Quetiapine-associated cholestasis causing lipoprotein-X and pseudohyponatraemia.

A case of intrahepatic cholestasis secondary to treatment with quetiapine in combination with lamotrigine and zopiclone, resulting in severe hypercholesterolaemia without overt lactescence of the plasma, is presented. Abundant lipoprotein-X was seen on lipoprotein electrophoresis. The patient was diagnosed and treated for hyponatraemia which was likely factitious and caused by hypercholesterolaemia. Cholestasis and hypercholesterolaemia resolved over a period of several months after the discontinuation of quetiapine.

Mortality in terrorist attacks: a unique modal of temporal death distribution.

BACKGROUND: Terror-related multiple casualty incidents (MCI) in Israel since September 2000 have resulted in a new pattern of injury as a result of the mechanisms of trauma. The objective of this study was to asses the temporal death distribution among the civilian casualties in the Jerusalem vicinity during a 3-year period. METHODS: All terrorist attacks in the Jerusalem district from September 2000 to September 2003 were included in this study. The data of all deaths were processed including the time of the attack, the evacuation time to the hospitals, and the time of death. RESULTS: During the study period 28 terror-related MCI occurred. A total of 2328 victims were injured and 273 died, for an overall fatality rate of 11.7%. A unique temporal death distribution was identified; 82.8% of the deaths occurred immediately, at the scene of the attack (scene death); of the remaining 17.2% of patients who died in the hospital, half died within 4 hours of arrival (immediate death), one quarter within 5-24 hours (early death), and one quarter later than that (late death). The temporal death distribution was significantly different when classifying the mechanism of trauma to suicide bombings versus shooting. The scene mortality was higher in the suicide bombings than in shooting attacks (86.7% versus 77%, P = 0.039 ). In contrast, the mortality within 1-24 hours was higher in the shooting attacks (17% versus 6.3%, P = 0.05). CONCLUSIONS: Terror-related MCI occurring in civilian settings have a unique temporal death distribution. A very high scene mortality is seen compared to the classical description of Donald Trunkey1 in 1983. The late deaths, which composed 30% of the mortality in civilian settings, comprise only 4.4% of the total mortality in MCIs. A rough estimate of the in-hospital mortality could be achieved after the first 4 hours, allowing the assessment and distribution of hospital resources. Futile care should be identified early and availability of ICU beds can be calculated according to the immediate mortality.

Patterns of injury in hospitalized terrorist victims.

Acts of terror increase the demand for acute care. This article describes the pattern of injury of terror victims hospitalized at 9 acute-care hospitals in Israel during a 15-month period of terrorism. To characterize patients hospitalized as a result of terror injuries, we compared terror casualties with other injuries regarding severity, outcome, and service utilization. Using data from the National Trauma Registry, characteristics of casualties are portrayed. During the study period, 23,048 patients were recorded, 561 of them (2.4%) were injured through terrorist acts. Seventy percent were younger than 29 years. Seventy-five percent were males. Thirteen percent of terror victims compared with 3% with other traumatic injuries, arrived by helicopter. Injury mechanism consisted mainly of explosions (n = 269, 48%) and gunshot injuries (n = 266, 47%). One third of the population experienced severe trauma (Injury Severity Score > or = 16). One hundred-forty-two patients (26%) needed to be admitted to the intensive-care unit. Inpatient mortality was 6% (n = 35). Fifty-five percent of the injuries (n = 306) included open wounds and 31% (n = 172) involved internal injuries; 39% (n = 221) sustained fractures. Half of the patients had a procedure in the operating room (n = 298). Duration of hospitalization was longer than 2 weeks for nearly 20% of the population. Injuries from terrorist acts are severe and impose a burden on the healthcare system. Further studies of the special injury pattern associated with terror are necessary to enhance secondary management and tertiary prevention when occurring.

[Trauma registry and injury].

The trauma registry network constitutes an essential database in every injury prevention system. In order to rationally estimate the extent of injury in general, and injuries from traffic accidents in particular, the trauma registry systems should contain the most comprehensive and broad database possible, in line with the operational definitions. Ideally, the base of the injury pyramid should also include mild injuries and even "near-misses". The Israeli National Trauma Registry has come a long way in the last few years. The eventual inclusion of all trauma centers in Israel will enable the establishment of a firm base for the allocation of resources by decision-makers.

Eardrum perforation in explosion survivors: is it a marker of pulmonary blast injury?

