Prehospital cardiopulmonary resuscitation of the critically injured patient

Prehospital cardiopulmonary resuscitation combined with endotracheal intubation, vigorous fluid resuscitation, and rapid transport can be effective in resuscitating trauma patients in cardiopulmonary arrest. Survival does not correlate with the injury severity score or transport time once the patient has arrested but does correlate with the mechanism of injury, endotracheal intubation, and placement of intravenous lines.     

Colon ischemia accompanying ruptured abdominal aortic aneurysm

Myocardial, cerebral, and renal ischemia are recognized as serious sequelae in patients surviving repair of ruptured abdominal aortic aneurysms. Colonic ischemia, though a documented consequence of aortic reconstruction, has received less emphasis in these patients. In a 5-year review of a single hospital's experience, 50 patients underwent an emergency operation for ruptured abdominal aortic aneurysm. Ninety-six percent of the patients were in shock preoperatively. Of the 37 patients who survived the initial surgical procedure, 12 (32%) were subsequently found to have colon ischemia diagnosed by proctoscopy, repeat laparotomy, or autopsy. Among 20 of the initial survivors who later died at intervals up to 6 weeks after aneurysm repair 8 (40%) had colon ischemia as the sole or major contributing cause of death. Because of the high incidence of this serious but remediable problem in patients undergoing emergency operation for ruptured abdominal aortic aneurysm, we now routinely perform: (a) intraoperative Doppler examination of the colonic arterial tree, with consideration of mesenteric revascularization if necessary, (b) daily postoperative sigmoidoscopy and examination of the stool for blood, and (c) aggressive “second-look” laparotomy in patients exhibiting any signs or symptoms suggesting colonic infarction. Our experience suggests that large bowel infarction is a common, lethal, and underemphasized complication following successful repair of ruptured abdominal aortic aneurysms.     

Cure of leukemia by marrow transplantation

One hundred and ten patients with end stage acute leukemia received a marrow transplant from an HLA identical sibling after chemotherapy and supralethal total body irradiation. A plot on a logarithmic scale of the survival of these patients discloses a decreasing death rate after transplantation. The initial rapid loss of patients in the first 130 days is primarily due to infection and graft vs host disease. The rate of leukemic relapse is relatively constant for the first two years after which the relapse rate becomes very low. Between 2 and 6 years, there have been no deaths. The flat slope of the long tail of the survival curve and the corresponding low relapse rate constitute an operational definition of cure of leukemia for the long-term survivors.     

Role of intraoperative pancreatography in patients with injury to the pancreas

Over a 10 year period, 54 patients presented with pancreatic trauma. During the first 5 years of the study, when pancreatography was not utilized for the assessment of pancreatic duct injury, 55 percent of the patients had major pancreatic complications. During the subsequent 5 years, suspected proximal duct injury was evaluated by intraoperative pancreatography. This resulted in a decrease of postoperative morbidity to 15 percent. In addition, there were no postoperative deaths during this period. The reduction in adverse sequelae after pancreatic trauma leads us to support the following principles of treatment: early recognition of pancreatic injury with immediate surgical intervention, complete exploration of the pancreas with the liberal use of intraoperative pancreatography to determine the presence of major duct injury, and the use of techniques which ensure control of duct disruption.     

Comparison of bretylium tosylate and lidocaine in management of out of hospital ventricular fibrillation: A randomized clinical trial

Bretylium tosylate was compared with lidocaine hydrochloride as initial drug therapy in 146 victims of out of hospital ventricular fibrillation in a randomized blinded trial. An organized rhythm was achieved in 89 and 93 percent and a stable perfusing rhythm in 58 and 60 percent of the patients who received bretylium and lidocaine, respectively. After initiation of advanced life support, an organized rhythm was first established after an average of 10.4 minutes and 10.6 minutes in the two respective groups, requiring an average of 2.8 defibrillatory shocks in those who received bretylium and 2.4 in the lidocaine-treated patients. Comparable numbers of patients were discharged from the hospital: 34 percent of those given bretylium and 26 percent of the patients whose Initial therapy was lidocaine. No instance of chemical defibrillation was observed with either drug. In this study, bretylium afforded neither significant advantage nor disadvantage compared with lidocaine in the initial management of ventricular fibrillation.     

Isolation of a new feline sarcoma virus (HZ1-FeSV): Biochemical and immunological characterization of its translation product

A new strain of feline sarcoma virus, designated HZ1-FeSV, was isolated from a 4-year-old domestic cat with multicentric fibrosarcoma. A primary tumor cell line was established and virus produced from that line was found to induce foci in feline embryonic lung fibroblasts (FLF3) and mink lung fibroblasts (CCL64) in tissue culture and fibro-sarcomas in inoculated 10-week-old kittens. The derivation of transformed nonproducer clones of FLF3 and CCL64 cells containing helper virus-rescuable, focus-forming activity indicated that HZ1-FeSV was defective for replication. The only discernible translation product of the HZ1-FeSV genome in cultured cells was a 100,000-Da polyprotein (P100) which contained amino-terminal sequences of the FeLV gag gene precursor protein covalently linked to a sarcoma virus-specific domain. Immunoprecipitates containing P100 exhibited a protein kinase actvity capable of phosphorylating tyrosine residues of P100. Immunologically, P100 was highly cross-reactive with gag-fes polyproteins encoded by two previously characterized strains of FeSV, the GA- and the ST-FeSV. By comparison of methionine-containing tryptic peptides, the HZ1-FeSV protein was shown to be more closely related to the GA-FeSV protein than to the ST-FeSV protein, but to be distinguishable from both other proteins.     

The variability of arterial pressure

Echocardiograms from 562 patients were examined for evidence of the pattern of tricuspid valve prolapse. Criteria for the diagnosis can be established similar to those applicable to mitral prolapse. In 500 consecutive patients without mitral valve prolapse, there were no cases of isolated tricuspid valve prolapse. Eleven of 53 (21 per cent) patients with mitral valve prolapse also had tricuspid valve prolapse. Four of six (67 per cent) patients with Marfan's syndrome and mitral valve prolapse also had tricuspid valve prolapse. The occurrence of this echocardiographic pattern as an isolated finding as well as associated with mitral valve prolapse was significantly less than previous angiographic reports. Patients with both these findings tended to be older than those with mitral valve prolapse alone, but clinically differed in no other way. Use of standardized technique can minimize errors in diagnosis.