Recommended guidelines for optimal design of a plastic surgery service during mass casualty events

OBJECTIVE

The objectives of the study were to evaluate the pattern of plastic surgery (PS) team intervention during the first 12 hours after a mass casualty blast.

METHODS

The records of 272 civilians injured from 1994 to 1997 in Tel Aviv were reviewed. Patients' injuries were classified according to the nature of their PS injury and the type of PS intervention. The procedure time and number of plastic surgeons involved were recorded in 20-minute intervals. The average and standard deviation of the peak demand (PD) timing for PS intervention were calculated. Linear correlation between the PD and the total number of wounded transferred to the Tel Aviv Sourasky Medical Center was evaluated by the correlation coefficient.

RESULTS

A distinct "double-peak" and five phases pattern of PS team intervention were observed. A linear correlation and a 1:5 ratio were found between the total number of wounded transferred to the Tel Aviv Sourasky Medical Center and the PD for PS intervention.

CONCLUSIONS

PS involvement has a predicted pattern related to the patient volume. Guidelines based on the conclusions drawn from this study can ensure an ordered, efficacious level of PS care during these events. A triple team plan is suggested, and adjustments in medical resources according to the specific nature of the event are described.

Methylene blue prevents pulmonary injury after intestinal ischemia-reperfusion

OBJECTIVE

To investigate the effect of methylene blue, an inhibitor of oxygen radicals, on lung injury caused by reperfusion of ischemic tissue.

METHODS

Intestinal ischemia-reperfusion injury was induced in rats by clamping the superior mesenteric artery for 1 hour. Thereafter, the experimental group was administered 1% methylene blue intraperitoneally and the control group received saline. After 4 hours, pulmonary histopathologic features were assessed, and lung wet-weight to dry-weight ratios and tissue xanthine oxidase were determined.

RESULTS

The control group suffered from severe pulmonary parenchymal damage, compared with slight damage in the experimental group. The number of sequestered neutrophils was significantly higher in the control group (319 +/- 60 polymorphonuclear cells per 10 high-power fields) than in the methylene blue-treated group (91 +/- 8 polymorphonuclear cells per 10 high-power fields; p < 0.001). The wet-weight to dry-weight ratio was significantly increased in the saline-treated rats compared with the methylene blue-treated group (6.19 +/- 0.28 vs. 5.07 +/- 0.21; p < 0.001). Xanthine oxidase activity was similar in both groups.

CONCLUSION

Methylene blue attenuated lung injury after intestinal ischemia-reperfusion. Inhibition of oxygen free radicals may be the protective mechanism.

Permissive hypercapnia ventilation in patients with severe pulmonary blast injury

OBJECTIVES

To describe our experience with the use of limited peak inspiratory pressure (PIP), volume-controlled ventilation, and permissive hypercapnia in patients with severe pulmonary blast injury.

METHODS

Patients with pulmonary blast injury were ventilated using volume-controlled, synchronized intermittent mandatory ventilation. Whenever PIP exceeded 40 cm H2O, the tidal volume was decreased to maintain PIP at less than 40 cm H2O. Whenever the arterial pH fell below 7.2, the ventilator rate was increased in increments of 2 breaths per minute until the arterial pH rose to 7.25.

RESULTS

Between 1994 and 1996, 17 patients with severe pulmonary blast injury (10 from enclosed space explosions and seven from open space ones), requiring mechanical ventilatory support were admitted to our intensive care unit. Four patients developed increasing PaCO2 levels (to 93 +/- 12 mm Hg) associated with the reduction in arterial pH that was corrected by increasing the ventilator rate. There was evidence of ventilator-induced pulmonary barotrauma. Of the 17 patients, 15 patients (88%) survived.

CONCLUSIONS

Limited PIP in a volume-controlled ventilation is a useful and safe mode of mechanical ventilation in patients with pulmonary blast injury.

Bursting pressure in anastomotic healing in experimentally induced colitis in rats

BACKGROUND

Experimental studies on healing of colonic anastomosis have been thoroughly investigated. However, clinical parameters of the healing process of anastomosis in the inflamed colon has not yet been reported.

METHODS

In the present study, healing of anastomosis in trinitrobenzene-sulfonic acid-induced colitis in rats was assessed by measuring the bursting pressure and bursting wall tension.

RESULTS

On postoperative day 4, bursting pressure and bursting wall tension were significantly lower (P < 0.001) in rats with colitis with or without anastomosis and normal colon with anastomosis, compared with normal colon without anastomosis. On postoperative day 7, bursting pressure and bursting wall tension of normal colon with anastomosis approached that of normal colon without anastomosis. However, bursting pressure and bursting wall tension of rats with colitis with or without anastomosis remained significantly lower (P < 0.001) than the latter. Furthermore, unlike rats without colitis in which perforation occurred mostly at the anastomotic line, the bursting site in colitic rats was predominantly away from the anastomotic line.

