appropriate antineoplastic therapy can often cure difficult problems as illustrated in tracheoesophageal fistula secondary to Hodgkin’s lymphoma [5]. Fistulization between the trachea and anterovisceral mediastinum, an uncommon entity, and its surgical management have not been reported when arising from mediastinal Hodgkin’s lymphoma. This case highlights diagnosis and surgical treatment of a challenging, potentially disastrous problem. Repair of a tracheal defect with an autogenous pericardial patch in the presence of an infected cavity once infection was controlled appeared a viable option for separation of the great vessels from the tracheobronchial tree. Experimental studies of pericardial incorporation have pointed to reepithelialization and eventual stiffening [6]. Further stabilization was provided with endobronchial stenting. Elimination of the residual space after debridement and buttressing of major vascular structures was accomplished with viable vascular tissue, ie, omental transposition. Fortuitously, the concomitant mediastinal fibrosis and omental transplant may have decreased the risk of progressive mediastinitis and afforded better antibiotic penetration. Hodgkin’s disease appearing like sclerosing mediastinitis has been previously reported [7]. A diagnosis of recurrent Hodgkin’s disease was finally obtained from mediastinal and tracheal biopsies to direct definitive treatment as multiple previous surgical procedures had failed to establish this. Initial biopsy specimens were nonspecific, having features consistent with multiple etiologic processes such as Castleman’s disease and postinfectious mediastinal fibrosis. Lastly, the use of endovascular stents for management of major mediastinal great vessel compression is demonstrated here as an evolving alternative to surgical bypass. The coated right pulmonary artery stent undoubtedly prevented major hemorrhage from occurring before and during the surgical correction.
References 1. Roach M III, Brophy N, Cox R, et al. Prognostic factors for patients relapsing after radiotherapy for early Hodgkin’s disease. J Clin Oncol 1990;8:623–9. 2. Healey EA, Tarbel N, Kalish L, et al. Prognostic factors for patients with Hodgkin’s disease in first relapse. Cancer 1993; 71:2613–20. 3. Yellin A, Mandel M, Rechavi G, Newman Y, Ramot B, Lieberman Y. Superior vena cava syndrome associated with lymphoma. Am J Dis Child 1992;146:1060–3. 4. Shields JJ, Cho KJ, Geisinger KR. Pulmonary artery constriction by mediastinal lymphoma simulating pulmonary embolus. Am J Roentgenol 1980;135:147–50. 5. Greven KM, Evans LS. The occurrence and management of © 1999 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
Ann Thorac Surg 1999;67:834 – 6
esophageal fistulas resulting from Hodgkin’s disease. Cancer 1992;69:1031–3. 6. Bryant LR, Eiseman B. Replacement of tracheobronchial defects with autogenous pericardium. J Thorac Cardiovasc Surg 1964;48:733– 40. 7. Flannery MT, Espino M, Altus P, Messina J, Wallach PM. Hodgkin’s disease masquerading as sclerosing mediastinitis. South Med J 1994;87:921–3.
Surgical Management and Followup of a Complex Tracheobronchial Injury Scot C. Schultz, MD, John W. Hammon, Jr, MD, Charles S. Turner, MD, Will F. McGuirt, Jr, MD, and Jean M. Nelson, MD Departments of Cardiothoracic Surgery, Section of Pediatric Surgery, General Surgery, Otolaryngology, and Anesthesiology, Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina
Tracheobronchial trauma is an uncommon condition with potentially devastating consequences. Appropriate pre-, intra-, and postoperative management is mandatory for a satisfactory functional outcome. We report a case of extensive tracheobronchial injury secondary to blunt trauma, which was managed successfully with emergent surgical repair and careful endoscopic follow-up. We review the important management decisions made in this case. (Ann Thorac Surg 1999;67:834 – 6) © 1999 by The Society of Thoracic Surgeons
T
racheobronchial injury after blunt trauma may involve the trachea or bronchi from the level of the cricoid cartilage to the division of the lobar bronchi. It is a rare entity that is frequently lethal, particularly when there is a delay in diagnosis. We report the management and follow-up of a 4-year-old boy who was ejected from a vehicle and suffered an extremely complex tracheobronchial injury.
Case Report A 4-year-old boy, an unrestrained back seat passenger, was ejected from a vehicle after a head-on collision. He arrived at an outside emergency department with a Glasgow coma score of 3, hypotensive, and tachycardic.
Accepted for publication Aug 13, 1998. Address reprint requests to Dr Hammon, Jr, Department of Cardiothoracic Surgery, Wake Forest University Medical Center, Medical Center Blvd, Winston-Salem, NC 27157-1096.
0003-4975/99/$20.00 PII S0003-4975(98)01206-5