[System and skill utilization in an Austrian emergency physician system: retrospective study]. / System- und Fertigkeitseinsatz in einem österreichischen Notarztsystem: retrospektive Studie.

BACKGROUND: The continuous rise in calls for emergency physicians and the low proportion of indicated missions has led to a loss of job attractiveness, which in turn renders services in some areas unable to sufficiently staff units. This retrospective analysis evaluated the frequency of emergency and general medical interventions in a ground-based emergency physician response system. METHODS: A retrospective analysis of anonymized data from the electronic documentation system of the emergency physician response unit at the Medical University of Graz was carried out. Calls answered by emergency physicians between 2010 and 2018 were extracted, measures carried out were evaluated and categorized into three groups: specific emergency interventions (category I), general medical interventions (category II) and no medical activity (category III). The frequency of occurrence of these categories was compared and incidences of individual measures per 100,000 inhabitants were calculated. RESULTS: A total of 15,409 primary responses and 322 secondary transports were extracted and analyzed. The annual rate of system activation rose almost continuously from 1442 calls in 2010 to 2301 calls in 2018. The 3687 (23.4%) cancellations resulted in 12,044 patient contacts. Of these, 2842 (18%) calls were coded as category I, 7372 (47%) as category II and 5518 (35%) as category III. The frequency of specific emergency measures and general medical interventions was estimated at 157/100,000 and 409/100,000 inhabitants, respectively. CONCLUSIONS: No specific emergency physician interventions were required in the majority of call-outs. The current model of preclinical care does not appear to be patient-oriented and efficient. Furthermore, the low proportion of critically ill and injured patients already leads to a reduction in attractiveness for emergency physicians and may introduce the threat of quality issues due to insufficient routine experience and lack of training.

[Reform of emergency physician training in Austria : Finally up to date?] / Reform der Notarztausbildung in Österreich : Endlich zeitgemäß?

During the last 20 years Austrian prehospital emergency medical services (EMS) have significantly improved. The structure and organization of Austrian EMS comply with European standards but training requirements for prehospital EMS physicians are insufficient when compared with other countries. Although some EMS systems follow the German or Swiss postgraduate training concepts, the legal requirements in Austria defining the scope of mandatory training for physicians in the prehospital setting are only minimal. Thus, besides board certification as a general practitioner or specialist of any discipline, the only formal requirement is a 1-week theoretical course comprising some manikin simulations. Experience in anesthesia or intensive care medicine is still not mandatory. The Austrian Society of Anesthesiology, Resuscitation and Intensive Care Medicine (ÖGARI) drafted a reform paper in 2009, which was adapted by the Austrian Chamber of Physicians, section of emergency medicine, and subsequently presented to the Austrian Ministry of Health. Due to the slowness of the legislation process, the relevant § 40 of the Austrian Physician 's Act is still unchanged. In the meantime, Austrian specialist training regulations were restructured in 2015 with significant consequences. Due to changes in the residency programs, board certification and subsequent full working permit becomes more difficult to obtain, thus further aggravating the shortage of emergency physicians in Austria. In order to counteract the threatening shortage of prehospital EMS physicians, the ÖGARI section of emergency medicine was requested by the Ministry of Health to develop a reasonable model for how physicians could be qualified and subsequently employed in EMS prior to full board certification. Presently, the Austrian Ministry of Health, the Chamber of Physicians and medical societies are in discussion on whether this approach might fit into the legal framework. This manuscript details the development and present status as well as key points of an ongoing discussion on how high-quality EMS care in Austria can be safeguarded in the future or could even make it impossible.

Medición prehospitalaria del exceso de base arterial y su posible papel en la predicción del desenlace tras una parada cardiaca extrahospitalaria / Prehospital measurement of arterial base excess and its role as a possible predictor

