An unexpected ending: brain death following acute severe asthma.

A 56-year-old woman presented to our hospital with acute severe asthma. As a consequence of severe refractory airflow limitation, moderate hypercapnia ensued for several days. Unexpectedly, the patient died as a result of brain stem herniation, in the absence of hypoxaemia, arterial hypotension or an intracranial mass lesion. We discuss the mechanisms that may have precipitated severe intracranial hypertension resulting in brain death, and the possible methods to detect and avoid such a devastating consequence.

The F.A.S.T.E.R. trial. Focused assessment by sonography in trauma during emergency retrieval: a feasibility study.

INTRODUCTION: This feasibility study aimed to establish if retrieval physicians can overcome the transport environment and obtain F.A.S.T. (focused assessment by sonography in trauma) images of suitable quality during patient retrieval in rotary wing aircraft such that diagnostic interpretation of free intra-abdominal fluid or pericardial fluid would be possible. MATERIALS AND METHODS: During a 6-month trial period, one of three retrieval physicians attempted to obtain the standard four quadrant F.A.S.T. views using a portable ultrasound on patients they retrieved. Ultrasound images were obtained whilst in-flight in a rotary wing aircraft. Image adequacy was assessed by the retrieval physician and by an independent blinded physician using strict clinical criteria. RESULTS: Thirty-eight patients were enrolled. Thirty-six patients had a complete F.A.S.T. scan attempted whilst a further two patients had their abdominal quadrants scanned without a pericardial view being attempted. Independent blinded physician review of scans agreed with the scanning retrieval physician that images were adequate for showing the F.A.S.T. quadrants appropriately in 143 of 150 quadrants imaged and inadequate in two. Blinded physician review disagreed with scanning physician regarding adequacy of image in 5 of 150 quadrants imaged. Scanning physicians were happy with adequacy of the view in all F.A.S.T. quadrants in 34 of the 36 patients in whom a complete F.A.S.T. was performed. Blinded physician review agreed in 30 of those cases. DISCUSSION: The physicians performing the F.A.S.T. examination, all incorporate ultrasound into their daily clinical practice thereby maintaining their skill level. This is likely to contribute to the high level of view adequacy. Independent blinded image review controlled for bias regarding view adequacy. Disagreement between scanning physician and reviewing physician assessment of view adequacy in 5 of the 150 views obtained is likely to relate to the difficulties in interpreting still ultrasound images, compared to interpreting real time images at point-of-care. There were no machine limitations. CONCLUSION: This study demonstrates that it is possible for critical care retrieval physicians to obtain adequate ultrasound F.A.S.T. images on patients using a portable ultrasound machine en-route to definitive care, in a rotary wing aircraft.

Use of point-of-care ultrasound by a critical care retrieval team.

Point-of-care ultrasound in the prehospital and retrieval environments has now become possible owing to decreased size and weight, and increasing robustness of some ultrasound machines. This report describes the initial experience of point-of-care ultrasound by an Australian critical care retrieval service using a portable ultrasound machine.

The use of point-of-care ultrasound by a critical care retrieval team to diagnose acute abdominal aortic aneurysm in the field.

The potential benefit of point-of-care ultrasound by medical retrieval teams is unclear. In the present case report, the diagnosis of an abdominal aortic aneurysm by a critical care retrieval team equipped with a portable ultrasound machine resulted in significant corrective alteration in patient management and subsequent disposition at the receiving institution.

Oxygen conservation during long-distance transport of ventilated patients: assessing the Modified Circle System.

INTRODUCTION: The Modified Circle System was developed to reduce the amount of oxygen required for long-distance transportation of ventilated patients. Formal testing of the system has never been documented. Various aspects of the system were tested, with the study broken into four parts. METHODS: Bench testing was performed with a test lung that simulated two different lung compliances. Four ventilators were tested with the system. The four parts to the study were oxygen flow rates, position of oxygen inflow, pressure drop across the system, and specific testing with the LP 10 ventilator. RESULTS: The minimum oxygen flows required to maintain forced inspiratory oxygen (FiO(2)) higher than 0.93 over a range of ventilator and lung settings was 1.5 L/min. The oxygen inflow is best connected directly to the CO(2) absorber unit. A significant pressure drop occurs across the system, which increases progressively with higher ventilator pressures. The LP 10 does not allow improved oxygen conservation when recycling gases via its air inlet port. CONCLUSION: The study provides previously unknown, clinically important information regarding the performance of the Modified Circle System.

The Bali bombing: civilian aeromedical evacuation.

After the Bali bombing on 12 October 2002, many injured Australians required evacuation to Darwin, and then to burns units around Australia. Many patients were evacuated from Denpasar by Qantas, with assistance from staff of civilian medical retrieval services. The transport of patients from Darwin to specialist burns units involved a coordinated response of civilian and military services. Some issues in responding to such disasters were identified, and a national coordinating network could improve future responses.

Blood transportation for medical retrieval services.

INTRODUCTION: Medical retrieval services resuscitate and retrieve the critically ill and injured. Lifesaving treatment includes the transfusion of red blood cells (RBCs). To ensure patient safety and maximum therapeutic benefit for the patient, the transportation of RBCs for transfusion must occur under optimal conditions. Blood shippers currently in use in Australia are principally polystyrene containers, often selected for low cost, although performance validation is becoming increasingly important. The quality of the blood to the consumer may be compromised by the use of inappropriate shippers and transport systems. METHODS: A prototype of a user-friendly soft pack blood shipper was developed and tested in various climatic conditions over 24 hour periods with the RBC temperature monitored. RESULTS: The blood shipper was validated to maintain blood temperature within an acceptable range (2 degrees to 10 degrees C (35.6 degrees-50 degrees F) for up to 16 hours during transport of ambient temperatures ranging from 8 degrees to 35 degrees C. (46.4 degrees-95 degrees F). CONCLUSION: The blood shipper provides adequate storage for blood products under a range of climatic conditions and time periods adequate for most retrieval purposes. This allows optimal blood transport system for the medical retrieval service, helping to ensure maximum patient safety and therapeutic benefit from transfusion. The validated blood shipper is also important to blood banks and blood consumers for nonretrieval blood transportation.