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Topical chemoprophylaxis
82
Injury
Reversed saphenous vein was used as arterial substitute. Continuity of major veins was restored wherever possible to reduce venous stasis and swelling of the limb. Six out of 9 arteriovenous fistulas were repaired initially. Technique, complications and results with a Z-year follow-up are described. Mandal A. K., Boitano M. A., Maxwell T. M. et al. (1976) Ninety-eight penetrating vascular injuries. J. Trauma 16, 354. Femoral
artery
injury
It is only recently
that success is being reported in the combined injury of fracture of the femoral shaft with injury to the superficial femoral artery. Eight cases are described; 6 were completely successful, 1 required below-knee amputation and i above-knee. The best policy is fixation of the fracture bv mate or nail and repair of the artery by saphenous ;e&t graft through separate incisions. The maximal time lag in restoring the circulation is discussed. Kootstra G., Schipper J. J., Boontje A. H. et al. (1976) Femoral shaft fractures with injury to the superficial femoral artery in civilian accidents. SNY~. Gynecol. Obstet. 142, 399. Gangrene
of the hand
Cannulation for monitoring arterial pressure and blood gases has been employed with increasing frequency. Major complications are rare because of extensive collateral circulation. Two cases of postcannulation ischaemia of the hand requiring amputation are reported. Falor W. H., Hansel H. R. and Williams G. B. (1976) Gangrene of the hand: a complication of radial artery cannulation. J. Trauma 16, 7 13. Traumatic
rupture
of aorta
From the Hospital of the Sacred Heart in Montreal, Canada, comes a report of 6 successfully treated ruptures of the aorta in the course of one year. The operation on one patient is described in detail since it was the first operation for the repair of a ruptured aortic arch managed by a sutureless bypass shunt allowing perfusion of all aortic arch vessels without extracorporeal circulation. Verdant A. et al. (1976) Rupture traumatic insituee de I’aorte thoracique avec deinsertion le l’artere sous-claviere gauche. Can. J. Surg. 19, 435. Burns Burns of the hand The principles applied to surgical management of the burned hand include (a) early excision of eschar with immediate closure by skin grafting; (b) prevention of infection; (c) control of oedema; (d) immobilization of hand and fingers in a functional position; (e) early restoration of motion. A series of 76 consecutive patients treated with primary excision and grafting is compared with a similar series treated with AgNO, without excision. Healing was quicker and the number of deformities and reconstructive procedures were
: the
British
Journal of Accident Surgery Vol. g/No. 1
much reduced in the excised group. The long term functional and cosmetic results also were far superior in the excised group. Burke S. F., Bondoc C. C., Quinby W. C. jun. et al. (1976) Primary surgical management of the deeply burned hand. J. Traumu 16, 583. Gastroduodenal
disease
after
burns
Forty-eight patients with burns of more than 35 per cent of the total body surface were evaluated within 72 h of the injury. In a prospective randomized fashion patients were chosen either to receive antacid therapy or not. An established lithium-flux technique was used to determine the integrity of the gastric mucosal barrier before group selection. Only 1 of 24 patients receiving treatment developed significant bleeding. Seven out of 24 patients not receiving antacid treatment had bleeding with gastric ulcer perforation in one. McAlhany J. C. jun., Czaja M. and Pruitt B. A. jun. (1976) Antacid control of complications from acute gastroduodenal disease after burns. J. Trauma 16, 645. Tangential
excision
and skin grafting
The authors favoured primarily tangential excision of deep dermal burns, judging the depth by appearance, perception of pin-prick and whether or not colour returned to an area that had been blanched by pressure. Among the complications were the formation of small sebaceous cysts under the grafts and a step at the graft edge. The cysts subsided spontaneously and there was no long term advantage in trimming the graft bed’s edge so as to allow the graft to lie flush with the surface. Thinner grafts were found to give less trouble than thicker ones. Tandon S. N. and Sutherland A. B. (1977) Some problems following tangential excision and skin grafting in dermal burns. Burns 3, 96. Burns of perineum
and buttocks
The study was based on 20 children between II months and I7 years of age. All the burns were treated by exposure with cleansing twice a day and trimming of eschar aided by whirlpool baths and a mixture of saline, hydrogen peroxide and a domestic detergent. Mafenide, gentamicin and silver sulphadiazine were applied to the burned areas until the dead tissue had separated, when the raw surfaces were prepared for grafting by the application of pigskin. Nevertheless Pseudomonas oeruginosa and Escherichia coli were often cultured. Colostomy was used in only 1 of the 20 cases. Rubis L., Law E. J. and MacMillan B. G. (1977) Management of burns of the perineum and buttocks. Bwm
3, 87.
