Non-collision injuries in public buses: a national survey of a neglected problem.

OBJECTIVES: This prospective, nationally representative, multi-centre study was undertaken to assess non-collision injuries sustained by public bus passengers in Israel. METHODS: The emergency departments (EDs) of six medical centres, which participated in this eight month study, were chosen to represent both urban and rural catchment areas. All patients diagnosed with injuries sustained on a public bus not involved in a road traffic accident were promptly evaluated for mechanism and nature of injury and demographic parameters. RESULTS: The study cohort consisted of 120 patients (86 were female, 34 were male, age range 3-89 years). Over half were older than 55 years. The most common injuries were to the limbs, vertebral column, and head. The major mechanism of injury was acceleration/deceleration. Most patients were standing when they sustained the injuries. There were no fatalities, and 17 patients were admitted to hospital (9 of 17, 52% older than 55 years). Extrapolation to yearly national statistics suggests a probable total of 729 such injuries. CONCLUSION: The significant injuries inflicted on passengers of public buses not involved in road traffic accidents warrant decisive preventative measures by transportation authorities.

The management of stab wounds to the heart with laceration of the left anterior descending coronary artery.

Penetrating cardiac injuries are an increasing cause of traumatic deaths in urban areas. The management of these injuries has undergone a transition from simple pericardiocentesis to cardiac ultrasound evaluation in the stable patient, and emergency thoracotomy and repair of myocardial wounds in the unstable patient in extremes. The incidence of traumatic coronary artery injury is not accurately known because not all victims are examined. With the improvement in emergency medical services, including speed of transportation of these patients, better resuscitation, and knowledgeable use of cardiac ultrasound or emergency room thoracotomy, more patients with coronary artery injuries will survive and reach the operating room. The operative management of the injured coronary artery is dependant on the location of the injury and whether there is myocardial dysfunction. Distal injuries with small myocardial infarction should be treated by ligation alone. Proximal injury and those injuries associate with larger area of ischaemia or infarction are best treated with coronary artery bypass. The role of cardiopulmonary bypass pump in these patients should be evaluated depending on the homodynamic stability of the patient. We present two cases of cardiac stab wounds with transection of the left anterior descending (LAD), which were successfully managed. A literature review regarding the management of combined cardiac and coronary artery injuries is also provided.

In vitro model of intravenous fluid administration: analysis of vein resistance to rapid fluid delivery.

Rapid fluid administration is the cornerstone of successful trauma resuscitation of patients in a state of shock. Intravenous (IV) fluid delivery is a physical intrusion into a vein which results in a complex interaction between the rigid catheter and the compliant vein. We present an experimental model of IV infusion into a vein-like compliant tube that (a) demonstrated the interdependence between fluid administration and blood flow in a compliant tube and (b) allowed investigation of the contribution of the central venous system (between the infusion site and the heart) to the total resistance to infusion flow rate. The results show that in cases with very high resistance in the central venous system a significant increase of infusion flow rate cannot be achieved just by increasing the infusion pressure. Similarly, in cases of small veins when only small catheters can be used, infusate flow rate may be increased only by using two independent infusion ports. In cases with increased tissue pressure due to edema, gravity-driven infusion may not produce sufficient perfusion of the vascular compartments. It was also shown that the vein valves do not always close, and that peripheral blood flow may continue together with the infusate fluid (e.g., when there is a small downstream resistance and infusion with a small catheter).

[Injuries due to falls in urban buses: 100 consecutive cases].

We reviewed the charts of 100 consecutive emergency department (ED) cases of injuries in public buses (not due to actual traffic accidents) seen during 7 months in 1995. There were 29 males and 71 females with a mean age of 55.6 +/- 21.4 years, median 60, and range 13-91. 92 were discharged home directly from the ED. 3 were admitted to general surgical wards, and 1 each to the orthopedic, medical and neurosurgical wards, while 2 soldiers were sent for observation to a military clinic. There were 28 spinal column, 27 head and 25 chest injuries; 1 patient died. There were no significant differences in admissions during the months of the year. 58% of injuries occurred during normal working hours, with a peak incidence at about 1000 hrs. The most common cause was falling while standing, due to sudden acceleration/deceleration or sharp turns. There are 1900 buses in Tel Aviv which carry 1.1 million passengers daily and most of which are capable of significant acceleration. A high proportion of passengers travel standing, and elderly passengers are more liable to fall when the bus accelerates, decelerates or turns. We calculate a potential national yearly bus injury toll from falls of more than 1000, which often result in significant morbidity and even mortality. A national survey is now being planned.

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.

[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.

Gastric serosal patch in distal pancreatectomy for injury: a neglected technique.