CONCLUSIONS

These results suggest that in surgery for inflammatory bowel disease, it is the adjoining inflamed bowel wall that is vulnerable to be perforated in response to increasing intraluminal pressure rather than the anastomosis that is braced by the sutures.

[Chylothorax following penetrating injury]

We describe a 19-year-old man with 9 stab wounds of the chest. Initial evaluation revealed paraplegia at the D-10 level and bilateral hemothorax. 2 days after admission right-sided chylothorax was diagnosed. Fasting and total parenteral nutrition resulted in complete clearance. Chylothorax can cause major metabolic consequences, but prompt treatment results in full recovery.

[Israel's ATLS program: summary and outlook]

In recent years a vigorous effort has been made to improve quality of primary trauma care in Israel. Advanced trauma life support courses (ATLS) were given to physicians throughout the country, regardless of their specialties. In 7 years 4229 physicians participated in 202 courses with an average success rate of 76%. In the future, issues such as mandatory vs. voluntary training, language barriers, and continuous decline of knowledge should be addressed if momentum is to be maintained.

Vaginal evisceration resulting from a water-slide injury

A case of vaginal evisceration resulting from sliding on a water chute is described. The treatment and mechanism of this rare injury are discussed.

Reduction of surgery-induced peritoneal adhesions by methylene blue

BACKGROUND

The possible involvement of inflammatory mediators such as nitric oxide (NO), and reports of protective effects of antioxidants, led us to test the effectiveness of methylene blue and NO synthesis inhibitor in reducing adhesion formation.

METHODS

Generation of adhesions in rats, by scraping the anterior uterine horn wall, was followed by intraperitoneal administration of saline methylene blue, or N alpha-t-BOC-omega-nitro-L-arginine. Additional rats received identical treatments, but without the serosal damage. Two weeks later, formation of adhesions was quantitatively graded.

RESULTS

Adhesions were found in <5% of the rats with the sham surgery, regardless of treatment. In the experimental group, >95% of the rats treated with saline or NO synthetase inhibitor had severe adhesions, in contrast to 5% of the methylene blue treated rats. Severity of adhesion was lower in the methylene blue group (P <0.001).

CONCLUSIONS

Methylene blue was very effective in preventing formation of peritoneal adhesions. Its activity is probably through inhibition of free-radical generation and not of nitric oxide action.

[ATLS course for surgery residents--should it be mandatory?]

Senior surgeons were asked about mandatory participation of general surgery residents in the advanced trauma life support (ATLS) course. Although trauma care in Israel is given by surgical residents, in the opinion of their senior mentors the course should continue to be mandatory for them.

Diarrheal epidemics among Rwandan refugees in 1994. Management and outcome in a field hospital

We describe the clinical course and outcome of Rwandan refugees with cholera-like illness (n = 567) and clinical dysentery (n = 1,062) treated at the Israeli Army field hospital in the disaster region of Goma, Zaire, during the summer of 1994. Vigorous fluid administration was the primary therapy, complemented with antibiotics for patients with presumed Shigella infection. Recovery rates were 94% and 96% for patients with cholera and dysentery, respectively. Mortality was substantially affected by comorbid conditions such as pneumonia and meningitis, which occurred in one-quarter of these patients. Infective, metabolic, and surgical complications (including three cases of intussusception) may have contributed to the deaths. The outcome of patients during diarrheal epidemics of cholera or bacillary dysentery may be favorable, even in disaster settings, if patients are evacuated promptly to medical facilities and appropriate therapy is instituted. We close with general observations on procedures to be followed in future epidemics of diarrheal diseases.

Methylene blue--a promising treatment modality in sepsis induced by bowel perforation

In this study, we compared the effects of methylene blue (MB) and an L-arginine analogue on host outcome, blood pressure, lung injury, and nitric oxide (NO) production in rats following fecal peritonitis induced by cecal ligation and puncture (CLP). Sepsis syndrome was induced in 90 rats: 30 were treated with MB, 30 with an NO synthase inhibitor, and 30 with normal saline. We found significantly less alveolar damage, higher blood pressure, better respiratory function, and delayed mortality among animals treated with MB compared to the control group. We conclude that the ability of MB to reduce alveolar damage and therefore to delay mortality in this animal septic shock model may give this harmless substance a role among the treatment modalities of septic shock syndrome induced by fecal peritonitis.

