A Storm, An Explosion, and Flying Rocks - An Unusual Injury due to a Lightning Strike in the Mountains.

BACKGROUND: Most injuries observed in victims of lightning strikes can be explained by electrothermal phenomena. Blast penetrating injuries caused by a lightning-strike-induced explosion of a nearby structure are rarely reported. CASE PRESENTATION: Here reported is the case of a patient with numerous mixed injuries caused by a lightning strike, including deep lacerations of both hips and thighs with rock fragments embedded in the wounds. Surgical removal of rock fragments from deep areas of the right hip and right lower leg was necessary. The cause of the formation of rock missiles was the lightning-strike-induced explosion of rock. Rapid evaporation of water enclosed in rock crevices was presumably the main force underlying the explosion. CONCLUSION: Blast penetrating injuries should be considered and excluded in all patients struck by lightning, particularly when occurring in rocky terrain. The diagnosis and treatment of such injuries can be difficult and require special preparation.

The management of unanticipated difficult airways in children of all age groups in anaesthetic practice - the position paper of an expert panel.

Children form a specific group of patients, as there are significant differences between children and adults in both anatomy and physiology. Difficult airway may be unanticipated or anticipated. Difficulties encountered during intubation may cause hypoxia, hypoxic brain injury and, in extreme situations, may result in the patient's death. There are few paediatric difficult-airway guidelines available in the current literature, and some of these have significant limitations. This position paper, intended for unanticipated difficult airway, was elaborated by the panel of specialists representing the Polish Society of Anaesthesiology and Intensive Care as well as the Polish Neonatal Society. It covers both elective intubation and emergency situations in children in all age groups. An integral part of the paper is an algorithm. The paper describes in detail all stages of the algorithm considering some modification in specific age groups, i.e. neonates.

Intubación realizada por profesionales sin experiencia en un maniquí mediante un dispositivo de vía aérea supraglótico con inmovilización de la columna cervical: comparación entre el uso de la máscara laríngea de intubación y el tubo de intubación laríngea / Intubation through 2 supraglottic airway device in cervical spine immobilization: a randomized trial of residents’ use of the intubating laryngeal mask airway and the intubating laryngeal tube in manikins

Objetivo: El objetivo de este estudio fue evaluar el uso de la mascarilla de intubación laríngea y el reciente tubo de intubación laríngea en manos de residentes con poca experiencia previa en intubación, simulando condiciones de movilidad reducida en la columna cervical. Métodos: Treinta residentes de anestesia de primer año participaron en el estudio (18 mujeres). Todos ellos tenían una experiencia mínima en intubación (< 10 intubaciones realizadas previamente). Los dos dispositivos fueron utilizados por cada participante con asignación al azar del orden. Se registró tanto el tiempo requerido para insertar el dispositivo supraglótico y ventilar a través de él (T1), como el tiempo de colocación del tubo hasta la intubación y ventilación con éxito (T2). También se evaluó la eficacia de la intubación y la facilidad de su uso. Resultados: El tiempo medio requerido para insertar el dispositivo de vía aérea supraglótica y ventilar a través de él fue similar para ambos dispositivos estudiados (15,3 s [DE 5,5] vs 15,4 s [DE 5.5]; p = 0,938). El tubo de intubación laríngea se asoció con un menor tiempo desde su inserción hasta la intubación y ventilación exitosa (25,4 s [DE 8,6] vs 31,9 s [SD 8,8], p = 0,005). No hubo intubaciones fallidas con el uso del tubo de intubación laríngea. Conclusiones: El nuevo tubo laríngeo puede ser una buena alternativa a la mascarilla laríngea, ya que acorta el tiempo requerido para intubar y ventilar con éxito el paciente. También mejora la tasa de intubaciones exitosas

Objectives: The aim of this study was to compare the intubating laryngeal mask (iLM) airway and the new intubating laryngeal tube (iLTS-D) in use by residents with minimal previous intubation experience during simulated conditions of reduced cervical spine mobility. Methods: Thirty first-year residents in anesthesiology participated in the study (18 women). All participants had minimal intubation experience (fewer than 10 previously performed intubations) and were novices in the specialty. Both devices were used by each participant after random assignment of order. We recorded the time required to insert the device and start to ventilate through it (T1) and the time from insertion and intubation to successful ventilation (T2). Efficacy of intubation and each resident’s assessment of ease of use were also assessed. Results: The residents’ mean (SD) T1 values were similar for the 2 devices (iLMA, 15.3 [5.5] seconds; iLTS-D, 15.4 [5.5] seconds; P=.938). T2 was shorter with the iLTS-D (25.4 [8.6] seconds vs 31.9 [8.8] seconds with the iLMA; P=.005). There were no failed intubation attempts with the iLTS-D. Conclusions: The new iLTS-D may be a good alternative to the iLMA because a patient can be intubated and successfully ventilated in less time. The rate of successful intubation is also better with the iLTS-D

Intubation through 2 supraglottic airway device in cervical spine immobilization: a randomized trial of residents' use of the intubating laryngeal mask airway and the intubating laryngeal tube in manikins. / Intubación realizada por profesionales sin experiencia en un maniquí mediante un dispositivo de vía aérea supraglótico con inmovilización de la columna cervical: comparación entre el uso de la máscara laríngea de intubación y el tubo de intubación laríngea.

