[Hurricane Ike and the University of Texas Medical Branch Hospital's evacuation]. / Hurrikan Ike. Evakuierung des Universitätsklinikums der University of Texas Medical Branch.

In September 2008 the University of Texas Medical Branch at Galveston was threatened by Hurricane Ike. The incident commander decided to evacuate the hospital. This is a report on how this was accomplished and the lessons learned. An adequate disaster preparedness plan, sufficient logistics, a comprehensive incident command center and the use of complex communication systems were crucial for success. Within 11 h a total of 469 patients had been evacuated using 143 ambulances, 23 helicopters, 2 fixed wing aircraft, buses and numerous passenger vans. The authors encourage physicians, as responsible members of the health care team, to be prepared to respond to disasters.

Radiological validation of tracheal tube insertion depth in out-of-hospital and in-hospital emergency patients.

We performed a 5-year, retrospective study using records of 1081 patients admitted to the trauma emergency room at a University Hospital to investigate the occurrence of tracheal tube malpositioning after emergency intubation in both the inpatient and outpatient settings, using chest radiographs and CT scans in the trauma emergency room. Prehospital patients and inpatients referred from peripheral hospitals were compared. This study showed that tracheal tube misplacements occur with an incidence of 18.2%, of which almost a third (5.7%) were placed in a main bronchus. We further show that tracheal intubation in emergency patients approximates the misplacement rates in the prehospital or in-hospital settings. We speculate that the skill level of the operator may be critical in determining the success of tracheal intubation. Based on our findings, all efforts should be made to verify the tube position with immediate radiographic confirmation after admission to the emergency room.

[Pathophysiology of acute lung injury in severe burn and smoke inhalation injury]. / Pathophysiologie des akuten Lungenversagens bei Schwerbrandverletzten mit Inhalationstrauma.

This review article describes the pathophysiological aspects of acute lung injury (ALI) and acute respiratory distress syndrome (ARDS), induced by combined burn and smoke inhalation and examines various therapeutic approaches. The injury results in a fall in arterial oxygenation as a result of airway obstruction, increased pulmonary transvascular fluid flux and loss of hypoxic pulmonary vasoconstriction. The changes in cardiopulmonary function are mediated by reactive oxygen and nitrogen species. Nitric oxide (NO) is generated by both inducible and constitutive isoforms of nitric oxide synthase (NOS). Recently, neuronal NOS emerged as a major component within the pathogenesis of ARDS. NO rapidly combines with the oxygen radical superoxide to form reactive and highly toxic nitrogen species such as peroxynitrite. The control of NO formation involves poly(ADP-ribose) polymerase and its ability to up-regulate the activity of nuclear transcription factors through ribosylation. In addition, present data support a major role of the bronchial circulation in the injury, as blockage of bronchial blood flow will also minimize the pulmonary injury. Current data suggest that cytotoxins and activated cells are formed in the airway and carried to the parenchyma.

Incidence and duration of residual paralysis at the end of surgery after multiple administrations of cisatracurium and rocuronium.

In a randomised, controlled, double-blind, multicentre trial in 338 patients, we assessed the incidence of residual paralysis following administration of cisatracurium or rocuronium. The incidence at the end of surgery was significantly lower in patients treated with rocuronium (62 of 142 patients, 44%) than in those given cisatracurium (99 of 175 patients, 57%) (p < 0.05). In contrast, with rocuronium the mean (SD) time between skin closure and extubation was 28 (28) min vs 18 (19) min for cisatracurium, and the duration 0.9 (time from administration of last top-up dose to recovery of the train-of-four ratio to 0.9) was significantly longer and more variable for rocuronium than for cisatracurium. Thus, after repeated administration, the duration and variability of duration of action are greater with rocuronium compared with cisatracurium. These pharmacodynamic differences do not necessarily translate into a higher incidence of residual paralysis, because clinicians compensate for the longer duration of action and variability of rocuronium by terminating administration of the neuromuscular blocking earlier.

Anti-emetic prophylaxis with oral tropisetron and/or dexamethasone.

