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Air within a pacemaker pocket may cause transient malfunction of a replacement unipolar cardiac pacemaker. This was noted in a patient in whom entrapped air prevented tissue contact of the anode, resulting in complete cessation of myocardial stimulation and absence of an electrocardiographic pacemaker artifact. Methods for avoiding this complication are proposed.

We reviewed 1,201 trauma deaths that occurred in Dade County, Florida, in 1982 in order to evaluate the need for an organized trauma network. There were 715 deaths (59.5%) at the scene. Of the remaining 486 patients who were transported to hospitals for treatment there were 240 central nervous syste

Major ductal injury is a determining factor in the outcome after pancreatic trauma. The purpose of this study was to determine the value of early endoscopic retrograde pancreatography (ERP) in patients with blunt pancreatic trauma. We attempted ERP in nine patients. Indications were abnormal

The effects of hemorrhagic shock and whole blood transfusions on red blood cell (RBC) Na+, K+, and ATP levels have been studied using two shock models. Group A animals were bled to a pressure of 40 mm Hg, following which no further blood was removed or returned. The blood pressure of these rats increased to approximately 70 mm Hg within 30 min and remained at that level for 2 hr. Group B animals were bled to a pressure of 40 mm Hg and maintained at that level for 2 hr. No significant changes in RBC Na+ or K+ levels were found in Group A animals subjected to shock. However, small but significant changes in RBC cations were observed in Group B animals subjected to hemorrhagic shock. In Group B, ATP levels decreased from 1.51 to 1.27 mmole/liter RBC. In another study (Group C), rats were subjected to shock as in Group B but were transfused with rat's whole blood which had been stored in cold ACD buffer for 6 days instead of their own shed blood. RBC Na+ of Group C increased from 3.5 ± 0.1 to 8.4 ± 0.7, and K+ decreased from 100.3 ± 2.3 to 85.0 ± 2.1. The RBC Na+ of stored blood itself increased by 288 and 355% at 3 and 6 days cold storage, respectively. These results indicate that (1) severe hemorrhagic shock produces small changes in RBC Na+ and K+ levels; and (2) large changes in RBC cation levels which have been reported previously in man may be due to the additional effect of transfusion of stored blood.

We reviewed 72 patients with penetrating trauma to the extremities who underwent arteriography for proximity injury only. None of the patients had clinical evidence of vascular trauma. There were 62 males and ten females, with a mean age of 29.9 years. Gunshot wounds were the most common cause of injury (91.7%) and the thigh was the most common site of injury (47.2%). A normal arteriogram was found in 55 of 72 patients (76.4%). The remaining 17 patients (23.6%) had arteriographic abnormalities that did not warrant surgery. Only one patient was explored (1.4%) for spasm of the popliteal artery. No vascular injury was found at surgery. This study suggests that routine arteriography in proximity injury only may be unnecessary and that these patients could safely be admitted to the hospital for a 24-hour period of observation.

We prospectively evaluated the efficacy of comprehensive field triage in 8,891 trauma patients transported to trauma centers in Dade County, Florida, over a 1-year period ending in September 1986. There were 5,685 males (63.9%) and 3,206 females (36.1%) with a mean age of 32.4 +/- 18.4 years. The overall accuracy for identifying severe injury for the entire group was 30.2%. A Trauma Score less than or equal to 12 was the most accurate predictor of severe injury. Of 669 patients in this group, 617 (92.2%) sustained severe injury and 361 died (54.0%). High-speed (greater than 40 m.p.h.) motor vehicle accident was the most common reason for triage; however, of 2,277 in this group 201 patients (9.0%) had severe injury and four patients (0.2%) died. Only nine deaths (0.9%) occurred in 1,004 patients with penetrating trauma whose Trauma Scores were greater than 12. Of the 8,891 patients 4,791 (53.9%) had moderate to severe injury. The overtriage rate was therefore 46.1% using this field categorization system.