Objetivo: La parada cardiorrespiratoria (PCR) conduce a un estado de acidosis mixtametabólica y respiratoria. Incluso tras una ventilación adecuada y la recuperación del pulso espontáneo (ROSC) la acidosis metabólica se refleja en un exceso de bases (EB).El objetivo del estudio es comprobar que el EB arterial se correlaciona con la mortalidad en el ámbito prehospitalario. Método: Se revisaron de forma retrospectiva las hojas de registro de los pacientes en PCR desde el 1 de enero de 2003 hasta 31 de diciembre de 2010. Se incluyeron 126pacientes con PCR no traumáticas en los que se obtuvo una gasometría en el curso de la reanimación cardiopulmonar (RCP). Se recogieron las siguientes variables: edad, sexo, tiempo hasta el inicio de la reanimación, causa de la PCR, ritmo inicial, duración de la reanimación, uso de trombolítico, adrenalina, bicarbonato, hipotermia terapéutica (..) (AU)

Objective: Cardiac arrest leads to a state of mixed respiratory and metabolic acidosis. Even after adequate ventilation and restoration of spontaneous circulation, metabolic acidosis as reflected by a negative base excess (BE) persists. We hypothesized that arterial BE measured in out-of-hospital cardiac arrest would be significantly associated with prehospital mortality. Methods: We retrospectively reviewed all protocol sheets of emergency medical responses to cardiac arrest in the period from January 1, 2003 to December 31, 2010. One hundred twenty-six adult non traumatic cardiac arrest patients in whom cardiopulmonary resuscitation (CPR) was attempted and an arterial blood gas sample was obtained during ongoing CPR were included for further analysis. The following data were collected: age, sex, delay, bystander or emergency medical technician CPR, cause of cardiac arrest, initial rhythm, CPR duration; use of thrombolytic therapy, epinephrine, sodium bicarbonate, and for a cooling device and blood gas sample parameters. The univariate association (..) (AU)

Prehospital fiberoptic intubation.

We present a case of a patient with severe multiple trauma who was treated at the scene by a physician-staffed trauma life support team. Due to a complete tracheal transection, a "cannot ventilate, cannot intubate"-situation occurred. The patient was then intubated using a fiberoptic bronchoscope in the prehospital setting. The current literature concerning fiberoptic intubation in emergencies is discussed.

[Virtual hepatic surgery - computer-assisted operation planning on the 3-dimensional reconstructed liver]. / Virtuelle hepatobiliäre Chirurgie - computerunterstützte Resektionsplanung an der dreidimensional rekonstruierten Leber.

Recent developments in image-based computer assistance provide an improved visualisation of the intrahepatic vascular branching system in a virtual three-dimensional model of the liver, allowing a quantitative assessment of any vascular territory. The advantages of computer-assisted resection planning refer to a better preoperative assessment of functional resectability in areas at risk for either devascularisation or impaired drainage. In selected cases, this information may have a considerable influence on operative planning, especially with regard to the extent of resection or the need for vascular reconstruction. Due to the great anatomical variability of the intrahepatic branching patterns of the right liver lobe, this seems to be particularly important in extended left hepatectomies or in repeat hepatectomy when intrahepatic vascular anatomy may be altered. The development of navigation techniques to ensure the accurate application of the preoperative planned resection line is under investigation but not available yet.

[Strategies for quality assessment of emergency helicopter rescue systems. The Graz model]. / Strategien zur Optimierung notärztlicher Kompetenz in der Flugrettung. Das Modell Graz.

PURPOSE: Preclinical emergency medical treatment necessitates a comprehensive interdisciplinary knowledge by the emergency physician as well as a high level of manual dexterity. The quality of treatment therefore depends on the level of education and continuous training in emergency medical techniques. Based on an evaluation of the frequency of life-saving interventions by a physician-staffed rescue helicopter system, strategies for in-hospital training of relevant skills are suggested. MATERIAL AND METHODS: At the outset, 10 important areas of treatment (e.g. intubation, chest tube etc.) and their frequency in emergency medical services were defined as the standard to be attained by emergency physicians within 1 year. The selection of the areas of treatment was based to some extent on international recommendations. The actual frequencies of the prehospital interventions were compared to the required minimum numbers by retrospective analysis of the helicopter rescue database (NACA-X). RESULTS: During the observation period of 1 year, 20 emergency physicians responded to 956 prehospital emergency calls. A life-threatening condition requiring an on-site intervention occurred in only 521 (54.5%) patients, so that the majority of physicians did not perform the required minimum number of interventions. In order to maintain their level of skill, the emergency physicians were required to undertake additional training at the local university hospital. CONCLUSION: The frequency of on-site life-saving interventions in emergency medicine is insufficient to fulfill the quota necessary to maintain adequate training of emergency physicians. Only a link-up program at a hospital for primary care can ensure an adequate training level.

