Positive correlation between blood alcohol level and ISS in road trauma

To assess the relationship between blood alcohol concentration (BAC) and injury severity in an unselected population of road accident victims, case notes of 820 consecutive road accident victims presenting to hospital in a 12 month period were reviewed retrospectively. Five hundred and thirty-five of these were eligible for BAC analysis and results, obtained from the Victoria Police and the Road Safety and Traffic Bureau were available in 429 cases. These were expressed as mg/100 ml (per cent). Injury severity was quantified using the Injury Severity Score (ISS). BAC was compared with injury severity in three ways. First, Spearman's correlation coefficient (rho) of 0.27 indicated a highly significant correlation (P < 0.01). Second, the median ISS for intoxicated patients (4) was significantly higher than that for sober patients (1) (P < 0.05). Third, when patients were grouped according to ISS, the prevalence of intoxication in each group rose with increasing injury severity (chi 2: P < 0.01). We conclude that there is a significant positive correlation between BAC and injury severity in road accident victims treated at a Melbourne hospital.

Familial abdominal aortic aneurysm: prevalence and implications for screening

The high prevalence of abdominal aortic aneurysm (AAA) in men over the age of 65 has led to the establishment of ultrasound screening programmes for this group. The apparent familial tendency towards AAA formation suggests that relatives of aneurysm patients may form another subpopulation in whom screening is appropriate. The first degree relatives of 100 consecutive aneurysm patients were identified. Of 110 relatives over 50 years of age, two were known to have had AAA and ultrasound scans were performed on 74, providing information on aortic size for 76 relatives (69%). No further aortic aneurysms (antero-posterior diameter > or = 4.0 cm) were found on scanning. However, nine relatives were demonstrated to have aortic dilatation (2.5-3.9 cm). Aortic dilatation was observed in 21% of male first degree relatives over 50 years of age, affecting 27% of sons and 17% of brothers. Only 4% of the sisters and none of the daughters were found to have aortic dilatation. The prevalence of aortic enlargement seems to be sufficiently high amongst male first degree relatives of AAA patients over 50 years of age to justify aortic screening.

Endoscopic transthoracic sympathectomy: experience in the south west of England

Thoracic sympathectomy has an established role in the management of primary palmar and axillary hyperhidrosis, Raynaud's phenomenon and occlusive vascular disease. Potential problems with traditional surgical approaches to the sympathetic chain include poor exposure, risk of damage to adjacent structures and postoperative pain. A minimally invasive endoscopic approach helps to overcome these problems. Using this technique, 45 procedures have been performed on 26 patients in two districts in the South West of England over the past five years. Follow-up information was available for 39 procedures. All 27 procedures for hyperhidrosis and both for occlusive vascular disease have produced a long-term improvement. Nine of the 10 procedures for Raynaud's phenomenon have also produced some degree of long-term improvement. Complications included four asymptomatic pneumothoraces, two patients with temporary unilateral Horner's syndrome and two instances of intercosto-brachial numbness. On the positive side, patients expressed satisfaction with the efficacy, rapid recovery and small unobtrusive scars produced by the procedure. Endoscopic transthoracic sympathectomy is effective, safe and well accepted by patients and we believe is now the method of choice for this procedure.

Correlation between injury severity scores and subjective ratings of injury severity: a basis for trauma audit

A retrospective review of 1900 road accident victims attending the emergency departments of two Melbourne hospitals was undertaken to identify Injury Severity Score levels which could distinguish between minor, moderate, severe and critical injury. Injuries scoring ISS 6 or below were designated 'minor' because they were associated with a low risk of requiring admission to hospital. Case notes of patients scoring above ISS 6 were then reviewed by a panel of clinicians, who independently rated each patient's overall injury severity as moderate, severe or critical according to what was recorded in the notes and their 'clinical' judgement. ISS values were compared with clinicians' ratings. Measures of each clinician's individual rating consistency, and correlation between pairs of clinicians with respect to inter-rater consistency, were made. By combining data from both hospitals it emerged that 'moderate' injury corresponded to ISS 8-13, 'severe' to ISS 14-20 and 'critical' to ISS 21 and above. These ISS breakpoints will be useful in selecting groups of injured patients for future trauma audit studies.

