No abstract

Ultrasound guidance should be considered for injection therapy in the management of Morton's neuroma.

Critically ill military trauma patients have been found to have a high incidence of psychological morbidity following their Intensive Care Unit (ICU) experience, including recall of significant auditory and visual hallucinations. It follows that this may be attributable to delirium, which has not been previously described in a young, previously fit population following trauma. The case-notes of 85 male patients (mean age 26 years), admitted to a single UK ICU following military trauma, were retrospectively assessed for delirium using DSM-IV criteria. Of the 993 ICU days assessed, 13.4% were deliriumpositive, with just over half of patients (51.8%) experiencing at least one day of delirium. On delirium-positive days, 69.2% received a documented intervention, with the majority of interventions (66.4%) being pharmacological, commonly with a sedative or anti-psychotic. Presence of delirium was significantly associated with severity of injury, assessed by Injury Severity Score (OR 1.037, 95% CI 1.003-1.072, p ¼ 0.031). Duration of ICU stay was significantly increased, from 4 to 8 days (p < 0.005), as was the duration of mechanical ventilation (for the 84.7% of patients who were ventilated) from 7 to 13 days (p < 0.005). Delirium is common in military trauma patients, despite their young age and premorbid fitness. A review of longer-term psychological outcomes should be considered.

‘Protective ventilation’ for acute respiratory distress syndrome (ARDS) and acute lung injury (ALI) is a major advance in intensive care medicine. However, components of protective ventilation expose the right heart to challenges. Acute cor pulmonale (ACP), patent foramen ovale (PFO) and right ventricular failure (RVF) are recognised complications that could potentially reduce the benefit of protective ventilation. We sought to determine the rates of ACP, PFO and RVF in critically ill adults undergoing protective ventilation with ARDS/ALI and to identify their impact on mortality and critical illness acuity. A comprehensive search of electronic databases including Medline (OVID, EmBase) and CINAHL (EBSCO) was undertaken, including Cochrane Library and international registries, between January 1991 and December 2011. A systematic review identified a total of 248 articles; 27 were reviewed in full and 22 studies were included. All 22 included studies were observational or quasi-experimental with no randomised, controlled trials available. ACP was present in 16–100%, PFO 1.3–22.0% and RVF 9.6–26.0%. Neither ACP nor PFO was associated with an adverse effect on mortality and ACP seemed reversible in survivors; however both ACP and PFO were associated with prolonged need for ICU support. RVF was variously associated with no increase in mortality to an odds ratio 5.1 for death in multivariate analysis. There was marked heterogeneity in the studies included, explaining the range of observed values. Recommendations for future research and practice were produced. Modern protective ventilation during ARDS has been shown to exert inconsistent effects on the right heart which may be of clinical significance. Further research is needed to determine these effects better.