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Rapid propagation of thrombus
210
INJURY: THE BRITISHJOURNAL OF ACCIDENTSURGERY
accurate fluid-balance charts in the diagnosis, and control of this condition with vasopressin. BOWERMAN,J. E., and HESLOP, I. H. (1971), ‘ Diabetes Insipidus associated with Maxillo-facial Injuries ‘, Br. J. oral Surg., 8, 197. Rapid Propagation of Thrombus Within an hour of deciding to ligate the femoral vein of a person who had had pulmonary embolism and had been shown by phlebography to have thrombus in the lower part of the thigh the authors found that there was thrombus above the inguinal ligament. It was their opinion that it had enlarged very rapidly. DOIG, R. L., and BROWSE,N. L. (1971), ‘Rapid Propagation of Thrombus in Deep Vein Thrombosis ‘, Br. med. J., 4, 210.
breath-holding, and the common practice of pre-dive hyperventilation is strongly condemned. At depths of 100 ft. using breathing apparatus, breathing effort is doubled and carbon dioxide retention can result from undue activity. Underwater competitions are therefore dangerous. There is advice to those who medically examine prospective divers. Nobody should dive who has upper respiratory infection, Eustachian catarrh, or g;dt;ease. Annual chest radiography is recomMILES, S. (1970),, ’ Sports Medicine. Medical Problems of Recreattonal Diving ‘, Jl R. CON. Gen. Practms,
19, 162.
SHOCK
Dural Tears in Maxillofacial Injuries This paper analyses 116 consecutive cases of maxillofacial injury associated with C.S.F. leak seen at the Roehampton and Westminster Hospital Oral Surgery Centres from 1959 to 1969. Although the incidence of dural tears is high, infective intracranial comolications are rare. It is suggested that routine prophylaxis with penicillin and idphonamides combined with early rigid fixation of the fractures prevents early infection, and dural healing under these circumstances is effective and permanent. LEOPARD. P. (1971). ‘Dural Tears in Maxillofacial Injuries ‘, B;. J. &al Surg., 8,222.
RECREATIONAL
J$;‘%
INJURIES
Acute Renal Failure in Near-drowning Grausz, Amend, and Earley from San Francisco report 2 examples of acute oliguric renal failure following near-drowning in sea water. Such a complication is well recognized in fresh water submersion. There is extensive haemolysis, anoxia, and hypotension leading on to the development of acute tubular necrosis. Aspiration of sea water does not produce extensive haemolysis but acute renal failure was found in 2 oatients who were nearlv drowned in sea water. The &-St patient developed- backache which got worse over 5 days when he presented with renal failure. The second man developed oliguria with severe bilateral flank pain 2 days after near-drowning in sea water. Both patients recovered without any residual renal insufficiency and neither patient showed any evidence of haemolysis. The authors conclude that renal tubular necrosis was caused by the combination of hypoxia and hypotension-the initial sequence being a rapid shift of water from vessels to sea water filled alveoli with resultant haemoconcentration and hypotension. GRAUSZ, H., AMEND, W., and EARLEY,L. (1971), ‘Acute Renal Failure complicating Submersion in Sea Water ‘, J. Am. med. Ass., 217, 207. Medical Problems of Recreational
Diving
Whilst emphasizing that diving is a pleasant sport for all age-groups the author advises enthusiasts to join established clubs where the dangers are known and safety regulations adhered to. Dangerously low oxygen levels in the blood can result from prolonged
Vasoactive Drugs in Shock In an editorial note Dr. Perey from Sherbrooke in Quebec writes about ‘ the great disillusion ‘, i.e., the failure of the bright promises for the value of vasoactive drugs in shock during the past 20 years. None of the commonly recommended vasodilators and vasoconstrictors has improved the chances of a patient’s survival from shock. The only exception is isoproterenol (a weak vasodilator) which may help some patients through its strong cardiotonic action. Dr. Perey suggests that the vasoactive approach may rest on a false hypothesis and that the vascular changes in shock do not constitute the disease itself, but represents the best possible balance between pressure and flow in the presence of reduction in circulating bloodvolume, changes in blood composition, increased metabolic requirements, and heart failure. Therefore, he states, we should concentrate on organ failure and correcting deficit rather than tamper with a probably flawless homeostatic response. He concludes, ‘ as for all the solutions of vasoactive wonder drugs with which we have infused our dying patients, they must surely go down in history as unexpected varieties of embalming fluid ‘. PEREY,B. J. (1971) ‘ Vasoactive Drugs in Shock: The Great Disillusion ‘, Can. J. Surg., 14, 295. Oxygen Transport in Shock
Blood gas, oxygen consumption, cardiac output, etc.? were measured in a series of injured patients divided into two groups, trauma without haemorrhage and trauma with haemorrhage. SHOEMAKER,W. C., Bon, D. R., KIM, S. I., BROWN, R. S., DREILING, D. A., and KARK,. A. E. (1971), ‘ Sequential Oxygen Transport and Acid-base Changes after Trauma to the Unanaesthetised Patient ‘, Surgery Gynec. Obstet., 132, 1033. Adrenal Cortical Secretion in Shock
In dogs, the levels of corticosteroid secretion in long-duration shock were compared with controls and with short-duration shock. In prolonged shock secretion was found to decrease. This might simply be due to diminished perfusion but, alternatively, it might be due to intracellular damage. HERMON,A. H., MOCK, E., and EGDAHL, R. H. (1971), ‘The Relationship of Adrenal Perfusion to Corticosteroid Secretion in Prolonged Haemorrhagic Shock ‘, Surgery Gynec. Obstet., 132, 795.