Topical chemoprophylaxis A controlled trial showed that 1 per cent silver sulphadiazine (SSu) cream applied daily (or at intervals of 2 or 3 days) to burns had greater prophylactic value against Pseudomonas aeruginosa than a
83
Abstracts cream containing 0.4 per cent silver phosphate with 0.2 per cent chlorhexidine gluconate (SPCI). In another controlled trial, SSu cream had greater prophylactic value against Staphylococcus aureus, P. aeruginosu, proteus species and miscellaneous coliform bacilli than a 10 per cent povidone-iodine (PVP-I) cream. It was inferred, from the results of an earlier trial, that silver nitrate chlorhexidine (SNCI) cream would be more effective than SPCI cream as a prophylactic agent against P. aeruginosa, apparently because of the greater solubility of silver nitrate; for this reason, SNCI cream was judged to be an appropriate substitute for SSu cream when sulphonamide-resistant Gram-negative bacilli were predominant in the ward. A trial of 10 per cent povidone-iodine and 0.5 per cent silver nitrate solutions applied 6-hourly to exposed burns of the face, compared with no topical showed that both solutions reduced application, bacterial colonization of the burns, but there was no significant reduction in colonization by individual pathogens. Babb J. R., Bridges K., Jackson D. M. et al. (1977) Topical chemoprophylaxis: trials in silver phosphate chlorhexidine, silver sulphadiazine and povidoneiodine preparations. Burns 3, 68.
These criteria are clearly stated under the headings ‘Conditions for considering diagnosis of brain death’, ‘Tests for confirming brain death’ and ‘Other considerations’. These guidelines include a recommendation that the decision to withdraw artificial support should be taken by two doctors. British Medical Journal (1976) Diagnosis of brain death. Statement issued by the honorary secretary of the Conference of Medical Royal Colleges and their Faculties in the United Kingdom on 11 October 1976. Br. Med. J. 2, 1187. Hormone
release
associated
with
parachuting
Measurements are reported in 14 subjects of rise in the blood plasma content of prolactin, thyrotropin and growth hormone following their first parachute jump. Whilst this is ascribed to emotional stress, other forms of stress, for example surgery under general anaesthesia, are well known to cause rise of plasma concentration of prolactin and of the growth hormone. Noel G. L., Dimond R. C., Earth J. M. et al. (1976) Prolactin, thyrotropin, and growth hormone release during stress associated with parachute jumping. Aviat. Space Environ. Med. 41, 543.
Organization prevention
topics and accident Potassium
Air bags and seat belts
A recent development is described which is a combination of an air bag and a seat belt producing a restraint system called the Inflataband. On impact the lap and over-shoulder components of the belt are inflated by air or gas, providing restraint and cushioning in the same system. This system (and others) have been tested using anthropomorphic dummies, cadavers and human volunteers-the latter in frontal impact of up to 32 mph. The restraining devices are triggered by sensors which cause them to deploy within 0.01 l-0.25 s after impact. They are fully inflated before the individual is impacted against them. Results show that the injury prevention potential of the Inflataband prototype warrants further development of the device. Ziperman H. H., Cromack J. R. and Clark J. M. (1976) Air bags and seatbelts in injury amelioration. J. Trmmn 16, 686. Diagnosis
of brain
death
This is the advice accepted from the Transplant Advisory Panel and working parties of the Royal Colleges of Surgeons, Physicians and Anaesthetists and approved by a Conference of the Medical Royal Colleges. The diagnostic criteria enable one to distinguish between those patients who retain the functional capacity to have a chance of even partial recovery from those in whom no such possibility exists.
losses
Experiments are reported showing heavy loss of potassium in persons, even fully acclimatized Indians, working in severe heat in the tropics. This results in a negative potassium balance on an ordinary dietary intake of potassium. Malhatra M. S., SridhavanK.andVenkataswamyA. (1976) Potassium losses in sweat under heat stress. Aviaf. Space Environ. Med. 47, 503. Cardiopulmonary
resuscitation
The crew of a special ambulance service based on Ulleval Hospital attempted to resuscitate 631 victims of cardiac arrest. Sixty-one per cent of 59 persons who were anoxic for less than 1 minute left hospital alive as against I7 per cent of those who were anoxic for l-5 minutes and only 9 per cent of those who were anoxic for 5-10 minutes. Of the 631 persons, 376 were not revived, 185 were revived but died later and 70 (11 per cent) left hospital alive, but 8 had suffered severe and others slight cerebral damage. Of the 631 persons, resuscitation was started by lay persons in 75, and 36 per cent of these survived, as against 8 per cent of those for whom resuscitation was delayed until the ambulance arrived. The authors recognize the difficulties-and the occasional dangers -of trying to teach the public how to carry out cardiopulmonary resuscitation but the results of this study persuade them that it requires favourable consideration. Lund I. and Skulberg A. (1976) Cardiopulmonary resuscitation by lay people. Lancer 2, 702.