Arterial oxygen tension increase 2-3 h after hyperbaric oxygen therapy: a prospective observational study.

BACKGROUND: Inhalation of hyperbaric oxygen (HBO) has been reported to decrease arterial oxygen tension (PaO(2)) in the early period after exposure. The current investigation aimed at evaluating whether and to what extent arterial blood gases were affected in mechanically ventilated intensive care patients within 6 h after HBO treatment. METHODS: Arterial blood gases were measured in 11 ventilated subjects [nine males, two females, synchronized intermittent mandatory ventilation (SIMV) mode] undergoing HBO therapy for necrotizing soft tissue infection (seven patients), burn injury (two patients), crush injury (one patient) and major abdominal surgery (one patient). Blood gases were obtained with the patients in the supine position under continuous analgesia and sedation before the hyperbaric session (baseline), during isopression, after decompression, after each transport, and 1, 2, 3 and 6 h after exposure. Heart rates and blood pressures were recorded. Intensive care unit (ICU) ventilator settings remained unchanged. Transport and chamber ventilator settings were adjusted to baseline with maintenance of tidal volumes and positive end-expiratory pressure (PEEP) levels. The hyperbaric protocol consisted of 222.9 kPa (2.2 absolute atmospheres) and a 50-min isopression phase. The paired Wilcoxon's test was used. RESULTS: Major findings (median values, 25%/75% quartiles) as per cent change of baseline: PaO(2) values decreased by 19.7% (7.0/31.7, P < 0.01) after 1 h and were elevated over baseline by 9.3% (1.5/13.7, P < 0.05) after 3 h. SaO(2), alveolar-arterial oxygen tension difference and PaO(2)/FiO(2) ratio behaved concomitantly. Acid-base status and carbon dioxide tension were unaffected. CONCLUSION: Arterial oxygen tension declines transiently after HBO and subsequently improves over baseline in intensive care patients on volume-controlled mechanical ventilation. The effectiveness of other ventilation modes or a standardized recruitment manoeuvre has yet to be evaluated.

The acute coronary syndrome--pre-hospital diagnostic quality.

BACKGROUND AND OBJECTIVE: In the Austrian emergency medical service (EMS), emergency medical technician-staffed and physician-staffed vehicles are in operation. Patients with suspected acute coronary syndromes (ACS) are treated in the pre-hospital phase and transported to the hospital by an emergency physician (EP). This study evaluates the diagnostic performance of EPs in ACS and the impact of this emergency system on the outcome of ACS in an urban area. DESIGN: Retrospective case control study. METHODS: All protocol sheets from the emergency physicians were searched for the diagnosis of ACS. The database of the emergency department (ED) was searched for patients with ACS as an admission diagnosis or ACS as discharge diagnosis. For patients admitted to an intensive care unit (ICU), the medical history from the ICU was reviewed. According to the diagnosis and the aggressiveness of therapy, patients were divided in five categories of severity at each stage of care (pre-hospital category, ED category, ICU category). RESULTS: A total of 3585 patients was analysed. Only 17.8% of the patients with ACS as the admission diagnosis and 20.3% of the patients with ACS as the discharge diagnosis were transported by an EP. 46.8% of the ACS diagnosis by EPs were confirmed in hospital. Patients transported by EPs showed a higher all-cause mortality in hospital (1.6% vs. 0.6%; p=0.011). There was no significant correlation between the pre-hospital category of patients treated by EPs and the ED category. When a 12-lead-electrocardiogram was recorded, the correlation improved slightly (rho: 0.139; p=0.006). CONCLUSIONS: The percentage of ACS patients transported to hospital by an EP is very low, and EPs seem to be "over-aware" in the diagnosis of ACS.

The influence of lunar phenomena on the incidence of emergency cases.

