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.

Safety of surgical intervention during the second trimester of pregnancy. A case report.

Surgical and anesthetic interventions during pregnancy are not hazard free. While an increase in fetal resorption and the abortion rate during the first trimester is well documented, a second-trimester intervention is assumed to be relatively safe. A case of acute transient oligohydramnios, fetal growth arrest and limb reduction anomaly following second-trimester abdominal surgery is reported for the first time.

Quantitative peritoneal lavage in evaluating acute abdominal pain of gynecological origin.

This study was performed in order to determine the value of assessing the volume of intraperitoneal fluid, the leucocyte count and the corrected leucocyte count in the peritoneal lavage in patients with acute abdominal pain of gynecological origin. Peritoneal lavage using the dye-dilution technique with Evans-Blue-Human Serum Albumin complex (EBA) as a marker was performed. It was found that an exudate volume of above 250 ml is highly suggestive of an intraperitoneal inflammatory process. The concentration of leucocytes and the corrected leucocyte count in the returned lavage fluid were found to be less reliable indicators of an inflammatory process in the peritoneal cavity than precise determination of the intraperitoneal exudate. It may be concluded that peritoneal lavage with EBA can be a useful adjunct in the evaluation of patients with acute abdominal pain of gynecological origin.

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.

Use of alfentanil for in vitro fertilization oocyte retrieval.

STUDY OBJECTIVES: To determine alfentanil levels with a specific radioimmunoassay in serum and ovarian follicular fluid. DESIGN: Observational study. SETTING: University hospital. PATIENTS: 14 ASA status I women undergoing oocyte retrieval for in vitro fertilization. INTERVENTIONS: General anesthesia was induced with alfentanil 15 micrograms/kg and midazolam 2 mg and maintained with alfentanil 0.5 mg, 60% nitrous oxide (N2O) in oxygen (O2) and midazolam up to a total of 4 mg. Oocyte retrieval was performed using a transvaginal ultrasound guided technique, 34 to 36 hours after human chorionic gonadotrophin administration. MEASUREMENTS AND MAIN RESULTS: Mean procedure time for oocyte retrieval was 18 +/- 2.4 (SEM) minutes. All patients were fully awake within 5 minutes and all patients except one were able to move from the operating table to the stretcher with minimal help. Mean total protein concentration in the follicular fluid was 3.8 +/- 0.4 mg%. Maximal serum alfentanil concentrations (Cmax) were attained 5 minutes after start of the procedure (tmax) and were 92 +/- 20 ng/ml. In contrast, alfentanil concentrations in the follicular fluid increased constantly throughout the procedure up to 8.9 +/- 0.8 ng/ml at 15 minutes. Clinical pregnancy rate was 3 of 14 patients. CONCLUSION: It is evident that during the oocyte retrieval procedure, the alfentanil concentrations in the follicular fluid are about ten-fold smaller than the serum alfentanil concentrations at the same time points. Similar pharmacokinetics have been shown when propofol was used as anesthetic. The low accumulation of alfentanil in the follicular fluid increases the attractiveness of alfentanil for anesthesia during oocyte retrieval for in vitro fertilization.

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.

Traumatic arm amputation, an uncommon parachuting injury.

Parachuting is a unique method of deploying troops. Accidents in parachuting are common, but usually carry minimal risk for severe injury. Most accidents occur during landing and injuries often affect the lower limbs and spine. Traumatic amputation of a limb is an extremely rare event in parachuting. We present a case of a parachutist who suffered a traumatic amputation of the left hand during jumping off the plane.

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.

[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.

[Medical kits in Army physicians' vehicles].

Physicians' medical kits (PMK) were distributed to 50 physicians, graduates of an advanced trauma life support course. The kits were always to be present in the physicians' designated vehicles, enabling them to provide advanced life support at the earliest possible stage (the "golden hour"). The kits have equipment for advanced airway intervention and management, chest trauma management (chest tube insertion, etc.) and fluid administration. To help assess the impact of the PMK and its cost effectiveness, questionnaires were sent to the physicians involved, of whom 35/50 responded. The questions included 2 subjects: the presence of the kit in the car and details of its use for injuries. The kit was present at all times in the cars of all except 1 of 31 physicians. 7 (22.5%) of them used the kit in 50 incidents which involved 74 injured persons. The injuries were caused by road accidents in 54 cases, in 17 by terrorist activity, and 3 cases involved heart attacks and cardiac resuscitation. Distribution of the PMK among army physicians appears to be valuable in the field, and before hospitalization.

[Patient-controlled i.v. morphine for acute postoperative pain].

The use of patient-controlled i.v. analgesia for postoperative pain relief in 60 cases is described. 0.1% morphine was given by Bard or Graseby microprocessor. After a loading dose of 2-6 mg, the pump delivered a bolus of 0.8-1.5 mg of morphine every 8-12 min. The dosages necessary to provide good analgesia varied from 30-85 mg (mean 48). Good pain scores of 0-2 (on a scale of 5) were obtained in 92%. The method was also found satisfactory by the families and health care providers, and is highly recommended for control of postoperative pain.

[Fentanyl vs alfentanil anesthesia for in vitro fertilization].

In a prospective double-blind study, 36 women undergoing ultrasonically guided oocyte retrieval for in vitro fertilization (IVF) were examined. Anesthesia in 19 was based on alfentanil, up to 0.025 mg/kg and in 17, fentanyl, 0.0025 mg/kg. There were no significant differences between groups with regard to age, weight, duration of procedure and pregnancy rate. There were no complications aside from nausea and vomiting. Amnesia for the puncture and analgesia were always perfect. Induction was significantly shorter for alfentanil, 1.3 +/- 0.7 min, than for fentanyl, 3.4 +/- 2.2 (p less than 0.01). All who received fentanyl were drowsy at the end of the procedure, while those in the alfentanil group were fully awake and able to move from operating table to stretcher with minimal help. We therefore recommend alfentanil as the base for anesthesia for IVF.

[Coniotomy: surgical airway management in trauma before hospitalization].

To assess the efficacy of prehospital coniotomy (cricothyrotomy), information regarding all coniotomies performed by military physicians during the last 3.5 years was analyzed. 26 were performed between October 1991 and May 1995, of which 23 were successful (88.4%). Failures were due to poor anatomic identification of the cricothyroid membrane. Most patients suffered head or neck injuries (in 61.5% and 19%, respectively). The main indications were anatomical distortion of the pharynx and larynx and failure to intubate. Intubation was attempted in 22 patients prior to coniotomy (multiple attempts in 17). Since coniotomy is a life-saving procedure, it should be part of the armamentarium of any physicians. Coniotomy in the field is associated with a high success rate. The procedure is recommended in trauma victims who need airway establishment and cannot be intubated or in whom intubation has failed.

[Problems raised by the administration of a peridural block in patients receiving anticoagulant therapy]. / Problèmes soulevés par l'administration d'un bloc péridural chez des patients recevant une thérapeutique anticoagulante.

More and more patients likely to get an epidural block are treated with anticoagulant or antiplatelet drugs. An epidural hematoma may be consecutive to an injury of the epidural venous plexus. The mechanisms of action of the different drugs are reviewed. The bleeding time is not an infallible indication of aspirin or other non steroidal antiinflammatory drugs platelet defect. The protocol used in our institution for the administration of an epidural block in this group of patients is discussed.

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.