Injury
Reversed saphenous vein was used as arterial substitute. Continuity of major veins was restored wherever possible to reduce venous stasis and swelling of the limb. Six out of 9 arteriovenous fistulas were repaired initially. Technique, complications and results with a Z-year follow-up are described. Mandal A. K., Boitano M. A., Maxwell T. M. et al. (1976) Ninety-eight penetrating vascular injuries. J. Trauma 16, 354. Femoral
artery
injury
It is only recently
that success is being reported in the combined injury of fracture of the femoral shaft with injury to the superficial femoral artery. Eight cases are described; 6 were completely successful, 1 required below-knee amputation and i above-knee. The best policy is fixation of the fracture bv mate or nail and repair of the artery by saphenous ;e&t graft through separate incisions. The maximal time lag in restoring the circulation is discussed. Kootstra G., Schipper J. J., Boontje A. H. et al. (1976) Femoral shaft fractures with injury to the superficial femoral artery in civilian accidents. SNY~. Gynecol. Obstet. 142, 399. Gangrene
of the hand
Cannulation for monitoring arterial pressure and blood gases has been employed with increasing frequency. Major complications are rare because of extensive collateral circulation. Two cases of postcannulation ischaemia of the hand requiring amputation are reported. Falor W. H., Hansel H. R. and Williams G. B. (1976) Gangrene of the hand: a complication of radial artery cannulation. J. Trauma 16, 7 13. Traumatic
rupture
of aorta
From the Hospital of the Sacred Heart in Montreal, Canada, comes a report of 6 successfully treated ruptures of the aorta in the course of one year. The operation on one patient is described in detail since it was the first operation for the repair of a ruptured aortic arch managed by a sutureless bypass shunt allowing perfusion of all aortic arch vessels without extracorporeal circulation. Verdant A. et al. (1976) Rupture traumatic insituee de I’aorte thoracique avec deinsertion le l’artere sous-claviere gauche. Can. J. Surg. 19, 435. Burns Burns of the hand The principles applied to surgical management of the burned hand include (a) early excision of eschar with immediate closure by skin grafting; (b) prevention of infection; (c) control of oedema; (d) immobilization of hand and fingers in a functional position; (e) early restoration of motion. A series of 76 consecutive patients treated with primary excision and grafting is compared with a similar series treated with AgNO, without excision. Healing was quicker and the number of deformities and reconstructive procedures were
: the
British
Journal of Accident Surgery Vol. g/No. 1
much reduced in the excised group. The long term functional and cosmetic results also were far superior in the excised group. Burke S. F., Bondoc C. C., Quinby W. C. jun. et al. (1976) Primary surgical management of the deeply burned hand. J. Traumu 16, 583. Gastroduodenal
disease
after
burns
Forty-eight patients with burns of more than 35 per cent of the total body surface were evaluated within 72 h of the injury. In a prospective randomized fashion patients were chosen either to receive antacid therapy or not. An established lithium-flux technique was used to determine the integrity of the gastric mucosal barrier before group selection. Only 1 of 24 patients receiving treatment developed significant bleeding. Seven out of 24 patients not receiving antacid treatment had bleeding with gastric ulcer perforation in one. McAlhany J. C. jun., Czaja M. and Pruitt B. A. jun. (1976) Antacid control of complications from acute gastroduodenal disease after burns. J. Trauma 16, 645. Tangential
excision
and skin grafting
The authors favoured primarily tangential excision of deep dermal burns, judging the depth by appearance, perception of pin-prick and whether or not colour returned to an area that had been blanched by pressure. Among the complications were the formation of small sebaceous cysts under the grafts and a step at the graft edge. The cysts subsided spontaneously and there was no long term advantage in trimming the graft bed’s edge so as to allow the graft to lie flush with the surface. Thinner grafts were found to give less trouble than thicker ones. Tandon S. N. and Sutherland A. B. (1977) Some problems following tangential excision and skin grafting in dermal burns. Burns 3, 96. Burns of perineum
and buttocks
The study was based on 20 children between II months and I7 years of age. All the burns were treated by exposure with cleansing twice a day and trimming of eschar aided by whirlpool baths and a mixture of saline, hydrogen peroxide and a domestic detergent. Mafenide, gentamicin and silver sulphadiazine were applied to the burned areas until the dead tissue had separated, when the raw surfaces were prepared for grafting by the application of pigskin. Nevertheless Pseudomonas oeruginosa and Escherichia coli were often cultured. Colostomy was used in only 1 of the 20 cases. Rubis L., Law E. J. and MacMillan B. G. (1977) Management of burns of the perineum and buttocks. Bwm
3, 87.