OBJECTIVES: The aim of this study was to compare the intubating laryngeal mask (iLM) airway and the new intubating laryngeal tube (iLTS-D) in use by residents with minimal previous intubation experience during simulated conditions of reduced cervical spine mobility. MATERIAL AND METHODS: Thirty first-year residents in anesthesiology participated in the study (18 women). All participants had minimal intubation experience (fewer than 10 previously performed intubations) and were novices in the specialty. Both devices were used by each participant after random assignment of order. We recorded the time required to insert the device and start to ventilate through it (T1) and the time from insertion and intubation to successful ventilation (T2). Efficacy of intubation and each resident's assessment of ease of use were also assessed.Observational study using biomechanical inertial sensors to detect movement in the spinal column during removal of helmets. RESULTS: The residents' mean (SD) T1 values were similar for the 2 devices (iLMA, 15.3 [5.5] seconds; iLTS-D, 15.4 [5.5] seconds; P=.938). T2 was shorter with the iLTS-D (25.4 [8.6] seconds vs 31.9 [8.8] seconds with the iLMA; P=.005). There were no failed intubation attempts with the iLTS-D. CONCLUSION: The new iLTS-D may be a good alternative to the iLMA because a patient can be intubated and successfully ventilated in less time. The rate of successful intubation is also better with the iLTS-D.

OBJETIVO: El objetivo de este estudio fue evaluar el uso de la mascarilla de intubación laríngea y el reciente tubo de intubación laríngea en manos de residentes con poca experiencia previa en intubación, simulando condiciones de movilidad reducida en la columna cervical. METODO: Treinta residentes de anestesia de primer año participaron en el estudio (18 mujeres). Todos ellos tenían una experiencia mínima en intubación (< 10 intubaciones realizadas previamente). Los dos dispositivos fueron utilizados por cada participante con asignación al azar del orden. Se registró tanto el tiempo requerido para insertar el dispositivo supraglótico y ventilar a través de él (T1), como el tiempo de colocación del tubo hasta la intubación y ventilación con éxito (T2). También se evaluó la eficacia de la intubación y la facilidad de su uso. RESULTADOS: El tiempo medio requerido para insertar el dispositivo de vía aérea supraglótica y ventilar a través de él fue similar para ambos dispositivos estudiados (15,3 s [DE 5,5] vs 15,4 s [DE 5.5]; p = 0,938). El tubo de intubación laríngea se asoció con un menor tiempo desde su inserción hasta la intubación y ventilación exitosa (25,4 s [DE 8,6] vs 31,9 s [SD 8,8], p = 0,005). No hubo intubaciones fallidas con el uso del tubo de intubación laríngea. CONCLUSIONES: El nuevo tubo laríngeo puede ser una buena alternativa a la mascarilla laríngea, ya que acorta el tiempo requerido para intubar y ventilar con éxito el paciente. También mejora la tasa de intubaciones exitosas.

The pressure exerted on the tongue during intubation with simultaneous cervical spine immobilisation: a comparison between four videolaryngoscopes and the Macintosh laryngoscope-a manikin study.

Excessive pressures exerted on the tongue during intubation may be associated with serious complications and may make intubation more difficult. The aim of this study was to evaluate five different intubating devices in the hands of experienced anaesthetists during simulated conditions of reduced cervical spine mobility. Forty senior anaesthetists participated in the study (female = 18, male = 22). The mean pressure exerted on the tongue during intubation was recorded with a standard manometer. The overall intubation success rate as well as the difference in exerted pressures between female and male anaesthetists were also assessed. The five studied devices were used by each participant and they were randomly chosen. Each anaesthetists participating in the study had over 15 years of clinical anaesthetic practice. The mean pressure exerted on the tongue during intubation was significantly lower when the videolaryngoscopes (VLs) were used (p < 0.0001 for each of the studied VL). There were failed intubation attempts with all of the studied devices, the highest failure rate was in the Airtraq® group, 10 in 40 (25%). Female anaesthetists exerted lower pressures during intubation with all studied devices (except the Airtraq®). However, the difference was only significant for the Macintosh laryngoscope (p = 0.0083). The blades of VLs exerted lower pressures on the tongue during intubation than the Macintosh laryngoscope blade. Their use may be associated with less complications. Furthermore, male anaesthetists exerted higher pressures on the soft tissues although this was neither statistically nor clinically significant. There was higher failed intubation rate in the male anaesthetist group.

