Technical and non-technical skills can be reliably assessed during paramedic simulation training.

BACKGROUND: Medical teams depend on technical skills (TS) as well as non-technical skills (NTS) for successful management of critical events. Simulated scenarios are an opportunity for presentation of similar crisis situations. The aim of this study was to test whether TS and NTS are assessable with satisfactory interrater reliability (IRR) during a regular paramedic training. METHODS: Thirty paramedics were rated by two independent observers using video-recording and previously validated checklists while managing two simulated emergency scenarios as a team of two. The observed items of the team's TS included type, order, and time of adequate medical care. The NTS were restricted to six team-oriented dimensions. The IRR was quantified by calculating the intraclass correlation coefficient (ICC). The z-transformed values of the TS and NTS were correlated by Pearson's correlation. Internal consistency was controlled using Cronbach's alpha. RESULTS: The average measures ICC for the IRR was between 0.97 [95% confidence interval (CI) 0.91-0.99] and 0.98 (95% CI 0.94-0.99) for the TS sum-score, and was 0.94 (95% CI 0.87-0.97) for the NTS sum-score; the Cronbach's alpha of this NTS sum-score was 0.86. There is a positive correlation between the normalised TS and NTS sum-scores (r=0.53; P<0.05). CONCLUSION: Assessment of TS and NTS is feasible and reliable during paramedic training in emergency scenarios. TS can be reliably assessed by one trained observer; for NTS, two trained raters provide a suitable condition for excellent observations. There is a significant positive correlation between TS and NTS.

[Vasopressin for therapy of persistent traumatic hemorrhagic shock: The VITRIS.at study]. / Vasopressin zur Therapie eines therapierefraktären traumatisch-hämorrhagischen Schocks: Die VITRIS.at-Studie.

While fluid management is established in controlled hemorrhagic shock, its use in uncontrolled hemorrhagic shock is being controversially discussed, because it may worsen bleeding. In the irreversible phase of hemorrhagic shock that was unresponsive to volume replacement, airway management and catecholamines, vasopressin was beneficial due to an increase in arterial blood pressure, shift of blood away from a subdiaphragmatic bleeding site towards the heart and brain and decrease of fluid resuscitation requirements. The purpose of this multicenter, randomized, controlled, international trial is to assess the effects of vasopressin (10 IU IV) vs. saline placebo IV (up to 3 injections at least 5 min apart) in patients with prehospital traumatic hemorrhagic shock that persists despite standard shock treatment. The study will be carried out by helicopter emergency medical service teams in Austria, Germany, Czech Republic, Portugal, the Netherlands and Switzerland. Inclusion criteria are adult trauma patients with presumed traumatic hemorrhagic shock (systolic arterial blood pressure <90 mmHg) that does not respond to the first 10 min of standard shock treatment (endotracheal intubation, fluid resuscitation and use of vasopressors) after arrival of the first emergency physician at the scene. The time window for randomization will close after 30 min of shock treatment. Exclusion criteria are terminal illness, no intravenous access, age <18 years, injury >60 min before randomization, cardiac arrest before randomization, presence of a do-not-resuscitate order, untreated tension pneumothorax, untreated cardiac tamponade, or known pregnancy. Primary study end-point is the hospital admission rate, secondary end-points are hemodynamic variables, fluid resuscitation requirements and hospital discharge rate.

Multiple-trauma management: standardized evaluation of the subjective experience of involved team members.

BACKGROUND AND OBJECTIVE: Staff attitude plays a pivotal role in quality management. The objective of the present study was to further define how interdisciplinary emergency hospital staff experience their daily work and the extent to which the professional speciality and training of an individual influences his/her assessment of multiple-trauma team performance. METHODS: The clinical staff involved in multiple-trauma emergency management of a university hospital was asked to answer a confidential questionnaire. Factorial analysis was used to identify 8 major dimensions from a total of 53 items. RESULTS: The questionnaire was returned by 128 team members. All professional groups were most dissatisfied with the dimensions 'education and training', 'work sequence between specialities' and 'communication between specialities'. Assessment of the quality of in-hospital emergency-trauma management differed significantly between professional specialities (ANOVA, F=5.2; P=0.028); surgeons gave the highest ratings for all but one dimension. Having taken an Advanced Trauma Life Support (ATLS) course influenced significantly the total rating of multiple-trauma treatments of anaesthetists and surgeons (F=5.5; P=0.024). CONCLUSIONS: The perceptions of interdisciplinary trauma team members without the completion of an ATLS training course were that they did not communicate enough with each other and that there were differences between their expectations and reality. The differences and the communication deficits were overcome in team members who had passed an ATLS course.

[Interdisciplinary emergency room management of trauma patients from the standpoint of coworkers]. / Interdisziplinäres Schockraum-Management unfallchirurgischer Patienten aus der Sicht der Mitarbeitenden.

INTRODUCTION: The purpose of this study was to examine whether staff questionnaire evaluation is useful for quality control in the emergency room (ER) setting. METHODS: Consecutive anonymous questionnaires (Likert scale 1-5) were filled out by the involved medical staff in all ER trauma cases in a university hospital from July 2002 to December 2003 (analysis of variance, P<0.05). RESULTS: In 171 ER cases, 844 staff members responded. Main criticisms concerned time management or satisfaction with personal ER training (Likert <4). Consultants rated the quality of their training significantly higher than younger doctors, two thirds of consultants vs one third of residents having passed an Advanced Trauma and Life Support course (P<0.001). Depending on responders' professional specialties and whether the situation concerned multiple trauma (Injury Severity Score >15), a significant systematic difference resulted. CONCLUSION: Our standardized staff questionnaire evaluation was revealed to be a discriminative instrument for quality management of trauma cases in the ER. To confirm these findings, correlation with clinical outcome data and further validation of the method are needed.