It is widely believed that the incidence of specific emergency cases shows clustering during long observation periods. Though there is no scientific proof, many physicians and other emergency staff believe in influences of the moon or the signs of the zodiac. The aim of our retrospective study over 6 years was to evaluate (a) if there are any statistically documented peaks of frequency of emergency cases at all, and (b) if they can be linked to lunar phenomena. We evaluated all three aspects of the moon: The 'synodic' moon (=lunar phases), the 'sideric' moon (=distance between moon and the earth) and the moon in her relation to the signs of the zodiac (=influence of the zodiac). A total of 11134 patients entered the study. We found highly significant clusters of emergency calls, mainly for lung disorders. However, neither aspect of the moon showed the slightest correlation with the frequency of emergency calls (sideric month (P=0.99), synodic month (P=0.85) and zodiac (P=0.85)). Trigonometric regression with the period of the anomalistic month (P=0.173) and with the synodic month (P=0.28) did not show any influence of the moon on emergency in either cases. Though our retrospective data analysis documented clustering of emergency cases, any influence of the moon and the signs of the zodiac can be definitely ruled out.

Hemodynamic and oxygenation profiles in the early period after hyperbaric oxygen therapy: an observational study of intensive-care patients.

BACKGROUND: We studied whether hemodynamic and oxygenation profiles are altered in critically ill patients after exposure to hyperbaric oxygen (HBO). METHODS: Ten intensive-care patients (two females, eight males) undergoing HBO treatment after major abdominal surgery, after burn injury and after CO poisoning were included. All subjects were put on mechanical ventilation and received continuous sedation, and had HBO treatment at 2.2 absolute atmospheres for 50 min. DESIGN: Observational prospective study, and repeated measure design. RESULTS: Hemodynamic and oxygen transport patterns were determined before (C0), 1 h (C1) and 2 h (C2) after HBO therapy with continuous cardiac output dual oximetry pulmonary arterial catheter, a central venous and radial arterial line. Data were analyzed with non-parametric repeated measure analysis. Key results are expressed as a percentage of baseline (C0 values correspond to 100%) at C1 and C2 (median values, lower and upper limit of confidence interval): cardiac index [C1: 105% (98-135), C2: 99% (91-117), P = 0.19], systemic (P = 0.62) and pulmonary vascular (P = 0.76) resistance indices were unchanged, but pulmonary venous admixture (Qs/Qt) increased [C1: 173% (112-298), C2: 140% (92-241), P = 0.00002)] and arterial oxygen tension decreased [C1: 76% (67-94), C2: 82% (72-112), P = 0.010]. CONCLUSION: The hemodynamic profile remained unaffected. The increase in Qs/Qt and the decrease in PaO2 may be attributed to the inhalation of HBO, and both are reversible.

Comparison of lactate or BE during out-of-hospital cardiac arrest to determine metabolic acidosis.

During cardiopulmonary resuscitation, pH and base excess (BE) decrease to a variable degree due to metabolic acidosis. The main cause has been shown to be lactate, which cannot be eliminated sufficiently because of low perfusion during cardiac massage. Both BE and lactate can be measured in the prehospital phase. The aim of the study was to determine if BE and lactate are comparable variables during cardiopulmonary resuscitation (CPR) and if the measurement of lactate level alone would be sufficient to determine the patient's metabolic status and sufficiently reliable to determine the administration of buffer solutions. During the observation period, we registered 31 patients (21 males, ten females) who were resuscitated according to European Resuscitation Council recommendations, who had blood gas analysis and lactate levels measured in blood taken by arterial puncture or arterial line. The first measurement from each patient was taken after primary resuscitation (within 5-20 min). The mean lactate level was 9.85+/-2.98 (range, 4.1-18.7) mmol/l, and the mean BE was -15.0+/-5.98 (range, 5.5 to -24.3). There were statistically significant correlations between the lactate level and BE and pH (linear correlation, r=-0.673, P<0,001 and r=-0,683, P<0,001, respectively), but not with pO2 and pCO2. The receiver-operated curve analysis showed that a cut-off point of 7.0 mmol/l lactate indicates a BE below -10 with a sensitivity of 96% and a specificity of 67%. Lactate measurement is a valuable tool to determine metabolic acidosis during CPR and may be able to replace blood gas analysis in this situation.

Differential lung ventilation and emergency hyperbaric oxygenation for repair of a tracheal tear.