BACKGROUND: The corticosteroid dexamethasone and the serotonine3 -antagonist tropisetron are both effective drugs for the prophylaxis of post-operative nausea and vomiting (PONV) when given intravenously. The aim of this trial was to evaluate the oral use of both drugs as part of a routine oral premedication and to compare their single and combined effectiveness. MATERIALS AND METHODS: In this randomized, placebo-controlled, double-blind study, 320 inpatients with a moderate-high risk of PONV (> or = 40% according to two validated risk scores) received an oral premedication 1-2 h pre-operatively with placebo, a fixed dose of tropisetron 5 mg, dexamethasone 8 mg, or a combination of both drugs. A standardized general anaesthesia was performed, including benzodiazepine premedication, propofol, rocuronium, desflurane in air/O2, fentanyl or sufentanil followed by a continuous infusion of remifentanil. Post-operative analgesia and anti-emetic rescue medication were standardized. The main outcome measures were the severity of PONV within the first 24 h (rated by a standardized scoring algorithm). The incidence of PONV was used as the secondary outcome. RESULTS: Data from 310 patients were analyzed. The mean severity score in the placebo-, tropisetron-, dexamethasone- and the combined-groups was 1.37, 0.8, 0.8 and 0.38, respectively. The incidence of PONV of any severity was 59.2%, 37.5%, 40% and 22.8%, respectively. The reduction of the incidence and the severity of PONV were statistically significant with all three interventions. Results from additional analyses suggested that both drugs were equally effective and that there was a simple additive effect of tropisetron and dexamethasone compared with placebo. CONCLUSION: Oral tropisetron and dexamethasone were both equally effective in reducing the severity and incidence of post-operative nausea and vomiting. The latter could be reduced by approximately 35% in a population of moderate-high risk for PONV. Both drugs had an additive effect. However, even in the combination group there still remained an unacceptably high incidence of PONV of more than 20%. This highlighted the need for a multimodal anti-emetic approach in high-risk patients and the importance of treatment of PONV.

[Treatment strategies for acute smoke inhalation injury]. / Behandlungsstrategien des akuten Rauchgasinhalationstraumas.

Most fatalities from fires are not due to burns, but are a result of inhalation of toxic gases produced during combustion. Fire produces a complex toxic environment, involving flame, heat, oxygen depletion, smoke and toxic gases such as carbon monoxide and cyanide. As a wide variety of synthetic materials is used in buildings, such as insulation, furniture, carpeting, electric wiring covering as well as decorative items, the potential for poisoning from inhalation of products of combustion is continuously increasing. The present review describes the pathophysiologic effects from smoke inhalation injury as well as strategies for emergency treatment on scene and in the intensive care setting.

Positive end-expiratory pressure ventilation increases extravascular lung water due to a decrease in lung lymph flow.

Positive end-expiratory pressure (PEEP) is used to improve gas exchange, increase functional residual capacity, recruit air spaces, and decrease pulmonary shunt in patients suffering from respiratory failure. The effect of PEEP on extravascular lung water (EVLW), however, is still not fully understood. This study was designed as a prospective laboratory experiment to evaluate the effects of PEEP on EVLW and pulmonary lymph flow (QL) under physiologic conditions. Twelve adult sheep were operatively prepared to measure haemodynamics of the systemic and pulmonary circulation, and to assess EVLW In addition, the lung lymphatic duct was cannulated and a tracheostomy performed. The animals were then mechanically ventilated in the awake-state without end-expiratory pressure (PEEP 0). After a two-hour baseline period, PEEP was increased to 10 cmH2O for the duration of two hours, and then reduced back to 0 cmH2O. Cardiopulmonary variables, QL, and arterial blood gases were recorded intermittently; EVLW was determined two hours after each change in PEEP. The increase in PEEP resulted in a decrease in QL (7 +/- 1 vs 5 +/- 1 ml/h) and an increase in EVLW (498 +/- 40 vs 630 +/- 58 ml; P<0.05 each) without affecting cardiac output. As PEEP was decreased back to baseline, QL increased significantly (5 +/- 1 vs 10 +/- 2 ml/h), whereas EVLW returned back to baseline. This study suggests that institution of PEEP produces a reversible increase in EVLW that is linked to a decrease in QL.