STUDY OBJECTIVES: To determine whether isolated eardrum perforation is a marker for concealed blast lung injury in survivors of terrorist bombings. METHODS: Survivors who arrived at hospitals after 11 terrorist bombings in Israel between April 6, 1994, and March 4, 1996, were examined otoscopically by ear, nose, and throat specialists. All patients with eardrum perforation underwent chest radiography and were hospitalized for at least 24 hours for observation. The clinical course and final outcome of patients with isolated perforation of the eardrums and of those with other blast injuries were surveyed. RESULTS: A total of 647 survivors were examined; 193 (29.8%) of them sustained primary blast injuries, including 142 with isolated eardrum perforation and 51 with other forms of blast injuries (18 with isolated pulmonary blast injury, 31 with combined otic and pulmonary injuries, and 2 with intestinal blast injury). Blast lung injury was promptly diagnosed on admission by physical examination and chest radiography. No patient presenting with isolated eardrum perforation developed later signs of pulmonary or intestinal blast injury (mean 0%; 95% confidence interval, 0% to 2.7%). CONCLUSION: Isolated eardrum perforation in survivors of explosions does not appear to be a marker of concealed pulmonary blast injury nor of a poor prognosis. Therefore, in a mass casualty event, persons who have sustained isolated eardrum perforation from explosions may safely be discharged from the emergency department after chest radiography and a brief observation period.

Advanced trauma life support versus Combat Trauma Life Support courses: a comparison of cognitive knowledge decline.

This prospective study was conducted to compare cognitive knowledge decline among graduates of the Advanced Trauma Life Support (ATLS) and Combat Trauma Life Support (CTLS) courses in Israel. The investigation was based on multiple-choice questions that tested the results of 211 ATLS and CTLS course graduates and was performed 3 to 66 months after completion of the courses. These results were then compared with the examination outcomes immediately after the course. A statistical model based on survival analysis was used to evaluate the decline pattern and extent and to compare the two courses. No significant difference was found in the rate of decline in knowledge gained from the two courses after a given period. Priority for refresher courses should be set regardless of type of course previously attended by physicians.

Cognitive knowledge decline after Advanced Trauma Life Support courses.

OBJECTIVE: To assess the cognitive knowledge decline among graduates of the Advanced Trauma Life Support (ATLS) program in Israel, to compare the rate of decline between surgeons and nonsurgeons, and to recommend appropriate timing for refresher courses. METHODS: A prospective study based on multiple-choice question test results of 220 ATLS course graduates was conducted 3 to 60 months after course completion. These results were then compared with the examination results immediately after the course. A statistical model based on survival analysis was used to evaluate the decline pattern and extent and to compare the study groups. RESULTS: A significant decline of cognitive knowledge over time among ATLS graduates was demonstrated. This decline was significantly greater in the nonsurgical group. A critical point of 20% cognitive knowledge loss among 50% of the examined physicians was observed around the 180th week after completion of the course. CONCLUSION: Physicians taking the ATLS course lose a significant part of their acquired cognitive knowledge after 3.5 years. Surgeons retain their cognitive knowledge for longer periods of time. Based on the study results, the optimal timing for a refresher course is between 3 and 4 years after the initial ATLS course.

Interhospital patient transfer: a quality improvement indicator for prehospital triage in mass casualties.

The need for interhospital patient transfer after mass casualties may be a consequence of triage errors. Indications for interhospital patient transfer following seven suicidal bus bombings in Israel were reviewed to identify possible errors in triage at the scene. Medical records of victims arriving to hospitals were analyzed for age, injury description, injury Severity Score (ISS), and indication and destination of interhospital transfer. A total of 473 victims were involved, 74 of whom died at the scene (15.6%). Mean victim age was 29 +/- 16 (SD) years. Interhospital transfer was necessary for 29 patients. Indications for transfer included (1) mandatory lifesaving procedures on route to trauma center (n = 14), (2) underdiagnosis at the scene (n = 1), (3) insufficient local resources (n = 9), and (4) triage-related errors (n = 5). The ratio between interhospital transfer due to triage errors and the victim population who may need to be transferred is suggested as quality assurance (QA/QI) indicator for triage.

The accumulated experience of the Israeli Advanced Trauma Life Support program.