In order to reassess the value of diagnostic peritoneal lavage (DPL) in patients with blunt abdominal trauma, we conducted a prospective study over a 15-month period involving 138 patients. There were 29 (28.3%) patients with positive DPL and 103 (71.7%) with negative DPL in this series. Of the 29 patients with positive DPL, 28 (96.5%) were found to have significant intra-abdominal injuries; 27 by exploratory laparotomy and in one case at autopsy. One patient with a grossly positive DPL had a negative exploratory laparotomy (3.4% false positive rate). All 109 patients with negative DPL were admitted. In only one case a significant intra-abdominal injury was demonstrated (0.9% false negative rate). The overall mortality in this series was 11.6% and there were no complications related to the DPL. Our results suggest that DPL is indeed an accurate indicator of significant intra-abdominal injuries in patients with blunt abdominal trauma.

The rhythmic movement of darkened Albizzia leaflets is accompanied by K + flux in pulvinule motor cells whose turgor changes control opening and closing. The azide-sensitive open phase is promoted by an increase in temperature from 16 to 33C (Q 10 = 3), implying active transport of K + ions during this period. The azide-insensitive closed phase is less temperature-sensitive and has a Q 10 less than 1, implying diffusion or some other physical process as the predominant pathway of K + flux at this time. Thus rhythmic leaflet movement is probably due to oscillation in active K + transport or membrane permeability or both. External electrolytes (0. 1 n) alter leaflet angle during the open, but not the closed, phase of the rhythm. All chlorides except NH 4 + promote opening, with divalent more effective than monovalent ions. Some anions promote and others inhibit opening; activity is not correlated with charge. It is likely that electrolytes alter leaflet movement by altering K + flux, accomplishing this by interacting with key macromolecules in motor cell membranes. Pfr phytochrome dampens the amplitude of rhythmic leaflet movement; this process is temperature sensitive (Q 10 = 2) and unaltered by 0.1 n salt solutions. Although K + flux is a common basis for phytochrome and rhythmic control of leaflet movement, different mechanisms are clearly involved.

We have reported the unusual finding of a grossly bile-stained peritoneal lavage 24 hours after blunt abdominal trauma, associated with neither enteric, hepatic, nor biliary tract injury at laparotomy. Intraoperative transcholecystic cholangiography is recommended in such a situation to rule out biliary tract injury.

• We reviewed 91 cases of intestinal perforation complicating typhoid fever treated at a rural hospital in Haiti over a ten-year period. Surgical management involved simple primary closure of the perforation (80 patients), small-bowel resection with anastomosis (two patients), simple drainage of the peritoneal cavity (two patients), and serosal patching of the perforation (one patient). Six patients died before surgery. The mortality was 30.8% for all 91 cases but 21.2% for those treated with primary closure of the perforation. We also reviewed the literature pertaining to the management of intestinal perforation complicating typhoid fever. (Arch Surg1983;118:1269-1271)

MALIGNANT tumors of the small intestine account for about 2% of all gastrointestinal malignancies.1The majority of these lesions are adenocarcinomas, followed by carcinoid tumors, lymphomas, and sarcomas. The most common site for carcinoid tumors is the appendix, followed by the jejunoileum. The most common clinical manifestation of jejunoileal carcinoids is small-bowel obstruction.1,2Gastrointestinal bleeding from jejunoileal carcinoids is rare but is surgically correctable. It is often difficult to locate the source of small intestinal hemorrhage prior to exploratory laparotomy. We recently treated a patient with multiple jejunoileal carcinoids associated with massive gastrointestinal hemorrhage. This case is presented along with a complete review of the pertinent literature to update the workup and treatment of bleeding small-bowel tumors. Report of a Case A 53-year-old man was admitted to the University of Miami/Jackson Memorial Medical Center on June 12, 1984, with near syncope. His medical history included chronic iron deficiency anemia