TRAUMA CENTER, AIR AMBULANCE

Trauma operating room in conjunction with an air ambulance system: Indications, interventions, and outcomes Law DK, Law JK, Brennan R, et al J Trauma 22:759-765 Sep 1982

The effectiveness of rapid transport by helicopter in con- junction with a trauma operating room was analyzed in a retrospective review of 198 trauma patients seen over a three-year period. Condition on arrival of these patients (32% without pulse or blood pressure, 45% hypotensive), method of injury (most were blunt injury in automobile accidents, followed by gunshot wounds and motorcycle accidents), percentage of patients intubated on arrival to the trauma operating room (58%), and number of patients re- quiring surgery after arrival in the trauma room (72%), attest to the severity of injury in this cohort. Despite rapid transport, expert prehospital care and resuscitation rendered by critical care nurse practitioners qualified by the Amer- ican College of Surgeons' Committee on Trauma, and early surgical treatment in a fully staffed and specially equipped trauma operating room adjacent to other operating suites, the overall mortality rate for the entire study group was 57%. In their discussion, the authors review the evolution of trauma care, the factors responsible for the statistics in their study, and the cost-effective aspects of high-risk trauma resuscitation. They further note that although defi- nite benefit was realized by the survivors in this study, the goal of increasing patient salvage must be put in perspective of what therapy is rational and realistic in order to evolve better methods and programs to improve accident-related morbidity and mortality. [Editor's note: Their experience of a dismal survival rate for patients who sustained cardiac arrest prior to arrival from multiple and blunt trauma (I of 73 patients survived; the survivor was discharged to a nurs- ing home in a comatose state) reflects that of other pub- lished series. One who arrests in the field from blunt trauma has dismal survival expectations regardless of how sophisticated the prehospital and inhospital trauma care.]

Paul Lewis, MD

TORSADES DE POINTES, ETIOLOGIC AGENTS

Torsades de pointes, a common arrhythmia, induced by medication Ko PT, Gulamhusein S, Kostuk W J, et al Can Med Assoc J 127:368-372 Sep 1982

During a one-year period four patients presented to the authors with syncope or recurrent ventricular fibrillation while taking antiarrhythmic agents or phenothiazines, and were found to have torsades de pointes. Membrane active

antiarrhythmics, including quinidine, disopyramide and procainamide, all of which prolong the Q-T interval, are the most frequently implicated causes of drug-induced torsades de pointes. Phenothiazines and hypokalemia are other causes. The definitive therapy is outlined. Antiarrhythmics that do not prolong the QT interval include propranolol, phenytoin, and bretylium. The authors conclude that the diagnosis should be suspected in patients presenting with syncope or ventricular tachycardia of recent onset, especial- ly when the medications mentioned above are involved. This arrhythmia should be treated with discontinuance of all medications that may predispose to this condition, accel- eration of the heart rate via overdrive pacing, correction of metabolic abnormalities, and judicious use of antiarrhyth- mics that do not prolong the QT interval.

Mike Murphy, MD

TESTES, TORSION, ENVIRONMENTAL CAUSE

Association of cold weather with testicular torsion Shukla RB, Kelly DG, Guiney EJ Br Med J 285:1459-1460 Nov 1982

Little is known about the etiology of torsion of the testis. Forty-six patients ranging in age from 3 months to 22 years with surgically proven testicular torsion were reviewed ret- rospectively. Forty of these 46 patients experienced their torsion when the temperature was less than 2 C. The ambient temperature was less than 2 C on 23.6% of the days during the five-year study period, while 87% of the torsions occurred at temperatures below 2 C, a statistically significant finding. Only four cases occurred between May and August. The authors suggest that cold may cause the testicular capsule, dartos, or cremasteric muscle to contract and produce torsion.

Ron M. Walls, MD

GONORRHEA, CERVICAL GRAM STAIN

The value of the cervical gram stain in the diagnosis and treatment of gonorrhea in women in a venereal disease clinic Lossick JG, Smeltzer MP, Curran JW Sex Trans Dis 9:124-127 Jul-Sep 1982

Because of the short incubation period of the disease and the fact that women, unlike men, seldom present with a characteristic clinical pattern of gonorrhea, competent laboratory assistance is essential to the diagnosis. In par- ticular, the endocervical gram stain provides the only im- mediate laboratory evidence upon which a clinical decision can be made. Most of the American literature on this sub- ject has addressed the unreliability of the cervical gram

12:5 May 1983 Annals of Emergency Medicine 338/111