The use of hemorrhage occluder pins for controlling paravertebral intercostal artery bleeding: case report

OBJECTIVE

To describe a technique for arresting traumatic bleeding uncontrollable by conventional means.

METHODS AND RESULTS

Major intrathoracic bleeding was stopped in a 17-year-old boy who had been stabbed in his right chest by using a Hemorrhage Occluder Pin (Surgical Instruments Inc., Placetia, Calif).

CONCLUSIONS

The use of occluder pins to stop bleeding from intercostal arteries may be life-saving.

Direct induction of acute lung and myocardial dysfunction by liver ischemia and reperfusion

OBJECTIVES

To investigate whether liver ischemia and reperfusion (IR) directly affect functions of remote organs.

BACKGROUND

Cardiovascular and respiratory dysfunction follows hemorrhage, spinal shock, or trauma as a result of no-flow-reflow phenomena. Hepatic IR induces remote organ damage probably by xanthine oxidase and oxygen species.

MATERIALS AND METHODS

Isolated rat livers, lungs, and hearts were perfused with Krebs-Henseleit solutions. After stabilization, livers were either perfused or made ischemic. Then, livers and hearts or livers and lungs were reperfused in series, and the liver was disconnected and the second organ continued to perfuse with the accumulated effluents.

MEASUREMENTS AND MAIN RESULTS

Ischemic and reperfused liver effluent contained high lactate dehydrogenase and uric acid concentrations compared with controls; xanthine oxidase increased 60 to 100 times. Ischemic and reperfused lung peak inspiratory pressure almost doubled; airway static compliance halved; myocardial contractility decreased to 70% of baseline; wet weight-to-dry weight ratios of lungs and livers increased.

CONCLUSION

Ischemic and reperfused liver can directly induce myocardial and pulmonary dysfunction, presumably by oxidant-induced injury.

Combat trauma life support training versus the original advanced trauma life support course: the impact of enhanced curriculum on final student scores

BACKGROUND

Within a military framework, the trauma course student, a young medical officer, is trained to become a trauma team leader and the first provider of medical aid. By adding battlefield medicine-related subjects to the basic Advanced Trauma Life Support (ATLS) course, as well as exercises tailored to the distinctive demands of military medicine, we could develop a special teaching unit: Combat Trauma Life Support (CTLS). The curriculum is basically the complete unchanged ATLS course of the American College of Surgeons enriched with lectures and practicums to fill the gap between the essentially civilian emergency department character of the ATLS course and the military tasks of the medical officer.

PURPOSE OF STUDY

To compare the cognitive knowledge achievements of trauma course participants in the Israel Defence Force Medical Corps and to delineate the impact of the course type on students' written test results.

DESIGN

A retrospective comparison analysis of pre- and post-course written test scores of 2,614 physicians who had participated in the ATLS and CTLS courses in the Israel Defence Force School of Military Medicine between 1990 and 1993.

RESULTS

The analysis indicated that students who undertook the CTLS course achieved statistically better results in written tests (87.9 +/- 8.7 vs. 79.6 +/- 11.4, R2 = 0.33).

CONCLUSIONS

We conclude that the CTLS comprehensive curriculum provides an improved training basis for the complex task of army battlefield trauma care support.

[Penetrating gluteal injuries management--the need for management protocols]

Gunshot wounds are the most common cause of penetrating injuries in the gluteal region (PIGR), while only 17.5% result from stabbing. Complications and even death have been described as resulting from stab injury in this area, which is thus a hazard that demands an algorithm for proper management. Recently, DiGiacomo et al. recommended that transpelvic bullet trajectory warrants surgery. Mercer et al., in a study of 81 patients with PIGR, recommended an algorithm based on anatomical gluteal zones and concluded that angiography is not mandatory in such injuries. We describe 9 cases of PIGR, 4 of which were from stab wound and 1 a gunshot wound, which bled from rami of the gluteal arteries. In 2 there was no apparent bleeding, and they were hemodynamically stable. Thus in this type of injury significant damage may be obscured. Our results suggest that angiography is important in the evaluation of such injuries an should be part of the protocol for management of PIGR.

[ATLS course in emergency medicine for physicians?]

Implementation of Advanced Trauma Life Support (ATLS) skills among practicing physicians and its perceived utility in their civilian practices, as well as in their potential army combat assignments, was evaluated. 177 physicians in various subspecialties, who were graduates of ATLS training courses, answered a specially designed telephone questionnaire. An unexpectedly high percentage of physicians (47%) had used their ATLS training when called to treat trauma victims. 67% of physicians stressed the contribution of the ATLS course to enhancing their skills. We believe that a properly designed ATLS course for general practitioners would be very beneficial for trauma victims.