BACKGROUND: Between January 1990 and May 1995 one faculty in Israel taught Advanced Trauma Life Support (ATLS) courses to 3,700 physicians. Two types of courses were given to three subpopulations. We studied the influence of demographic variables on students' achievements in the course and compared students' achievements as a function of their course type. STUDY DESIGN: This study was conducted as a concurrent longitudinal study. RESULTS: Achievements of 3,700 students were analyzed. The precourse grade, type of course, and their interaction were found to have a significant effect on the postcourse grades. Physicians practicing surgical subspecialties, in general, did better, as did students educated in English-speaking countries. Students who took part in the Combat Trauma Life Support (CTLS) course, which included the entire ATLS course and additional lectures and exercises, also ended with better scores. CONCLUSIONS: Physician's country of origin and clinical subspecialty have a significant effect on the cognitive achievement in the ATLS course provided in Israel. An expanded ATLS course (CTLS), to include additional military trauma topics as well as additional skill station training, can improve the results of the postcourse grades.

Penile intracorporeal infusion--possible access to the systemic circulation. Pressure flow studies in dogs and humans.

OBJECTIVE: To assess penile intracorporeal infusion as a simple alternative method of intravenous access during the initial phase of fluid resuscitation in male patients. DESIGN: Laboratory pressure flow studies in dogs and in humans. SUBJECTS: 5 male mongrel dogs, and 10 male patients who were being investigated for psychogenic impotence (n = 5) or organic impotence (n = 5). INTERVENTIONS: Dogs- two 19G needles were inserted into the canine corpora cavernosa, one for fluid infusion, and the other for cavernosal pressure monitoring. Ringer's lactate solution was infused into the corpora cavernosa, through an infusion pump. The dogs were then bled until systolic blood pressure reached 60 mmHg, and resuscitated by transfusion of autologous blood into the corpora cavernosa. HUMANS: Ringer's lactate solution was infused into a corpus cavernosum through a 19G scalp vein needle. Pressure monitoring was done through another 19 G needle. MAIN OUTCOME MEASURE: Fluid flow rates and in humans time taken to insert an intracorporeal needle. RESULTS: Mean (SD) infusion rate through the canine corpora was 110 (22) ml/minute for Ringer's lactate solution and 109 (18) ml/minute for autologous blood. Mean infusion rate into the human corpora was 89.7 (12) ml/minute in the psychogenic impotent patients, and 88.2 (9) ml/minute in the organic impotent patients. Mean time taken to insert the needle was 15 (7) sec. CONCLUSIONS: An intracorporeal infusion line can be established in a short period of time and adequate quantities of fluids can be infused through the human and canine corpora cavernosa.

The efficacy of integrating "smart simulated casualties" in hospital disaster drills.

INTRODUCTION: Full-scale disaster drills are complex, expensive, and may involve hundreds or thousands of people. However, even when carefully planned, they often fail to manifest the details of medical care given to the casualties during the drill. OBJECTIVE: To assess the feasibility of integrating physicians among the simulated casualties of a hospital disaster drill. METHODS: A total of 178 physicians graduating an Advanced Trauma Life Support (ATLS) course participated in eight hospital disaster drills during 1994 as "Smart Victims." The participants were given cards with descriptions of their injury and detailed instructions on how to manipulate their medical condition according to the medical care provided in the hospital. They also were given coded questionnaires to fill out during the process of the drill. Conclusions were drawn from analysis of the questionnaires and from a roundtable discussion following each drill. RESULTS: The "smart casualties" made comments on the following topics: 1) triage (over-triage in 9%, and under-triage in 4%); 2) treatment sites; 3) medical equipment usage (i.e., shortage of ventilators and splinting devices); 4) medical knowledge and care rendered by the hospital staff; 5) evacuation and escorting of the wounded; 6) management of patients with post-traumatic stress disorder; and 7) medical documentation. Their comments contributed valuable information on the quality of medical care and organization, and identified obstacles that otherwise would have been overlooked. The "smart casualties" were very cooperative and indicated that their participation in the drill contributed to their understanding of disaster situations in hospitals. CONCLUSION: Integrating physicians among the simulated casualties in a hospital disaster drill may contribute to achieving the objectives of hospital disaster drills and add to disaster management education of the simulated casualty physicians.

Ketamine in the field: the use of ketamine for induction of anaesthesia before intubation in injured patients in the field.