INJURY: THE BRITISHJOURNAL OF ACCIDENTSURGERY
accurate fluid-balance charts in the diagnosis, and control of this condition with vasopressin. BOWERMAN,J. E., and HESLOP, I. H. (1971), ‘ Diabetes Insipidus associated with Maxillo-facial Injuries ‘, Br. J. oral Surg., 8, 197. Rapid Propagation of Thrombus Within an hour of deciding to ligate the femoral vein of a person who had had pulmonary embolism and had been shown by phlebography to have thrombus in the lower part of the thigh the authors found that there was thrombus above the inguinal ligament. It was their opinion that it had enlarged very rapidly. DOIG, R. L., and BROWSE,N. L. (1971), ‘Rapid Propagation of Thrombus in Deep Vein Thrombosis ‘, Br. med. J., 4, 210.
breath-holding, and the common practice of pre-dive hyperventilation is strongly condemned. At depths of 100 ft. using breathing apparatus, breathing effort is doubled and carbon dioxide retention can result from undue activity. Underwater competitions are therefore dangerous. There is advice to those who medically examine prospective divers. Nobody should dive who has upper respiratory infection, Eustachian catarrh, or g;dt;ease. Annual chest radiography is recomMILES, S. (1970),, ’ Sports Medicine. Medical Problems of Recreattonal Diving ‘, Jl R. CON. Gen. Practms,
19, 162.
SHOCK
Dural Tears in Maxillofacial Injuries This paper analyses 116 consecutive cases of maxillofacial injury associated with C.S.F. leak seen at the Roehampton and Westminster Hospital Oral Surgery Centres from 1959 to 1969. Although the incidence of dural tears is high, infective intracranial comolications are rare. It is suggested that routine prophylaxis with penicillin and idphonamides combined with early rigid fixation of the fractures prevents early infection, and dural healing under these circumstances is effective and permanent. LEOPARD. P. (1971). ‘Dural Tears in Maxillofacial Injuries ‘, B;. J. &al Surg., 8,222.
RECREATIONAL
J$;‘%
INJURIES
Acute Renal Failure in Near-drowning Grausz, Amend, and Earley from San Francisco report 2 examples of acute oliguric renal failure following near-drowning in sea water. Such a complication is well recognized in fresh water submersion. There is extensive haemolysis, anoxia, and hypotension leading on to the development of acute tubular necrosis. Aspiration of sea water does not produce extensive haemolysis but acute renal failure was found in 2 oatients who were nearlv drowned in sea water. The &-St patient developed- backache which got worse over 5 days when he presented with renal failure. The second man developed oliguria with severe bilateral flank pain 2 days after near-drowning in sea water. Both patients recovered without any residual renal insufficiency and neither patient showed any evidence of haemolysis. The authors conclude that renal tubular necrosis was caused by the combination of hypoxia and hypotension-the initial sequence being a rapid shift of water from vessels to sea water filled alveoli with resultant haemoconcentration and hypotension. GRAUSZ, H., AMEND, W., and EARLEY,L. (1971), ‘Acute Renal Failure complicating Submersion in Sea Water ‘, J. Am. med. Ass., 217, 207. Medical Problems of Recreational
Diving
Whilst emphasizing that diving is a pleasant sport for all age-groups the author advises enthusiasts to join established clubs where the dangers are known and safety regulations adhered to. Dangerously low oxygen levels in the blood can result from prolonged
Vasoactive Drugs in Shock In an editorial note Dr. Perey from Sherbrooke in Quebec writes about ‘ the great disillusion ‘, i.e., the failure of the bright promises for the value of vasoactive drugs in shock during the past 20 years. None of the commonly recommended vasodilators and vasoconstrictors has improved the chances of a patient’s survival from shock. The only exception is isoproterenol (a weak vasodilator) which may help some patients through its strong cardiotonic action. Dr. Perey suggests that the vasoactive approach may rest on a false hypothesis and that the vascular changes in shock do not constitute the disease itself, but represents the best possible balance between pressure and flow in the presence of reduction in circulating bloodvolume, changes in blood composition, increased metabolic requirements, and heart failure. Therefore, he states, we should concentrate on organ failure and correcting deficit rather than tamper with a probably flawless homeostatic response. He concludes, ‘ as for all the solutions of vasoactive wonder drugs with which we have infused our dying patients, they must surely go down in history as unexpected varieties of embalming fluid ‘. PEREY,B. J. (1971) ‘ Vasoactive Drugs in Shock: The Great Disillusion ‘, Can. J. Surg., 14, 295. Oxygen Transport in Shock
Blood gas, oxygen consumption, cardiac output, etc.? were measured in a series of injured patients divided into two groups, trauma without haemorrhage and trauma with haemorrhage. SHOEMAKER,W. C., Bon, D. R., KIM, S. I., BROWN, R. S., DREILING, D. A., and KARK,. A. E. (1971), ‘ Sequential Oxygen Transport and Acid-base Changes after Trauma to the Unanaesthetised Patient ‘, Surgery Gynec. Obstet., 132, 1033. Adrenal Cortical Secretion in Shock
In dogs, the levels of corticosteroid secretion in long-duration shock were compared with controls and with short-duration shock. In prolonged shock secretion was found to decrease. This might simply be due to diminished perfusion but, alternatively, it might be due to intracellular damage. HERMON,A. H., MOCK, E., and EGDAHL, R. H. (1971), ‘The Relationship of Adrenal Perfusion to Corticosteroid Secretion in Prolonged Haemorrhagic Shock ‘, Surgery Gynec. Obstet., 132, 795.