Autologous predonation, haemodilution and intraoperative blood salvage in elective abdominal aortic aneurysm repair

The feasibility of predonated autologous blood transfusion and intraoperative blood salvage in elective abdominal aortic aneurysm repair was studied. Twenty consecutive patients were evaluated, of whom five were excluded according to protocol criteria. Patients each donated 1 unit blood 14 and 7 days before operation. A third unit was withdrawn in the anaesthetic room and replaced with Hartmann's solution, producing a haemodiluted state. Intraoperative losses were minimized using the Haemonetics Cell Saver III Plus autotransfusion system. Predonated blood from two patients passed its expiry date owing to repeated operation postponements, leaving 13 patients for study. The mean(s.d.) intraoperative blood loss was 700(300) ml with a mean(s.d.) intraoperative salvage of 420(300) ml. Two patients were transfused intraoperative salvage of 420(300) ml. Two patients were transfused according to clinical need. Thus nine patients safely avoided homologous transfusion. With autologous predonation, haemodilution and intraoperative blood salvage, elective aortic aneurysm repair can be performed safely with minimal need for homologous blood.

Breast cancer management: a rural perspective

Audit of a general surgical practice in the rural Victorian town of Echuca identified 28 new patients with breast cancer between September 1992 and August 1995 (10% of those with breast conditions). The rural setting was no impediment to breast conservation (achieved in 68% of the 25 who had surgery) or to a multidisciplinary approach (management was planned in conjunction with an oncologist and/or specialist breast surgeon for 26 of the 28 patients).

Studies of the surgical scrub

BACKGROUND

To evaluate the effectiveness of various scrub techniques in reducing bacterial skin flora, the present study was developed in three stages.

METHODS

Each stage involved fingertip bacterial colony counts measured before, immediately after and 30 min after a variety of handwashing techniques using 10% povidone iodine solution. The first compared 1, 2 or 3 non-timed washes from fingertips to elbows in 10 volunteers. The second compared two volunteers scrubbing for equal durations with or without friction rubbing, while the third involved 15 volunteers who each scrubbed for different time intervals.

RESULTS

The first stage showed that a single wash episode failed to provide lasting bacterial colony count reductions on fingertip cultures. The second showed that enduring colony count reductions occur whether friction rubbing of the hands was used or not, and the third showed that a 30 s wash was as effective as washing for longer periods in reducing fingertip flora.

CONCLUSIONS

These findings suggest that prolonged vigorous pre-operative scrubbing is unnecessary, although more than a cursory wash is required to produce lasting fingertip antisepsis.

Diagnostic accuracy in head-injured patients: an emergency department audit

Records of 197 patients admitted to hospital with head injury were studied retrospectively to assess the influence of altered conscious state on injury misdiagnosis in the Emergency department (ED). Diagnostic errors were identified by discrepancies between an initial Injury Severity Score (ISS) calculated according to injuries diagnosed in the ED and a final ISS based on diagnoses confirmed on discharge from hospital, or death. The Glasgow Coma Scale (GCS) was used to assess neurological status. ISS discrepancies were present in 56 patients (29 per cent). These discrepancies arose because of: (i) failure of interpretation of radiographs; (ii) inadequate clinical examination; and (iii) inaccurate injury description in the ED notes. The risk of injury misdiagnosis was greatest for thoracic, abdominal and spinal injury, followed in descending order by extremity (limb), head, and external (skin and subcutaneous) injury. Although there was no linear correlation between GCS and ISS discrepancy rate, ISS discrepancies were significantly more frequent in comatose patients that in non-comatose patients (chi 2 = 3.69, 1 df; P < 0.05). Individual staff performance is at least as important as head injury severity in determining diagnostic accuracy on initial assessment in the ED.

Bleeding anorectal varix

Profuse bright rectal bleeding from anorectal varices is a serious but rare condition which can be difficult to diagnose. The case of a 47 year old man with bleeding anorectal varix is reported, with a discussion of the diagnostic difficulties, investigation and treatment.

Selective cholangiography with laparoscopic cholecystectomy: review of a protocol

OBJECTIVE

To report the results of a protocol for the preoperative diagnosis of stones in the common bile duct in patients with symptomatic cholelithiasis.

DESIGN

Prospective open study.

SETTING

District general hospital, United Kingdom.

INTERVENTIONS

Ultrasonography and liver function tests, and in selected patients preoperative cholangiography.

MAIN OUTCOME MEASURES

The ability of the investigations to diagnose stones in the common bile duct preoperatively.

RESULTS

Ultrasonography or liver function tests, or both indicated that 53 patients were at low risk of having stones in the common duct, and they underwent laparoscopic cholecystectomy without further investigation. A further 38 patients had minor abnormalities on the first two investigations and underwent intravenous cholangiography; ductal stones were identified in 6. Nine patients were thought to be at high risk and so underwent endoscopic retrograde cholangiopancreatography (ERCP) or open exploration of the common bile duct, and stones were found in 5. No further stones have been identified after a minimum follow up of 12 months.

CONCLUSION

Selective preoperative cholangiography is a reliable way of detecting stones in the common bile duct before laparoscopic cholecystectomy.