Climate change and the green energy paradox: the consequences for twaite shad Alosa fallax from the River Severn, U.K.

A stock-recruitment model with a temperature component was used to estimate the effect of an increase in temperature predicted by climate change projections on population persistence and distribution of twaite shad Alosa fallax. An increase of 1 and 2° C above the current mean summer (June to August) water temperature of 17·8° C was estimated to result in a three and six-fold increase in the population, respectively. Climate change is also predicted to result in an earlier commencement to their spawning migration into fresh water. The model was expanded to investigate the effect of any additional mortality that might arise from a tidal power barrage across the Severn Estuary. Turbine mortality was separated into two components: (1) juvenile (pre-maturation) on their out migration during their first year and on their first return to the river to spawn and (2) post-maturation mortality on adults on the repeat spawning component of the population. Under current conditions, decreasing pre-maturation and post-maturation survival by 8% is estimated to result in the stock becoming extinct. It is estimated that an increase in mean summer water temperature of 1° C would mean that survival pre and post-maturation would need to be reduced by c. 10% before the stock becomes extinct. Therefore, climate change is likely to be beneficial to populations of A. fallax within U.K. rivers, increasing survival and thus, population persistence.

The risk of infection after colon injury.

We reviewed 137 patients with colon injury and applied multiple regression analysis to determine the influence of various parameters on colon-related infection. The complications of intra-abdominal abscess, wound infection, and peristomal abscess occurred in 25% of patients. The mortality rate was 3.6%, and four of five late deaths were caused by infection. Multiple regression analysis identified the amount of blood transfused, patient age, number of associated injuries, and injury to the spleen as significantly associated with infection (p less than 0.05). In the absence of these risk factors, the likelihood of infection is low, suggesting that primary repair or resection and anastomosis are safe methods of management for colon injury. When these factors are present, the risk of infection is high, and colostomy is the preferred method of management.

Effect of the duration of symptoms, transport time, and length of emergency room stay on morbidity and mortality in patients with ruptured abdominal aortic aneurysms.

BACKGROUND: Despite improvements in emergency medical services, surgical technology, and postoperative critical care, ruptured abdominal aortic aneurysm (AAA) is associated with constantly high morbidity and mortality. To determine the effect of the duration of symptoms, transport time to hospital, and length of emergency department assessment on outcome, we evaluated 124 consecutive patients with ruptured AAA treated during the past decade. METHODS: The medical records for 122 patients were abstracted for preoperative hypotension, cardiopulmonary resuscitation (CPR), blood loss, and three time intervals: symptom onset to operation, transport time to hospital, and emergency department assessment. RESULTS: Intraoperative mortality was 26% (n = 32), 30-day mortality was 51% (n = 63), and cumulative hospital mortality was 56% (n = 69). Death occurred in 52 (64%) of 81 patients with hypotension compared with 14 (35%) of 40 patients without hypotension (p < or = 0.01). Hypotension was present in 37 (82%) of 45 patients who arrived in the operating room in 2 hours or less compared with 26 (60%) of the 43 patients who arrived later than 2 hours (p < or = 0.05). Death followed in 21 (91%) of 23 patients who received CPR compared with 46 (46%) of 99 patients who did not receive CPR (p < or = 0.01). Bowel ischemia was observed in 18 (30%) of 60 patients who received more than 10 units of blood compared with 3 (5%) of 61 patients who received 10 units or less (p < or = 0.01). CONCLUSIONS: For patients with ruptured AAA, prolonged presurgical time was associated with a more hemodynamically stable patient and a lower mortality. Progressive bleeding in those hemodynamically stable patients was reflected by a larger blood transfusion requirement. Such patients exhibited an increased incidence of ischemic bowel complications, perhaps caused by splanchnic arterial ischemia augmented by preexisting atherosclerosis, as well as extrinsic compression by mesenteric hematomas.

Pediatric Trauma Score. Predictor of hospital resource use?

The Pediatric Trauma Score has been recommended to triage children with scores of 8 or less to a level 1 pediatric trauma center. The Injury Severity Score correlates well with the Pediatric Trauma Score. During a 36-month period ending December 31, 1985, paramedics saw 983 pediatric trauma patients (aged 17 years and younger) and intervened with advanced life support procedures in 196 (20%). One hundred forty-four patients receiving advanced life support were transported to either a level 1 adult trauma center or a pediatric community hospital. Our data confirm the correlation between Pediatric Trauma Score and Injury Severity Score and support recommendations to transport patients with Pediatric Trauma Scores of 8 or less to trauma facilities. We also conclude that Pediatric Trauma Scores may be useful in predicting hospital resource use.

