Eitan Melamed

The combative multitrauma patient: a protocol for prehospital management.

Objective To describe the management of the combative trauma patient in the prehospital setting, and to suggest a protocol for management. Methods A retrospective, prehospital case series conducted in Israel among military medical teams over the course of nearly 2 years, between January 2000 and October 2002. We collected a case series of patients who became combative following traumatic injury. Following data collection, we summoned an expert panel and developed a protocol for physicians and paramedics upon encountering a combative trauma patient. Results Available data were found for 11 patients and these were included in the analysis. Most victims included in this study were injured under military or geographical circumstances mandating a long time interval from injury to definitive care, namely 114 min (range 38–225 min). Five patients received intravenous ketamine, in three of which it was coadministered with midazolam. Sedation with ketamine given alone, or combined with other drugs, was effective in all five cases. In no case did a patient become more agitated after administration. No adverse effects were recorded by the prehospital caregivers. Conclusions In this article, an algorithmic approach to the treatment of the patients agitation is outlined, using ketamine as the principal sedating agent, either alone or combined with midazolam. The combination of both drugs is suggested for the effective sedation of adult prehospital combative patient population.

The Use of a Chitosan-Based Hyaluronate Gel in Musculoskeletal Afflictions

INTRODUCTION: Many disorders in clinical orthopedics present tissue degeneration and lack of repair due to lack of a scaffold., Chitosan is a sugar polymer that is produced from chitin., The current abstract describes our experience with chitosan as a tissue regeneration supporting scaffold. MATERIALS AND METHODS:, Several models were evaluated including the rat acute rotator cuff model, the lapine Masudas disc degeneration model and, the medial menisectomy rat model., RESULTS: The use of chitosan enhances tendon repair in the rat rotator cuff model and prevents muscle atrophy., The use of chitosan gel appears to prevent disc degeneration in the masuda model., In the osteoarthritis model the use of chitosan leads to better cartilage preservation and less osteophyte formation., Animal pain is reduced as measured using an in capacitance meter. DISCUSSION:, The use of chitosan gel allows repair of several difficult animal models simulating common orthopedic maladies.

Locking plastic tie--a simple technique for securing a chest tube.

A quick and simple technique for securing a chest tube in the prehospital setting is described. The technique makes use of a plastic tie with a self-locking mechanism that is wrapped around the tube and sutured to the skin. The use of a plastic tie is recommended as a valuable component to chest tube kits for use in the prehospital setting.

Letters to the Editor: Evaluation and Treatment of Spinal Injuries in the Patient with Polytrauma

To the Editor: We would like to congratulate the authors on their detailed review of the evaluation and treatment of spinal injuries in their article titled: “Evaluation and Treatment of Spinal Injuries in the Patient with Polytrauma” by RV Patel, W DeLong Jr., and EJ Vresilovic. We would, however, like to make a comment concerning steroids in spinal cord injury. The authors recommend the administration of methylprednisolone in case of neurological deficit, and base their recommendation on the NASCIS II and III guidelines. Since these guidelines were published, the euphoria for this therapy was gradually replaced by the realization that the evidence available for efficacy, let alone safety, does not justify clinical usage. Much has been written regarding the unsatisfactory methods and therefore results of NASCIS, that steroids improve neurological outcome. The main criticism of the validity of these trails is directed towards the use of subgroup analysis. In NASCIS II, there was no benefit overall in the methylprednisolone-treated group; however, subgroup analyses detected a small gain in the total motor and sensory score in a subgroup of 62 patients who had received the drug within 8 hours of injury. The arm of the treatment group is reduced from approximately 160 patients who received methylprednisolone within a time window of 12 hours, to 62 patients in the subgroup alone. In addition to the smaller sample size, the benefits of randomization are lost when performing such analyses, yet another reason to be cautious when interpreting subgroup analysis results. This type of analysis carries an inherent risk of finding a difference where it actually does not exist and should be used primarily as a source of hypotheses to be tested by future research and not to change clinical policy. Additional problem with NASCIS is that it ignores the effect of surgical decompression of the spinal cord on neurological recovery. An animal study showed that surgical decompression with steroids resulted in improved neurological recovery when compared to steroids or surgery alone. The American Association of Neurological Surgeons/ Congress of Neurological Surgeons Joint Section of Disorders of the Spine and Peripheral Nerves recently published guidelines for the management of acute cervical spine and spinal cord injuries. The most controversial part of the guidelines is the conclusion to recommend the use of methylprednisolone only as an option without demonstrated clinical benefit rather than a standard of care, due to insufficient evidence. The Canadian Neurosurgical Society published similar recommendations regarding the use of methylprednisolone in spinal cord injury, in which this agent is considered only as a therapeutic option. More recently, the early anecdotal evidence of adverse effects has been supported by scientific evidence that this treatment can be positively harmful, such as giving rise to acute myopathy. Perhaps both sides of this controversy should have been discussed. Readers are encouraged to read these guidelines and the relevant associated literature to establish their own perspective on this issue.