PURPOSE: To report the anaesthetic management of a case of tracheal rupture, using different types of ventilation and additional hyperbaric oxygenation (HBO). CLINICAL FEATURES: An 8 cm postintubation tracheal tear was repaired in a 66-yr-old woman with acute myocardial reinfarction, mediastinal and subcutaneous emphysema, cardiac failure and unrecognized lymphoma. Intraoperative monitoring included dual oximetry: arterial (SaO2) and mixed venous saturations (SvO2). Maintenance of free surgical access and a series of life-threatening events like dislocation of the jet catheter required many ventilation modes. An episode of supraventricular tachycardia was interrupted by cardioversion. Differential lung ventilation with a combination of conventional and high-frequency jet ventilation (HFJV) modes preserved oxygenation (PO2 139.2 mm Hg, PCO2 42.4 mm Hg, FiO2 1.0) until acute tube obstruction and decrease of saturation values (SaO2 58%, SvO2 45%) required emergency HBO: immediate cardiac and respiratory stabilization was provided by double-lung HFJV and apneic oxygenation under hyperbaric conditions at 2.5 atmospheres absolute for 35 min (SaO2 100%). The patient recovered from surgery but died of non-Hodgkin lymphoma. CONCLUSION: The combination of different ventilation modes including HFJV and the additional use of HBO resulted in sufficient oxygenation during tracheal repair.

Fusion of angiography and intravascular ultrasound in vivo: establishing the absolute 3-D frame orientation.

Data fusion of biplane angiography and intravascular ultrasound (IVUS) facilitates geometrically correct reconstruction of coronary vessels. The locations of IVUS frames along the catheter pullback trajectory can be identified, however the IVUS image orientations remain ambiguous. An automated approach to determination of correct IVUS image orientation in three-dimensional space is reported. Analytical calculation of the catheter twist is followed by statistical optimization determining the absolute IVUS image orientation. The fusion method was applied to data acquired in patients undergoing routine coronary intervention, demonstrating the feasibility and good performance of our approach.

A double-blind, controlled clinical trial of homeopathy and an analysis of lunar phases and postoperative outcome.

OBJECTIVE: To use scientific methods to evaluate 2 claims made by practitioners of alternative medicine. DESIGN: A placebo-controlled, double-blind study of homeopathy in children with warts, and a cohort study of the influence of lunar phases on postoperative outcome in surgical patients. SETTING: Outpatients of a dermatology department (homeopathy study) and inpatients evaluated at an anesthesiology department (lunar phases). SUBJECTS: Sixty volunteers for the homeopathy study and 14,970 consecutive patients undergoing surgery under general anesthesia for the lunar phase study. INTERVENTIONS: Treatment of children with warts with individually selected homeopathic preparations (homeopathic study); surgical procedures including abdominal, vascular, cardiac, thoracic, plastic, and orthopedic operations and assessment of the lunar phase at the time of operation (lunar phase study). MAIN OUTCOME MEASURES: Reduction of area occupied by warts by at least 50% within 8 weeks; death from any cause within 30 days after surgery. RESULTS: Nine of 30 subjects in the homeopathy group and 7 of 30 subjects in the placebo group experienced at least 50% reduction in area occupied by warts (chi 2 = 0.34; P = .56); the mortality rate was 1.20% in patients operated on during waxing moon and 1.33% in patients operated on during waning moon (chi 2 = 0.49; P = .50). CONCLUSIONS: Statements and methods of alternative medicine--as far as they concern observable clinical phenomena--can be tested by scientific methods. When such tests yield negative results, as in the studies presented herein the particular method or statement should be abandoned. Otherwise one would run the risk of supporting superstition and quackery.

[Preclinical blood gas analysis. 2. Experience with three blood gas analyzers in emergency care]. / Die präklinische Blutgasanalyse. Teil 2: Erfahrungen mit 3 Blutgasanalysegeräten im Notarztdienst.

