Benjamin Honigman

Prehospital advanced trauma life support for critical blunt trauma victims

The ability of paramedics to deliver advanced trauma life support (ATLS) in an expedient fashion for victims of trauma has been strongly challenged. In this study, the records of 114 consecutive victims of blunt trauma who underwent laparotomy or thoracotomy were reviewed. Prehospital care was rendered by paramedics operating under strict protocols. The mean response time (minutes +/- SEM) to the scene was 5.6 +/- 0.27. On-scene time was 13.9 +/- 0.62. The time to return to the hospital was 8.0 +/- 0.4. On-scene time included assessing hazards at the scene, patient extrication, spine immobilization (n = 98), application of oxygen (n = 94), measurement of vital signs (n = 114), splinting of 59 limbs, and the following ATLS procedures: endotracheal intubation (n = 31), IV access (n = 106), ECG monitoring (n = 69), procurement of blood for tests including type and cross (n = 58), and application of a pneumatic antishock garment (PASG) (n = 31). On-scene times were analyzed according to the number of ATLS procedures performed: insertion of one IV line (n = 46), 14.8 +/- 1.03 minutes; two IV lines (n = 28), 13.4 +/- 0.92; one IV line plus intubation (n = 7), 14.0 +/- 2.94; two IV lines plus intubation (n = 9), 17.0 +/- 2.38; and two IV lines plus intubation plus PASG (n = 13), 12.4 +/- 1.36. Of the 161 IV attempts, 94% were completed successfully. Of 36 attempts at endotracheal intubation, 89% were successful.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute organic brain syndrome: a review of 100 cases.

A retrospective review of 100 admissions to Denver General Hospital with a diagnosis of acute organic brain syndrome was conducted. A total of 44% of the patients were found to have a chronic organic brain syndrome with a superimposed acute insult which caused decompensation. The other 56% of patients developed acute organic brain syndromes de novo for a variety of reasons. The most common etiologic factors producing decompensation of the chronic OBS were infections (in 23%) and environmental changes (in 17%). The most common etiologic factor causing AOBS de novo was drug-related. In most cases, a toxicologic screen, lumbar puncture, and CT scan of the brain should be a part of the investigation of any patient with AOBS.

Open Thoracotomy Procedural Competency: Validity Study of Teaching and Assessment Modalities

STUDY OBJECTIVESnTo determine (1) reliability and validity estimates of three modalities used to assess open thoracotomy procedural competency and (2) the effect of computer practice on procedural performance as measured by the three assessment modalities.nnnMETHODSnAn experimental, sequential assessment design with volunteer examinees completing all three assessment modalities (paper, computer, pig model) was implemented at the animal support facilities of a university medical school with an affiliated emergency medicine residency program. Level of physician training (student, resident, faculty) and type of computer practice (thoracotomy, cricothyrotomy) were independent variables. Procedural competency scores were determined for each modality; scores were defined in terms of performance time and performance accuracy for three thoracotomy procedures (opening the chest, pericardiotomy, and aortic cross-clamping).nnnRESULTSnThoracotomy performance on the pig reliably discriminated among examinees known to differ in level of training. However, computer simulation performance did not significantly differ among examinees with different levels of training. Computer simulation practice significantly improved later performance on the computer assessment (P < .05) but not on the pig assessment. The greatest predictor of procedural competency (time and accuracy) on the pig assessment was the ability to sequentially order procedural steps.nnnCONCLUSIONnThis study establishes the pig model as superior to the paper and computer models as the criterion standard for open thoracotomy assessment. Psychometric properties support the pig model as the most reliable and valid model yet described for assessing thoracotomy procedural competency. Computer simulation practice using visual images (complex anatomy) and the sequential ordering of procedural steps through paper modeling show promise for teaching and assessment of prerequisite skills required to develop psychomotor procedural competency.

A comparison of PTV and endotracheal ventilation in an acute trauma model.

Percutaneous transtracheal ventilation (PTV) is an active airway management technique that may be an alternative to cricothyroidotomy in critically injured patients. A canine trauma model was devised to compare the ventilatory capacity and hemodynamic effects of PTV to endotracheal intubation. Mongrel dogs (25-37 kg), splenectomized 14 days previously, were anesthetized with pentobarbital and bled to a mean arterial pressure (MAP) of 20 mm Hg. Animals were maintained at this MAP for 1 hour, then resuscitated with simultaneous: a) aortic crossclamping via left thoracotomy, b) Ringers lactate infusion, and c) active airway support. Control animals (N = 5), intubated with a cuffed endotracheal tube, were ventilated at a rate of 12 per minute, a tidal volume of 500 cc and an FIO2 of 60%. In study animals (N = 5), PTV, for a duration of 1 second, was instituted at the same rate and FIO2. There was no statistically significant difference between the two groups with regard to pO2, pCO2, pH, and hemodynamic parameters. PTV was also performed in the emergency department on four patients unresponsive to resuscitative thoracotomy for postinjury cardiac arrest. PTV rate was 12/minute; duration, 1 second; and FIO2, 100%. Mean values (+/- SEM) for pH, pO2, and pCO2 obtained after 15 minutes of PTV were 7.14 +/- 0.03, 322 +/- 49.5 torr, and 21.5 +/- 4.7 torr, respectively. PTV is comparable to endotracheal intubation with respect to oxygenation, ventilation and hemodynamic response (p greater than 0.05). Our preliminary clinical study corroborates its efficacy in the acute trauma setting and supports further clinical investigation.

Percutaneous transtracheal ventilation in a canine shock model with an open thorax

This study evaluates the effectiveness of percutaneous transtracheal ventilation (PTV) in a canine shock model. Five mongrel dogs (25 to 35 kg), splenectomized two weeks prior to study, were anesthetized (pentobarbital, 22 mg/kg) and bled to and sustained at a mean arterial pressure (MAP) of 20 mm Hg for 60 minutes. Ringers lactate was infused and the descending thoracic aorta was cross-clamped. Simultaneously, PTV was begun with 60% O2 through the cricothyroid membrane. Hemodynamic measurements and arterial blood gases were obtained at 0, 5, 15, and 30 minutes following the initiation of PTV. Orotracheal ventilation was then instituted in place of PTV and continued for 30 minutes, and measurements were repeated. Auto-transfusion was also begun at this time. During PTV, PO2 and PCO2 were adequate in all dogs at each interval. We conclude that PTV provides effective oxygenation and ventilation in dogs subjected to profound shock, thoractomy, and thoracic aortic cross-clamp.