ABSTRACT
INTRODUCTION: Traumatic brain injury (TBI) is the leading cause of combat casualties in modern war with an estimated 20% of casualties experiencing head injury. Since the release of the Brain Trauma Foundation's Guidelines for the Management of Severe Traumatic Brain Injury in 1995, recommendations for management of TBI have included the avoidance of routine hyperventilation. However, both published and anecdotal data suggest that many patients with TBI are inappropriately ventilated during transport, thereby increasing the risk of morbidity and mortality from secondary brain injury. MATERIALS AND METHODS: Enlisted Air Force personnel with prior emergency medical technician training completing a 3-week trauma course were evaluated on their ability to provide manual ventilation. Participants provided manual ventilation using either an in-situ endotracheal tube (ETT) or standard face mask on a standardized simulated patient manikin with TBI on the first and last days of the course. Manual ventilation was provided via a standard manual ventilator and a novel manual ventilator designed to limit tidal volume (VT) and respiratory rate (RR). Participants were given didactic and hands-on training on the third day of the course. Half of the participants were given simulator feedback during the hands-on training. All students provided 2 minutes of manual ventilation with each respirator. Data were collected on the breath-to-breath RR, VT, and peak airway pressures generated by the participant for each trial and were averaged for each trial. A minute ventilation (MV) was then derived from the calculated RR and VT. RESULTS: One hundred fifty-six personnel in the trauma course were evaluated in this study. Significant differences were found in the participant's performance with manual ventilation with the novel compared to the traditional ventilator. Before training, MV with the novel ventilator was less than with the traditional ventilator by 2.1 ± 0.4 L/min (P = .0003) and 1.6 ± 0.5 L/min (P = .0489) via ETT and face mask, respectively. This effect persisted after training with a difference between the devices of 1.8 ± 0.4 L/min (P = .0069) via ETT. Both traditional education interventions (didactics with hands-on training) and simulator-based feedback did not make a significant difference in participant's performance in delivering MV. CONCLUSIONS: The use of a novel ventilator that limits RR and VT may be useful in preventing hyperventilation in TBI patients. Didactic education and simulator-based feedback training may not have significant impact on improving ventilation practices in prehospital providers.
ABSTRACT
Posterior reversible encephalopathy syndrome (PRES) is a rare neurologic disorder that has recently become more frequently diagnosed. While the exact etiology of PRES remains unclear, multiple diseases are associated with PRES. Moreover, there is increasing recognition of the association of PRES in pre-eclampsia/eclampsia with advancements in imaging techniques and increased awareness of the disorder. While pre-eclampsia/eclampsia alone presents unique perioperative challenges, PRES further complicates anesthetic management. Unfortunately, the anesthetic management for these critically ill and complex patients is not well elucidated and it is unclear whether the anesthetic choice may actually worsen neurologic symptoms. We describe two different presentations of PRES with pre-eclampsia/eclampsia, their anesthetic implications, and management.