Cefotaxime and metronidazole in severe intra-abdominal infection.

To assess the efficacy of cefotaxime in the treatment of severe intra-abdominal infections, we reviewed the bacteriology of secondary peritonitis and evaluated the efficacy of cefotaxime and metronidazole in 79 patients undergoing staged abdominal repair. We were able to demonstrate that the combination of an aggressive surgical policy with an effective antimicrobial regimen eliminates pathogens from the previously infected peritoneal cavity. Additional improvement in results awaits further advances in supportive care and/or methods to reverse the cascades of the excessive inflammatory or cytokine responses.

Tracheoesophageal fistula after blunt chest trauma.

Tracheoesophageal fistula is a very rare but potentially life-threatening complication of blunt chest trauma. Prior reviews have revealed that the victims were all young men involved in deceleration or crush injuries. Of those involved in motor vehicle accidents, most were thrown against the steering wheel. Herein, we review the world literature on this injury and include our own report of 1 of the few cases of traumatic tracheoesophageal fistula involving a female victim. In this case, the victim was an unrestrained driver thrown against an air bag.

Electrocardiographic characteristics in EMD.

Little has been written concerning the initial electrocardiographic (EKG) characteristics and/or changes which occur as the result of treatment in the electromechanical dissociation (EMD) patient. The purpose of this retrospective study was to determine predictive indicators of successful resuscitation in EMD by evaluating various EKG parameters. During 72 months, ending December 31st, 1985, there were 503 non-poisoned, prehospital adult cardiac arrest patients whose initial rhythm was EMD. All patients had their initial prehospital EKG rhythm strip evaluated for rhythm type, rate, the presence of P waves, QT interval and QRS interval. In successfully resuscitated patients, the prehospital initial rhythm analysis and the rhythm analysis on emergency department presentation were compared. Successfully resuscitated patients presenting with EMD had significantly faster initial rates, higher incidences of P waves and average QRS and QT intervals shorter than patients not responding to therapy. Furthermore, successfully resuscitated patients had significantly increased heart rates, developed new onset of P waves, and shortened QT intervals in response to treatment. Successfully resuscitated and save patients had average initial and final QRS complex lengths within normal limits. Organized atrial activity on the initial EKG was also correlated with successful resuscitation. No patient with an initial EKG rhythm of second or third degree AV block survived to hospital discharge. No patient who presented to the emergency department with atrial fibrillation survived to hospital discharge. Similarly, supraventricular tachycaydia following resuscitative efforts appeared to be associated with a negative outcome. Rate normalization following treatment was correlated with save rate. Wide complex rhythms without atrial activity were most highly associated with unsuccessful resuscitation. We believe these observed electrocardiographic characteristics and/or changes in response to treatment may have predictive value in evaluating patients with EMD.

Human immunodeficiency virus and infectious considerations.

In summary, HIV is a retrovirus with devastating consequences for those infected. Primary modes of transmission are through sexual contact and parenteral exposure to infected blood and body fluids. Prevalence of the virus among trauma patients, risk of exposure, and infection of health care workers are variable and to a large extent not known. Existing HIV infection and AIDS have both direct and indirect effects on care and outcome of trauma patients. Caring for these patients presents many challenges. Manifestations and complications of each condition may mask, mimic, or compound the other. Optimal care and outcome depend on knowledge of both diseases, and the specific nuances of their management. As with all trauma patients, a team approach coordinated by an identified team leader is indicated. Finally, to protect both the patient and the care giver, policies that effectively reduce exposure must be formulated, promulgated, and practiced.

Soft tissue abscesses associated with parenteral drug abuse: presentation, microbiology, and treatment.

