Balazs Imre Bodai

Prehospital stabilization of critically injured patients: a failed concept

Prehospital resuscitation and stabilization of major trauma victims is increasingly employed. To evaluate the benefits of one such maneuver, fluid administration, we reviewed 52 consecutive trauma cases in which patients had a blood pressure of less than 100 mm Hg either at the scene or on arrival to hospital. In all cases, transport time to hospital was less than IV establishment time. Fluid volume infused had little influence on final outcomes. A percentage of patients with correctable surgical lesions might have been salvaged had prompt transport been instituted. Field maneuvers in critically injured patients should be minimized to decrease ultimate mortality.

Diagnosis and management of ingested foreign bodies: A ten-year experience

Ingested gastrointestinal foreign bodies may be managed by observation, endoscopy, and/or surgical intervention. We retrospectively reviewed 87 consecutive cases of foreign body ingestion. In 49 patients the ingested foreign body had passed beyond the gastroesophageal junction, and these cases form the basis of this study. Of the 49 patients, 19 (38.7%) required surgical intervention for removal of the swallowed object. Nearly 75% of these patients had swallowed objects that were more than 6.5 cm in length. Of 30 adults, more than 50% required surgery for removal of the foreign body. However, fewer than 16% of children who had swallowed and retained foreign bodies required surgery for ultimate cure. Based on these findings, guidelines are presented for the management of foreign body ingestion.

A field evaluation of the Esophageal Obturator Airway.

: The Esophageal Obturator Airway (EOA) has been considered an effective ventilatory technique for cardiopulmonary resuscitation; however, few studies of its field effectiveness have been performed. We evaluated the EOA in 158 cases of prehospital cardiac arrest resuscitated by EMT II personnel utilizing the EOA for airway maintenance. The time of insertion from arrival of the unit and the number of unsuccessful attempts were recorded. The EOA took longer than 4 minutes to insert in 47% of cases. It was incapable of being placed in 18.3% of cases, and required two or more attempts at insertion in 30%. There were six survivors in this series (3.7%). Subsequently, we measured arterial blood gas levels during ventilation with the EOA and after endotracheal intubation in 13 patients. Arterial oxygen tension greater than 60 mm Hg was achieved in only four of 13 patients with the EOA. All patients were hypercarbic and acidotic using the EOA. There was marked improvement in all parameters following ET intubation. The EOA presents technical problems which make it inferior to ET tubes in resuscitation of individuals in the field with cardiac arrest. Close monitoring of its use should be undertaken in areas where it is the primary method for airway maintenance.

Effect of hypoproteinemia on pulmonary and soft tissue edema formation.

The effect of acute hypoproteinemia on the rate of fluid flux across the pulmonary and soft tissue microcir-culations was studied in the unanesthetized sheep. Lymph flow was used to monitor fluid flux, a protein depletion of 30–50% of baseline value was produced by plasmapheresis. Vascular hydrostatic pressures and cardiac output were maintained constant with crystalloid infusion. The measured oncotic pressure in plasma, πp, rapidly decreased as did the oncotic gradient between plasma and lymph. Lung and soft tissue lymph flow increased 2-to 3-fold immediately after protein depletion. Lung interstitial oncotic pressure, πL, as measured in lymph, decreased to return the oncotic gradient and lymph flow to baseline by 24 h. Soft tissue oncotic gradient also returned to baseline by 24 h, but lymph flow remained significantly elevated for the next 48 h, indicating an increase in fluid flux unrelated to changes in oncotic pressure. Lymph flow rapidly returned to baseline when protein was returned. Protein depletion may alter the soft tissue interstitial matrix, allowing for edema formation. More effective mechanisms prevent this from occurring in the lung.

The Effect of Ketamine on Endotoxin-induced Lung Injury

We investigated the effects of ketamine HCl on endotoxin-induced pulmonary injury in 20 chronically instrumented sheep with Sung lymph fistulas. The caudal mediastinal lymph node was cannulated in 20 ewes (45–55 kg). The catheter was externalized and the lymph allowed to drain freely. Pulmonary injury was induced by an intravenous infusion of Escherichia coli endotoxin (1.0–1.5 μ/kg body wt) over a 5-min period in 11 animals. The injury was characterized by an increase in pulmonary arterial pressure, pulmonary arterial wedge pressure, and lung lymph flow. There was no change in mean systemic arterial pressure. These changes were significantly attenuated by intravenous administration of ketamine HCl (5 mg/kg) following endotoxin injury in 9 other animals. When ketamine was given, the pulmonary arterial pressure decreased 32%, lung lymph flow decreased 27%, and systemic blood pressure increased 22%. Potential mechanisms for the hemodynamic effects of ketamine HCl in sepsis are discussed with particular reference to the pulmonary microvasculature.

Mistakes in treatment of accident cases before reaching hospital

INTRODUCTION EACH year in the United States, over I50000 patients die after accidents. Injury remains the major cause of death in patients less than 38 years of age. The past 15 years have seen dramatic advances in the care of patients with serious injuries and their fast transport to hospital. This is mainly due to experience gained in the Vietnam war where rapid evacuation led to a significant drop in the mortality rate of severely injured patients (Trunkey, 1982). Field resuscitation of apparently moribund patients began in the late 1960s with reports of successful treatment of cardiac arrests before reaching hospital (Adgey et al., 1969). Defibrillation on the spot, administration of drugs and other measures have improved survival (Crampton et al., 1975). While patients who appear clinically dead in the field from medical causes, i.e. cardiac or respiratory arrest, can occasionally be saved, this is not the case in those patients who appear clinically dead after potentially correctable surgical lesions (McSwain et al., 1980; Bodai et al., 1983) Why are the. salvage rates not similar? An analysis of the emergency technician’s role in field resuscitation appears to provide some insight into this discrepancy. Emergency rescue personnel are currently able to provide the following services: (I) placement of endotracheal tubes, oesophageal obturator airways or provision of bag-mask ventilation; (2) insertion of intravenous lines; (3) administrations of drugs; (4) externally applied thoracic compressions for cardiopulmonary resuscitation; (5) defibrillation; and (6) application of antishock trousers. While nearly all of these manoeuvres are valuable in the resuscitation of medical cases, they are, for the most part, futile in surgical cases. This is because the underlying aetiologies and pathophysiologies of medical and surgical cases differ, at least in the initial phase. We shall examine and review the essential contributions of each of these techniques to field resuscitation and demonstrate that some may actually hamper the successful salvage of victims of multiple injuries. AIRWAY MANAGEMENT Airway control is critical in the management of cases of either cause. Adequate oxygenation and ventilation are prerequisites for successful primary care. Some outside rescuers are trained to place an endotracheal tube, an oesophageal obturator airway or to employ bag-mask ventilation. Endotracheal intubation, as opposed to the oesophageal obturator airway or bag-mask systems, appears to be the most effective ventilatory technique for field resuscitation. Studies reporting field successes have usually used endotracheal intubation, whereas there were consistently fewer successes with the oesophageal obturator airway (Smith et al., 1983). We believe that rescuers trained in endotracheal intubation are necessary for complete care. We recommend the exclusive use of endotracheal intubation to control the airway in the critically injured patient before reaching hospital. Unfortunately, because of cost and licensing requirements, not all rescuers are trained in endotracheal intubation.