Distal pancreatectomy to manage disruption of the body and tail of the pancreas is a well-established surgical procedure. Fistula formation after distal pancreatectomy for injury may be as high as 24 per cent, and its treatment, although non-operative, prolongs hospitalization and increases the patient's discomfort. We describe the gastric serosal patch technique designed to cover the pancreatic stump after distal pancreatectomy in injured patients. Although this procedure has been previously described, it did not receive appropriate acclaim. Our experience suggests that this technique may eliminate fistula formation and other complications, thereby reducing patient discomfort, morbidity and hospital stay.

[Patterns of injuries and preventive measures for motorcycle accidents].

Retrospective analysis of a series of 32 motorcyclists admitted after road accidents was performed. 62% were injured on scooters with 50 cc engine capacity and most of the combined injuries occurred in this group. Most crashes occurred at road junctions. Riders of scooters with larger engine capacities tended to wear protective garments as opposed to riders with smaller engines. There was no correlation between engine capacity and severity of injury. We conclude that motorcyclists should receive special education, especially as to behavior on entering road junctions. We recommend that taxes on protective garments should be lowered in order to encourage motorcyclists to use them.

[Whipple operation in trauma].

Pancreato-duodenectomy is a formidable operation for the critically injured patient. We describe a patient who sustained a stab wound to the stomach and duodenum. At operation this injury could not be reconstructed. A Whipple operation was performed in which the pancreatic stump was stapled and recovery was uneventful, although there was a low output fistula from the pancreatic stump. Limited indications for the Whipple procedure in trauma patients are suggested.

[Blunt perineal injuries].

Blunt perineal and anal injuries are rare. We describe 2 patients who suffered injury to the perineum and anal canal due to blunt force. New surgical techniques for the reconstruction of the sphincteric mechanism are promising and should be used by the initial treating surgeon as minimal procedures in the perineal region. Anal tagging, minimal debridement, approximation of the edges of perineal laceration, repeated irrigation and loop-colostomy for fecal diversion should be the only initial surgical procedures.

[Kapoera--popular dance or martial art?].

Kapoera, a combination of acrobatics and coordinated athletic movement, is believed to have been introduced to South America during the 19th century by transported African slaves. The dance does not involve intentional physical contact, but during 6 months, 3 patients were admitted here for injuries induced by the forceful movements of this dance. 2 underwent exploratory laparotomy that revealed bowel perforations and 1 suffered a comminuted nasal bone fracture. Medical personnel should be familiar with the potential hazards of this dance and martial art.

Extraperitoneal rectal gunshot injuries.

Extraperitoneal rectal gunshot injuries are rare, but may be encountered in civilian practice. We report on a series of 26 such cases. The aim of the study is to attempt to evolve a treatment policy of this injury. The principles of management include the repair of rectal wound in selected cases and the formation of a diverting colostomy. Distal rectal washout and presacral drainage, although advocated by some authors, do not seem to be indispensable adjuncts to the management of these injuries.

Colonic bleeding due to rupture of an isolated iliac artery aneurysm into a caecal carcinoma.

We describe a case of a fistula between an atherosclerotic aneurysm of the right common iliac artery and a caecal carcinoma, causing massive colonic bleeding. A fistula between a true aneurysm and a carcinoma of the colon has not to our knowledge been previously reported. Various aspects of this case are discussed from a pathogenetic point of view.

Alpha-adrenergic blocker for posthernioplasty urinary retention. Prevention and treatment.

In a prospective, randomized study, 102 patients over the age of 60 years underwent inguinal hernioplasty. We compared a group of 58 patients who received phenoxybenzamine hydrochloride with a control group of 44 patients. The phenolsulfonphthalein test was performed in all patients. Twenty-six (25.5%) of the 102 patients developed acute urinary retention after the hernioplasty; all of them were in the control group. All of these 26 patients had pathological phenolsulfonphthalein test. In 21 of these 26 patients, urinary retention disappeared within 48 hours following phenoxybenzamine administration.

Intrarectal bypass graft in low anterior resection and sigmoid obstruction--an experimental study.

The most common causes for morbidity and mortality in colorectal resections are anastomotic leaks. In low anterior resection, the incidence of anastomotic leakage ranges from 17 to 50%. With the use of the stapler technique, leakage incidence rate remains high and ranges from 10 to 25%. Colostomy formation and closures are associated with considerable morbidity and mortality. Due to the high incidence of anastomotic leakage rate in low anterior resection, and the additional complications of diverting colostomy formation and closure, the use of a rectal stent-intrarectal bypass graft has been instituted. This is carried out by means of a silastic graft, which prevents the fecal stream and gas pressure from coming into contact with the anastomotic site at the low rectum. The efficacy of intrarectal bypass graft was examined in two high-risk surgical situations, the first in very low anterior resection and the other, after early sigmoid obstruction. In both situations the intrarectal bypass graft provided for a safe anastomosis. Even when dehiscence and early obstructions occur, the tube may prevent leakage. This procedure presents effective practical implications which obviate the need for a proximal colostomy formation, thereby eliminating the physical and psychological stress that accompanies colostomies.