Unanticipated difficult airway management in children - the consensus statement of the Paediatric Anaesthesiology and Intensive Care Section and the Airway Management Section of the Polish Society of Anaesthesiology and Intensive Therapy and the Polish So.

Tracheal intubation may be defined as an artificial airway established in order to provide mechanical ventilation of the lungs during surgical procedures under general anaesthesia, treatment in an intensive care unit, as well as in emergency situations. Difficulties encountered during intubation may cause hypoxia, hypoxic brain injury and, in extreme situations, may result in the patient's death. There may be unanticipated and anticipated difficult airway. Children form a specific group of patients as there are significant differences in both anatomy and physiology. There are some limitations in equipment used for the airway management in children. There are only few paediatric difficult airway guidelines available, some of which have significant limitations. The presented algorithm was created by a group of specialists who represent the Polish Society of Anaesthesiology and Intensive Therapy, as well as the Polish Neonatology Society. This algorithm is intended for the unanticipated difficult airway in children and can be used in all age groups. It covers both elective intubation, as well as rescue techniques. A guide forms an integral part of the algorithm. It describes in detail all stages of the algorithm considering some modifications in a specific age group, e.g. neonates. The main aim of Stage I is to optimise conditions for face mask ventilation, laryngoscopy and intubation. Stage IIA focuses on maximising the chances of successful intubation when face mask ventilation is possible. Stage IIB outlines actions aimed at improving face mask ventilation. Stage IIIA describes the use of a SAD (Supraglottic Airway Device) during effective face mask ventilation or in a CICV (Cannot Intubate, Cannot Ventilate) situation. Stage IIIB outlines intubation through a SAD. Stage IV describes rescue techniques and outlines possible options of either proceeding with surgery or postponing it, depending on clinical situation.

Airway Management with Cervical Spine Immobilisation: A Comparison between the Macintosh Laryngoscope, Truview Evo2, and Totaltrack VLM Used by Novices--A Manikin Study.

Airway management in patients with suspected cervical spine injury plays an important role in the pathway of care of trauma patients. The aim of this study was to evaluate three different airway devices during intubation of a patient with reduced cervical spine mobility. Forty students of the third year of emergency medicine studies participated in the study (F = 26, M = 14). The time required to obtain a view of the entry to the larynx and successful ventilation time were recorded. Cormack-Lehane laryngoscopic view and damage to the incisors were also assessed. All three airway devices were used by each student (a novice) and they were randomly chosen. The mean time required to obtain the entry-to-the-larynx view was the shortest for the Macintosh laryngoscope 13.4 s (±2.14). Truview Evo2 had the shortest successful ventilation time 35.7 s (±9.27). The best view of the entry to the larynx was obtained by the Totaltrack VLM device. The Truview Evo2 and Totaltrack VLM may be an alternative to the classic Macintosh laryngoscope for intubation of trauma patients with suspected injury to the cervical spine. The use of new devices enables achieving better laryngoscopic view as well as minimising incisor damage during intubation.

[Advanced methods of prehospital bleeding management based on the experience and standards of tactical medicine]. / Zaawansowane metody tamowania krwotoku w warunkach przedszpitalnych w oparciu o doswiadczenia i standardy medycyny taktycznej.

Hemostatic agents are currently used in the form of special granules or soaked gauze. Their use is particularly advantageous in difficult body location (e.g. on neck, armpit or groin), where other methods of bleeding control are impossible to use or fail. In a tactical environment tranexamic acid received first class recommendation for use in case of severe bleeding in the US Army. Its application should be considered in case of traumatic amputation, penetrating chest and abdominal trauma or hemorrhagic shock. The aim of the implementation of hypotensive resuscitation is to maintain perfusion of vital organs in patient with hypovolemia, without excessive fluid infusion. Modern method of bleeding control in combat condition are compression clamps. The purpose of these devices is to compress blood vessel by external pressure pads, especially in difficult to access arteries and large veins in the pelvis or in the distal abdominal aorta.

[Modern methods of prehospital bleeding management based on the experience and standards of tactical medicine]. / Wspólczesne metody tamowania krwotoku w warunkach przedszpitalnych w oparciu o doswiadczenia i standardy medycyny taktycznej.

Isolated limb hemorrhage represents 60% of avoidable deaths and remains the leading cause of death in combat zone. Ideal tourniquet must be light, durable and cheap. They should completely stop the flow of arterial blood in the limb, and their attachment should be quick and easy. Tourniquets applied in correct location save lives by stopping the bleeding. Their use in civil environment appear to be particularly relevant in the mass casualties events. Modern bandages used by the military, were designed mostly in the form of an elastic bandage, which attachment has to be easy and quick. Sequential wrapping of elastic dressing around the wound produces compressive force which aim is to stem the bleeding by pressing vessel from the outside. Dressings are made of materials which adhere well to the wound, causing the seal and leave no fragments in the injured tissue. The combination of all components enables fast and effective application of the dressing in the most demanding conditions.