UNLABELLED: Within the last few years the use of Point-of-Care Analyzers increased. These testing is primarily performed in the emergency room, intensive care units, and in the operating room using small portable analyzers. The fact of being transportable and working with rechargeable or changable batteries and disposable cartridges caused us to use blood gas analysis in the prehospital setting. METHODS: We tested three available blood gas analyzers: AVL OPTI 1, IRMA Blood Analyzer and the i-Stat Portlab System. All analyzers work with single-use cartridges and the calibration procedure is automatic. The AVL OPTI 1 uses a calibration gas and sucks in the blood by itself. The IRMA and the i-Stat system use a containing calibration gel, which must be removed from the sensory by injecting the blood sample. In all analyzers the results appear within 2-4 min on the screen. The OPTI 1 and the IRMA are able to print out the results automatically, the i-Stat uses an additional printer connected over an infrared adapter. RESULTS: During the observation period of 2 years more than 320 prehospital blood gas analyses were performed (200 with the OPTI 1.70 with IRMA and 50 with the i-Stat). All devices served their purpose. The main problems appeared with the application of the blood samples at the IRMA and the i-Stat. Because of this intricate procedures 21.4% and 20% of all tries failed. The time spent on the measurement was 2 to 5 minutes. CONCLUSIONS: All tested devices worked satisfactorily. Relating to the safety, the performance and the use the AVL OPTI 1 has to become the best notes. But this system is much more bigger and heavier than the others, especially the i-Stat Blood analyzer.

[Preclinical blood gas analysis. 1. The value of preclinical blood gas analysis]. / Die präklinische Blutgasanalyse Teil 1: Der Stellenwert der präklinischen Blutgasanalyse.

UNLABELLED: Prehospital blood gas analysis is a new method in out-of-hospital emergency care. In a prospective pilot study we evaluated the feasibility of prehospital compensation of severe acidosis relying on different monitoring systems to evaluate patients oxygen, carbon dioxide or acid-base status, respectively. METHODS: With the help of arterial blood gas checks taken at the site of the emergency, the acid base status of patients undergoing out of hospital cardiopulmonary resuscitation was analysed. The values derived from the first arterial puncture were used to determine the presence and the type of acidosis. The data of the arterial blood gas checks were set into relation with the time elapsed since the beginning of resuscitation and they were compared with end-tidal CO2. RESULTS: During the observation period 26 blood gas analyses from patients who had out-of-hospital resuscitation because of cardiac arrest were done. Twenty three patients had severe acidosis (pH range < 6.9 to 7.31), one had alkalosis (pH 7.51). Only two had an arterial pH within normal range. The pCO2 was variable (range: 24 to 97 mm Hg). The correlation of pH with time from the beginning of resuscitation to arterial puncture was poor (r = 0.407, p < 0.05). There was no correlation between pH and BE (r = 0.267) or pH and pCO2, (r = 0.016) respectively. Prehospital capnometry had a poor correlation with arterial pCO2 in most emergency patients. Only patients with respiratory disturbances of extrapulmonary origin showed a good correlation between end-tidal CO2 and the arterial pCO2. In severely ill patients the arterio-alveolar CO2-difference was unexpectedly high (> 15 mm Hg). In four patients resuscitation was not successful until compensation of an unexpectedly severe acidosis based upon the findings from blood-gas analysis had been performed. CONCLUSIONS: Arterial blood gas analysis proved to be helpful in the optimal management of out of hospital cardiac arrest. The incidence of severe acidosis in patients undergoing cardiopulmonary resuscitation was 80%. The probability of developing acidosis was found to increase slightly depending on the time elapsed since the beginning of CPR. The application of a calculated buffering of acidosis with sodium bicarbonate showed a good outcome in selected cases. In emergency patients alternative methods fail to detect severe disturbances of the patients oxygen and/or carbon dioxide status and the acid-base balance. Management of prehospital cardiac arrest could be optimized by the routine use of blood gas analysis.

Operations on patients deemed "unfit for operation and anaesthesia": what are the consequences?