Abscess formation at the site of drug injection is the commonest infectious complication in drug addicts. This study characterizes the clinical presentation of the condition, its current microbiology, and treatment outcome. All patients presenting for treatment of soft tissue abscesses associated with parenteral drug abuse over a 21-month period were studied. Sixty-six patients with 70 subcutaneous abscesses after injection of cocaine (85%), heroin (5%), or unreported drugs (10%) were identified. Only 42% were febrile (T > 37.5 degrees C), 54 percent had leukocytosis, and 47 percent had wound fluctuance. Wound cultures (243 isolates in 57 patients) grew predominately anaerobes (143 isolates) and facultative gram-positive cocci (88 isolates). Twenty-six blood cultures were obtained, and five (19%) were positive, two with the same bacteria isolated from the wound. Of the patients tested, 29 percent were positive for hepatitis B surface antigen and 9 percent for HIV. Simple incision and drainage was effective in all cases. Classical signs and symptoms of infection and abscess formation may be absent in this patient population. Many of these patients carry other blood-borne infections which the health professional must guard against. Cocaine injection, and "mixed" aerobic-anaerobic infections predominated, in contrast to earlier reports, when narcotics and aerobes predominated. Simple incision and drainage is adequate treatment; antibiotics, when given, should cover gram-positive and anaerobic bacteria; gram-negative coverage is unnecessary.

The relationship of the level of training and area of medical specialization with registrant performance in an advanced trauma life-support course.

Approved advanced trauma life-support (ATLS) programs were given to 160 residents and practitioners of various specialties, utilizing a standardized 50-item, multiple-choice posttest. Level of training (practitioner v resident) and area of medical specialization with registrant performance on total score and in specific subcontent areas of ATLS were evaluated by subjecting total and subcontent percent scores to a two-way analysis of variance and Newman-Keuls pairwise comparisons. Practitioners outperformed the residents in the subcontent area of abdominal injuries, P less than .05. In specialization, emergency medicine outperformed internal medicine specialists, P less than .05. Pairwise differences among specialists were not statistically significant. In airway problems, surgeons and internists were outperformed by emergency medicine, whereas in burns, emergency medicine and family practitioners significantly outperformed the surgeons. Emergency medicine outperformed internal medicine, P less than .05, in subcontent area of extremity injuries. We conclude that registrants are likely to benefit from an ATLS course, but preliminary evidence would seem to justify some "tailoring" of the ATLS curriculum for different registrant specialty groups.

Changes in splenic size after abdominal trauma.

After blunt abdominal trauma, the spleen often increases in volume on serial computed tomographic (CT) scans. To determine the frequency and significance of such enlargement, the authors performed a retrospective analysis of 44 hemodynamically stable patients who had experienced recent blunt abdominal trauma. The severity of splenic, hepatic, or other visceral injuries seen on each CT scan was numerically scored, and the amount of intraperitoneal fluid was assessed. Twenty-five patients (57%) had over 10% enlargement (average enlargement, 56%) on follow-up scans. Increasing volume did not correlate with clinical deterioration or the need for splenectomy. It did correlate modestly with the amount of blood in the peritoneum on CT scans, the number of units of blood transfused, and two clinical indexes of systemic trauma. Therefore, an enlarging spleen is not a CT indicator of a deteriorating clinical condition. This phenomenon is most likely due to marked adrenergic stimulation after injury and changing fluid volumes.

Operative management of intraabdominal infection.

Surgical principles in the management of intraabdominal infection have remained constant. Rather, it is the application of these principles in selected cases that has varied. Judgement, therefore, becomes paramount for the surgeon. In selected cases multiple planned relaparotomies may be the most effective means of closing the infectious source and eliminating toxic infectious materials. The Burr has proven to be an effective yet safe means of permitting entry and closure of the abdominal fascia.

Pneumoperitoneum as a complication of cardiopulmonary resuscitation.

A case of pneumoperitoneum following cardiopulmonary resuscitation (CPR) is reported and 11 cases in the literature are reviewed. Four patients had laparotomies failing to demonstrate any visceral perforation or evidence of peritonitis in spite of the massive pneumoperitoneum present. Operative intervention immediately after resuscitation is associated with potentially high morbidity and mortality. Several diagnostic tools are used, including peritoneal lavage and contrast media tests, to accurately diagnose perforated viscus. To avoid an unnecessary celiotomy a clinical treatment protocol has been developed for patients with pneumoperitoneum secondary to CPR. Such diagnostic tools as peritoneal lavage and water-soluble contrast medium test are reviewed and included in this protocol. A nonsurgical approach to patient management may be reasonable if certain criteria are met.

Recommended helmet removal techniques in a cervical spine injured patient.

Helmet removal techniques in the absence of C-spine injuries have been developed and promulgated. Utilizing a cadaver model, these techniques were demonstrated to adversely affect pre-existing C-spine injury. Removal of helmets with cast cutters is recommended.