Topical chemoprophylaxis A controlled trial showed that 1 per cent silver sulphadiazine (SSu) cream applied daily (or at intervals of 2 or 3 days) to burns had greater prophylactic value against Pseudomonas aeruginosa than a
83
Abstracts cream containing 0.4 per cent silver phosphate with 0.2 per cent chlorhexidine gluconate (SPCI). In another controlled trial, SSu cream had greater prophylactic value against Staphylococcus aureus, P. aeruginosu, proteus species and miscellaneous coliform bacilli than a 10 per cent povidone-iodine (PVP-I) cream. It was inferred, from the results of an earlier trial, that silver nitrate chlorhexidine (SNCI) cream would be more effective than SPCI cream as a prophylactic agent against P. aeruginosa, apparently because of the greater solubility of silver nitrate; for this reason, SNCI cream was judged to be an appropriate substitute for SSu cream when sulphonamide-resistant Gram-negative bacilli were predominant in the ward. A trial of 10 per cent povidone-iodine and 0.5 per cent silver nitrate solutions applied 6-hourly to exposed burns of the face, compared with no topical showed that both solutions reduced application, bacterial colonization of the burns, but there was no significant reduction in colonization by individual pathogens. Babb J. R., Bridges K., Jackson D. M. et al. (1977) Topical chemoprophylaxis: trials in silver phosphate chlorhexidine, silver sulphadiazine and povidoneiodine preparations. Burns 3, 68.
These criteria are clearly stated under the headings ‘Conditions for considering diagnosis of brain death’, ‘Tests for confirming brain death’ and ‘Other considerations’. These guidelines include a recommendation that the decision to withdraw artificial support should be taken by two doctors. British Medical Journal (1976) Diagnosis of brain death. Statement issued by the honorary secretary of the Conference of Medical Royal Colleges and their Faculties in the United Kingdom on 11 October 1976. Br. Med. J. 2, 1187. Hormone
release
associated
with
parachuting
Measurements are reported in 14 subjects of rise in the blood plasma content of prolactin, thyrotropin and growth hormone following their first parachute jump. Whilst this is ascribed to emotional stress, other forms of stress, for example surgery under general anaesthesia, are well known to cause rise of plasma concentration of prolactin and of the growth hormone. Noel G. L., Dimond R. C., Earth J. M. et al. (1976) Prolactin, thyrotropin, and growth hormone release during stress associated with parachute jumping. Aviat. Space Environ. Med. 41, 543.
Organization prevention
topics and accident Potassium
Air bags and seat belts
A recent development is described which is a combination of an air bag and a seat belt producing a restraint system called the Inflataband. On impact the lap and over-shoulder components of the belt are inflated by air or gas, providing restraint and cushioning in the same system. This system (and others) have been tested using anthropomorphic dummies, cadavers and human volunteers-the latter in frontal impact of up to 32 mph. The restraining devices are triggered by sensors which cause them to deploy within 0.01 l-0.25 s after impact. They are fully inflated before the individual is impacted against them. Results show that the injury prevention potential of the Inflataband prototype warrants further development of the device. Ziperman H. H., Cromack J. R. and Clark J. M. (1976) Air bags and seatbelts in injury amelioration. J. Trmmn 16, 686. Diagnosis
of brain
death
This is the advice accepted from the Transplant Advisory Panel and working parties of the Royal Colleges of Surgeons, Physicians and Anaesthetists and approved by a Conference of the Medical Royal Colleges. The diagnostic criteria enable one to distinguish between those patients who retain the functional capacity to have a chance of even partial recovery from those in whom no such possibility exists.
losses
Experiments are reported showing heavy loss of potassium in persons, even fully acclimatized Indians, working in severe heat in the tropics. This results in a negative potassium balance on an ordinary dietary intake of potassium. Malhatra M. S., SridhavanK.andVenkataswamyA. (1976) Potassium losses in sweat under heat stress. Aviaf. Space Environ. Med. 47, 503. Cardiopulmonary
resuscitation
The crew of a special ambulance service based on Ulleval Hospital attempted to resuscitate 631 victims of cardiac arrest. Sixty-one per cent of 59 persons who were anoxic for less than 1 minute left hospital alive as against I7 per cent of those who were anoxic for l-5 minutes and only 9 per cent of those who were anoxic for 5-10 minutes. Of the 631 persons, 376 were not revived, 185 were revived but died later and 70 (11 per cent) left hospital alive, but 8 had suffered severe and others slight cerebral damage. Of the 631 persons, resuscitation was started by lay persons in 75, and 36 per cent of these survived, as against 8 per cent of those for whom resuscitation was delayed until the ambulance arrived. The authors recognize the difficulties-and the occasional dangers -of trying to teach the public how to carry out cardiopulmonary resuscitation but the results of this study persuade them that it requires favourable consideration. Lund I. and Skulberg A. (1976) Cardiopulmonary resuscitation by lay people. Lancer 2, 702.