Intubating the subconscious, struggling patient in a pre-hospital setting can be a difficult task even in experienced hands. We performed a clinical prospective study to evaluate the applicability of ketamine for induction of anaesthesia before intubation in the field. Ketamine was distributed to all air medical rescue teams--trained reserve army volunteers from various medical specialties. Lectures and literature concerning the use of ketamine for anaesthesia induction before intubation were given. The physicians were instructed to administer ketamine, in a dose of 2 mg/kg intravenously, if a single intubation attempt failed. Following the administration of ketamine, a questionnaire was filled in by the physician. Analysis of the data was performed after 24 months. During the study period, intubation was indicated in 161 injured patients evacuated by air in Israel. In 29 patients (18 per cent) the first intubation attempt had failed and they were given ketamine. The reasons for failure of the first intubation attempt were restlessness or trismus in 23 patients and traumatic distortion of the upper airway anatomical landmarks in six. Following ketamine administration, intubation was successful in 19 patients (65.5 per cent) in all of whom the indication for ketamine administration was restlessness or trismus. All patients with upper airway anatomy distortion were given a cricothyroidotomy. There were no complications attributed to ketamine. All patients reached hospital alive. This preliminary study suggests that the use of ketamine in this pre-hospital setting is safe. The drug is effective in cases where the primary reason for failure to intubate is restlessness or trismus. The drug is not effective in cases of anatomical damage to the upper airway. In these cases, cricothyroidotomy should probably be performed as early as possible.

Prehospital cricothyroidotomy by physicians.

To evaluate cricothyroidotomy in the field and the influence of physicians' medical specialty or previous experience on the success rate of this procedure, a retrospective study was conducted. Between October 1991 and April 1995, 29 cricothyroidotomies were performed in the prehospital setting in Israel. Twenty-six (89.6%) cricothyroidotomies were successfully performed. There was no evidence of higher success rate when the performers were surgeons, anesthesiologists, or intensive care specialists (100% success), compared to that of all other specialties (83.33%). All physicians had successfully completed the Advanced Trauma Life Support (ATLS) course, but only three had previously performed cricothyroidotomy. Acute complications included failure to establish an airway in 3 cases, minor bleeding in 2 cases, and an air leak around the cannula in 1 patient. These results show that following brief training (eg, the ATLS course) physicians are capable of performing emergency cricothyroidotomy in the field with a high success rate and minimal complications, regardless of medical specialty.

The trimodal death distribution of trauma victims: military experience from the Lebanon War.

INTRODUCTION: Mortality in war is traditionally divided into two categories: killed in action and died of wounds. Mortality in civilian trauma is generally divided into three categories: immediate death (50%), early death (30%), and late death (20%). Can we identify a trimodal death distribution among war victims? METHODS: We analyzed data for casualties in the Lebanon War from June 6 to September 20, 1982. During this period a total of 1,950 soldiers were injured; 351 (18%) of them died. Time of injury and time of death of the victims was determined from real-time recordings during the battle and from hospital files. RESULTS: Analyzing the time of death revealed that 329 of the soldiers (93.7%) died within the first hour after injury, 7 soldiers died 1 to 4 hours after injury (2%), and 15 soldiers died 24 hours to 75 days after injury (4.3%). The most common causes of death during the first hour after injury were central nervous system (CNS) injuries 31%, exsanguination 30%, incineration 21%, and combined CNS injury and exsanguination 10.9%. Exsanguination was the leading cause of death 1 to 4 hours after injury (86%). CNS injury was the most common cause of late death (60%). Only 1.1% of the soldiers who reached the hospital alive died of their wounds. CONCLUSIONS: A trimodal mortality distribution with different causes of death in each peak can be identified in the mortality pattern of Israeli soldiers during the Lebanon War. The relative height of the different peaks and the causes of death in the third peak are different from those found in civilian trauma. We believe that prompt medical treatment and expeditious evacuation from the battle zone led to a very low death rate among the wounded soldiers who had reached the hospital alive. The same factors may have increased the relative portion of CNS injuries as a cause of late death.

Blast injuries: bus versus open-air bombings--a comparative study of injuries in survivors of open-air versus confined-space explosions.

OBJECTIVES: To compare injury patterns resulting from explosions in the open air versus within confined spaces. METHODS: Medical charts of 297 victims of four bombing events were analyzed. Two explosions occurred in the open air and two inside buses. Similar explosive devices were applied in all four incidents. The incidence of primary blast injuries, significant penetrating trauma (Abbreviated Injury Scale score > or = 2), burns, Injury Severity Score, Revised Trauma Score, and mortality were compared between the two populations. RESULTS: A total of 204 casualties were involved in open-air bombings, 15 of whom died (7.8%). Ninety-three victims were involved in bus bombings, 46 of whom died (49%). The difference in mortality rate was highly significant, p < 0.00001. Primary blast injuries were observed in 25 and 31 victims (34.2% and 77.5% of admitted victims), respectively (p = 0.00003). Median Injury Severity Score was 4 versus 18, respectively (p < 0.0001). CONCLUSION: Explosions in confined spaces are associated with a higher incidence of primary blast injuries, with more severe injuries and with a higher mortality rate in comparison with explosions in the open air.