Etappenlavage: advanced diffuse peritonitis managed by planned multiple laparotomies utilizing zippers, slide fastener, and Velcro analogue for temporary abdominal closure.

Etappenlavage is defined as a series of planned multiple operative procedures performed at a 24-hour interval. It includes a commitment to reexplore the patient's abdomen at the initial corrective operation. This is a report of a prospective study of 117 patients treated by etappenlavage for severe advanced suppurative peritonitis in 2 institutions. Etappenlavage was performed in 15% of all patients with operations for peritonitis. In these patients, the abdominal infection had progressed to an advanced stage of severe functional impairment. A total of 669 laparotomies were performed and the abdomen closed temporarily utilizing retention sutures (n = 45), a simple zipper (n = 26), a slide fastener (n = 29), and Velcro analogue (n = 17). An average of 6.1 procedures were necessary to control the infection. In 57% of the patients, additional complications were recognized and repaired after the initial operation. Patients were artificially ventilated for an average of 17 days. The median duration of therapy was 33 (range, 3-183) days. Twenty-eight patients died between days 3 and 71 (median, 9) after initiation of therapy. In 88%, uncomplicated wound healing was observed after wounds were closed definitely. In the last 17 patients, no complications were attributable to the use of 2 adhesive sheets of polyamide plus nylon or perlon for temporary abdomimal closure (Velcro-like artificial burr). APACHE II scoring predicted a median mortality of 47%. The actual mortality was 25%. Overall, the mortality of advanced diffuse peritonitis was reduced from a predicted 34-93% (APACHE II/SIS scoring) to 24%. Velcro analogue (artificial burr) was the most practical device for temporary abdominal closure.

Prehospital advanced emergency care: a potential pitfall.

Effective prehospital treatment of the severely injured and acutely ill by an Advanced Emergency Care system may change symptoms and signs by the time patients arrive at the hospital. To provide optimal care, physicians must appreciate the capabilities and limitations of the EMT-paramedic. The EMT-paramedic must report verbally and via written record the course of prehospital events. Cardiac rhythms must be documented for review. It should be the responsibility of the medical directors of such Advanced Emergency Care systems to provide supervision, refresher training, critiques, and evaluation, to establish medical responsibility and credibility.

A profile of geriatric trauma in southeastern Wisconsin.

The purpose of this study was to profile geriatric trauma in southeastern Wisconsin, including injury mechanisms, severity of injury, outcome, hospital lengths of stay, and total cost. We conducted a retrospective chart review of trauma victims over age 65 admitted to the Milwaukee County Medical Complex between July 1991 and October 1992. Cases were excluded if the patients had sustained isolated head or orthopedic injuries, thermal burns, or penetrating trauma. A total of 65 cases were studied. The population had a mean age of 75.8 +/- 8.2 years; 53.8% were women and 46.2% were men. The leading mechanisms of injury were in decreasing order were motor vehicle crashes, falls, and auto-pedestrian injuries. The mortality rate was 29.2%. The mean length of stay in the hospital was 13.5 days. The total charge was approximately $1.3 million dollars. Motor vehicle crashes accounted for 61.5% of injuries. Safety devices and driver awareness programs may be under used in this population. The mortality rate is high with a moderate level of injury severity.

Motorboat propeller injuries in Wisconsin: enumeration and prevention.

STUDY OBJECTIVE: To ascertain the nature and extent of motorboat propeller injuries in Wisconsin. DESIGN: Retrospective study of deaths and injuries from outboard motor propellers reported to the Wisconsin Division of Health, Vital Statistics, and reported by a statewide retrospective survey of emergency departments. RESULTS: For the study period 1987 through 1989, three fatalities were found in Vital Statistics and Emergency Department records and 14 nonfatal injuries reported by respondents to the Wisconsin emergency department survey. Thirty-six percent (5 of 14) of the nonfatal injuries occurred in water skiers. Injuries involved the lower extremities in 10 of 14 nonfatal cases (71%), frequently in association with other anatomic areas. At least three cases involved very severe injuries, with mean acute care medical charges of more than $100,000 per case. CONCLUSIONS: Where boating is common, fatal and severe injuries from propellers occur with regularity. These injuries are often severe, requiring complicated and expensive treatment. The authors urge improved documentation of the incidence of propeller injuries, and an active exploration of prevention strategies including fitting motorboat propellers with guards.