BACKGROUND: The decision "patient unfit for anaesthesia and operation" is likely to cause a delay of the scheduled operation. This retrospective evaluation was done: 1) to determine the correctness of preoperative tentative diagnoses of coexisting diseases making anaesthesia and operation excessively risky in relation to the physician's training status; 2) to examine the question of whether preoperative medical management modified according to the anaesthesiologist's suggestions had a positive impact on the perioperative course. METHODS: The medical records of patients scheduled for elective non-cardiac surgery who were rated "unfit for operation and anaesthesia" were evaluated. The accuracy of the tentative diagnoses was examined for relation to the training status of the anaesthesiologists. The preoperative management was tested for its impact on postoperative outcome. RESULTS: During the observation period 16,122 patients underwent preoperative anaesthesiological assessment; 1021 (6.3%) were initially considered to be unfit for operation and anaesthesia. The records of 807 patients were available for review. The accuracy of the tentative diagnoses was 70%, and was not significantly affected by the training status of the physicians (P = 0.022). Four hundred and seventeen patients were excluded from the second part of the investigation (discharged without operation, underwent operation using local anaesthesia or tentative diagnosis not confirmed). Three hundred and ninety patients were operated under general anaesthesia. Group I (n = 216) was managed according to the anaesthesiologist's suggestions and was found to have a significantly lower complication rate (18.1%) than group II (n = 174) in which the suggestions from the preoperative assessment were ignored (32.2%; P < 0.05). The perioperative mortality rate in group I was 2.3% compared with 5.2% in group II (n.s.; P > 0.05). CONCLUSIONS: We conclude that the anaesthesiology decision "patient unfit for operation and anaesthesia" has a high accuracy, independent of the anaesthesiologist's training status, and that preoperative medical management significantly reduces complications.

Iatrogenic ruptures of the tracheobronchial tree.

We did a retrospective study in 12 patients with iatrogenic tracheal or tracheobronchial ruptures treated since 1975. Ten female subjects, one male subject, and one child (age range, 8 to 72 years), all of whom had undergone intratracheal intubation, were admitted to the hospital. Four patients had been intubated with a double-lumen catheter (two Carlens type with carinal spur, two Robertshaw without spur), and seven had had "high volume-low pressure" tubes, placed under emergency conditions in three of those seven cases. In one further case, an unsuccessful attempt of percutaneous tracheostomy had been made. The localization of the ruptures (all of them longitudinally in the membranaceous wall; length, 2 to 13 cm; mean, 7 cm) comprised both cervical and intrathoracic trachea in seven, the intrathoracic trachea in three instances, and the left main stem bronchus in two cases. Ten patients had mediastinal and subcutaneous emphysema, seven presented with a pneumothorax, and nine had intratracheal bleeding. The interval until the onset of symptoms and diagnoses differed widely: twice diagnoses were made intraoperatively, during thoracic surgery. The longest interval until diagnosis was 5 days; only then did the patient show subcutaneous emphysema and have retrosternal pain. All patients had surgical repair. Nine recovered without sequelae, and three died of septic multiorgan failure.

A comparison of the end-tidal-CO2 documented by capnometry and the arterial pCO2 in emergency patients.

Satisfactory artificial ventilation is defined as sufficient oxygenation and normo- or slight arterial hypocarbia. Monitoring end tidal CO2 values with non-invasive capnometry is a routine procedure in anaesthesia, emergency medicine and intensive care. In anaesthesia the ventilation volume is adjusted to the capnometric end tidal CO2 (ETCO2), taking into account a normal variation from the pACO2 of 3-8 mmHg. We evaluated the usefulness and practicability of using ETCO2 for correctly adjusting ventilation parameters in prehospital emergency care, by comparing arterial pCO2 and ETCO2 of 27 intubated and ventilated patients. We used the side-stream capnometry module of the Defigard 2000 (Bruker, ChemoMedica Austria) and a portable blood gas analyzer (OPTI 1, AVL Graz, Austria). Evaluation of the group of patients as a whole showed that there was no correlation whatsoever between the end expiratory and arterial CO2. Dividing the patients into three subgroups (1, During CPR; II, respiratory disturbances of pulmonary and cardiac origin; III, extrapulmonary respiratory disturbances), we found that only patients without primary cardiorespiratory damage showed a slight, but not statistically significant, correlation. This can be explained by the fact that almost any degree of cardiorespiratory failure causes changes of the ventilation-perfusion ratio, impairing pulmonary CO2 elimination. We conclude, that the ventilation of emergency patients can only be correctly adjusted according to values derived from an arterial blood gas analysis and ETCO2 measurements cannot be absolutely relied upon for accuracy except, perhaps, in patients without primary cardiorespiratory dysfunction.