Trauma: development of a sub-algorithm.

BACKGROUND: Anaesthetists are regularly involved in the management of patients who have suffered trauma. Acute physiological derangements can occur at any time after the original injury, with life threatening sequelae. These problems may be complex in nature and evolve rapidly, often with an obscure aetiology, so a systematic approach to them is essential. OBJECTIVES: To examine the role of a previously described core algorithm "COVER ABCD-A SWIFT CHECK" supplemented by a specific sub-algorithm for trauma, in the management of anaesthesia involving trauma cases. METHODS: The potential performance of a structured approach for each of the trauma incidents among the first 4000 incidents reported to the Australian Incident Monitoring Study (AIMS) was compared with the actual performance as reported by the anaesthetists involved. RESULTS: There were 38 relevant reports relating to trauma in the first 4000 reports to AIMS. In 39% of these there was "emergency corner cutting", although in the majority the urgency was thought to have been more perceived than real. The previously described "core" crisis management algorithm for crises during general anaesthesia was an effective means of discovering (82%), diagnosing (68%), and correcting (66%) the majority of trauma incidents. However a sub-algorithm specific for the traumatised patient was required for unusual, obscure, or complex presentations. CONCLUSION: Although the small numbers preclude validation of the sub-algorithm, it would have successfully managed all the trauma cases reported to AIMS.

Mobile intensive care services in rural South Australia.

In the 12 years from 1984 to 1995, Adelaide-based mobile intensive care teams transported 4443 critically ill patients from rural areas in South Australia and adjacent States to tertiary-level hospitals in Adelaide. The SA Ambulance Service undertook communications, support staffing and deployment of transport. Average radial distances in 819 road missions were 71 km, in 808 helicopter missions 122 km, and in 2777 fixed-wing aircraft missions 398 km. The largest groups of patients were neonates (23%) and those with trauma (25%). Rural hospitals made 96% of the requests for intensive care transport; 4% came from ambulance or other emergency service crews at accident locations. Emergency surgical or operative obstetrical procedures were performed on 2.7% of patients before transport. One hundred and thirteen patients (2.5%) died during resuscitation or transport, with one death deemed to be preventable.

Undiagnosed post-traumatic stress disorder following motor vehicle accidents.

OBJECTIVES: To determine the pattern of emergence of post-traumatic stress disorder (PTSD) among motor vehicle accident victims and to examine the influence of PTSD on subsequent levels of disability. DESIGN: A longitudinal study of motor vehicle accident victims one month and 18 months after the accident. SUBJECTS: Twenty-four motor vehicle accident victims admitted by the trauma team at the Royal Adelaide Hospital. A 52% response rate was achieved. MAIN OUTCOME MEASURES: Post-traumatic stress disorder as diagnosed by the Diagnostic Interview Schedule and disability as measured with the Sickness Impact Profile. RESULTS: Eighteen months after their accidents, six of the 24 subjects had clinically significant PTSD and one was considered borderline. None had been previously diagnosed or treated. The group with PTSD had higher scores on all measures of psychological distress one month after the accident and were more likely to use immature psychological defences. There was no association between physical outcome (measured with the modified Glasgow Outcome Scale) at six months and subsequent diagnosis of PTSD. However, the group with PTSD had higher levels of disability on assessment with the Sickness Impact Profile, particularly in the domain of social functioning. The results suggest PTSD was associated with work-related dysfunction equal to that associated with severe physical handicap. CONCLUSION: The data from this pilot study suggest that PTSD after motor vehicle accidents is an important cause of disability, which may also become the focus for damages in litigation. Thus, there is a need for further investigation of the early patterns of distress and to design preventive programs for victims of road accidents.

The influence of renal function on the renal clearance of morphine and its glucuronide metabolites in intensive-care patients.

1. The relationships between renal creatinine clearance and the renal clearances of morphine, morphine-3-glucuronide (M3G) and morphine-6-glucuronide (M6G) were studied in fifteen intensive-care patients who were receiving morphine sulphate by constant intravenous infusion and who had diverse renal function. 2. An arterial blood sample was collected before and after a 4-5 h urine collection. Plasma and urine concentrations of morphine, M3G and M6G were measured by h.p.l.c. Plasma binding of all three compounds in drug-free plasma from healthy volunteers was determined by ultrafiltration. Measured renal creatinine clearance (CLCr,meas) was calculated from plasma and urinary creatinine concentrations (from h.p.l.c.). Also, creatinine clearance was predicted (CLCr,pred) from routine laboratory determination of plasma creatinine (Jaffe method). 3. There were significant linear relationships (P less than 0.001) between CLCr,meas and the renal clearances of morphine, M3G and M6G. The unbound renal clearance of morphine exceeded CLCr,meas (P less than 0.002) while the unbound renal clearances of M3G and M6G did not differ from CLCr,meas (P greater than 0.5). 4. In ten of the patients who received a constant infusion of morphine for at least 6 h, the dose-normalised plasma concentrations of M3G and M6G increased with decreasing CLCr,pred. Significant (P less than 0.001) relationships were observed between the reciprocal of CLCr,pred and the dose-normalised plasma concentrations of M3G and M6G. 5. The results indicate the importance of renal function in determining the renal clearances and plasma concentrations of M3G and M6G during intravenous infusion with morphine in intensive-care patients.

A prospective comparison of a percutaneous tracheostomy technique with standard surgical tracheostomy.

A prospective non-randomized study was undertaken to compare, in intensive care patients, the safety and utility of a percutaneous tracheostomy technique performed at the bedside with a surgical tracheostomy technique performed in the operating room. During a 21 month period, 153 percutaneous tracheostomies were performed. Complications occurred in 6 patients (3.9%). Secondary wound haemorrhage occurred in 4 patients and primary wound haemorrhage occurred in 2 patients. During the same period, 74 surgical tracheostomies were performed. Complications occurred in 14 patients (18.9%) which included tracheal obstruction, haemorrhage, pneumothorax, wound infection, wound breakdown and one death. In comparison to surgical tracheostomies, percutaneous tracheostomies were rapidly and easily performed at the bedside and were associated with significantly fewer complications.

A simple percutaneous tracheostomy technique.

PCT techniques have significant advantages when compared with the standard techniques of tracheostomy. We have developed an instrument that facilitates the operation of PCT, which we found increased the simplicity and safety of the procedure.