[The hereditary motor-sensory neuropathy Charcot-Marie-Tooth disease: anesthesiologic management--case report with literature review]. / Die hereditäre motorischsensible Neuropathie: Charcot-Marie-Tooth-Erkrankung. Anästhesiologisches Management--ein Fallbericht und eine Literaturübersicht.

A 53-year-old woman diagnosed as having hereditary motor-sensory neuropathy Charcot-Marie-Tooth (CMT) disease Type 2, underwent inguinal hernia surgery. In this patient CMT disease was manifested as distal muscle weakness and wasting. Anaesthetic experience with patients who have CMT disease is limited. Association to malignant hyperthermia is very unlikely although there is one case report that shows that there could be a relationship. We describe a total intravenous anaesthesia (TIVA) protocol with propofol and alfentanil without any muscle relaxants after fiberoptic intubation. The patient made an uneventful recovery and was discharged from the hospital on the fourth postoperative day. TIVA was a safe technique in this patient and should be considered as an alternative for patients presenting with CMT disease.

In search of the most suitable technique for truncal spinal immobilization with associated radiography.

The spineboard (SB) and the vacuum mattress (VM) are utilized for prehospital and emergency department (ED) immobilization of the spine. While permitting excellent pictures to be taken, the SB is a very painful device that can only be used for a limited time. The current study investigated the feasibility of different models of the VM for radiography. Computed tomography for each of seven VMs showed different degrees of shadows from the sac containing the polystyrole balls. This was related first of all to a high contrast of the sac in comparison with its contents and to a sometimes considerable shrinkage of the latter that resulted in further folding into the sac and, secondly, also to very broad mattresses, additional chambers within the VM and various grips and supports for lifting the mattress. Therefore, some features designed for prehospital use of the VM are actually acting against its use for diagnostic purposes. The aim of this study was to discuss and identify possible properties of a device that is useful for both immobilization and diagnostic purposes.

Team performance in the emergency room: assessment of inter-disciplinary attitudes.

In-hospital emergency medicine in central Europe relies on inter-disciplinary co-operation. To improve team performance in the emergency room (ER), a questionnaire for assessment of attitudes and judgements in resuscitation procedures was developed. A total of 43 items were evaluated according to a five-point Likert scale. With a response rate of 81%, 143 questionnaires were evaluated. Assessment of data was performed with regard to professional speciality and level in the medical hierarchy. Factorial analysis identified four main factors: Assessment of 'quality of performance' (F1), 'importance of structure' (F2), 'quality of team culture' (F3), and 'importance of hierarchy' (F4). Influences from the categories 'speciality' and 'hierarchy' and from the covariate 'gender' on these main factors were evaluated by two-factorial analysis of variance. For all four factors, 'speciality' produced significant differences. Surgeons accorded high values to F1 and low values to F2, whereas anaesthesiologists accorded low values to F1 and high values to F2. F3 showed a low ranking from within the ER nursing staff and the residents in internal medicine, whereas F4 received high scores by medical residents and staff members. For F1 and F3, there was a tendency towards hierarchy dependency, whereas no factor was influenced by gender. In conclusion, team performance in the ER is mainly influenced by different perceptions and attitudes of the different disciplines involved in the resuscitation process.

Abdominal haemorrhage--a preventable cause of death after field stabilization?

The causes of preventable death vary in different operational settings, and the topic has not previously been explored in a fully developed central European rescue system. The factors associated with potentially preventable death were studied in a retrospective study of 430 fatal traffic accident victims (1980-96) in Lörrach County, Germany. Mission protocols could be retrieved for detailed analysis in 239 of the cases. These were studied in order to identify factors associated with preventable death. At the scene of the accident, 38% of the patients died without cardiopulmonary resuscitation (CPR) and 18% after CPR. Four patients died after a certain delay without CPR before reaching hospital. A total of 43% of the victims were admitted to hospital, 5% had received prehospital CPR and the remaining 38% had not. In a subgroup representing the experience of a single emergency physician 60 fatalities were studied. Of these, 27 (45%) patients died within the hospital; almost half of these cases (13/27) had been conscious at some time after the accident and of these, seven (7/13) died from intra-abdominal bleeding within 4 h after admission. The same cause of death was found in 3 of the 14 comatose patients. Pleural drainage was carried out in four patients and unrecognized pneumothoraces or spinal injuries did not occur. Tracheal intubation was employed in 24/27. Medical antishock trousers (MAST) were not available. The data indicate that intra-abdominal haemorrhage is an underestimated cause of death in a comprehensive rescue system, possibly as a consequence of field stabilization. The use of MAST may be a relevant therapeutic option to prevent these fatalities. The method offers the possibility of intra-abdominal compression and haemostasis after tracheal intubation has been performed. Previous controlled studies on MAST may have been biased by faulty methodology (e.g. absence of tracheal intubation) and inappropriate indications (e.g. other causes of shock). The value of MAST in comprehensive rescue systems should therefore be reassessed. The difficulties in identifying factors leading to preventable death in a retrospective analysis, are discussed and it is recommended that a permanent prospective quality control be performed in all cases of fatal accidents in order to ensure the continued improvement of prehospital emergency medical systems.

Comparative spinal distribution and clearance kinetics of intrathecally administered morphine, fentanyl, alfentanil, and sufentanil.

BACKGROUND: Despite widespread use, little is known about the comparative pharmacokinetics of intrathecally administered opioids. The present study was designed to characterize the rate and extent of opioid distribution within cerebrospinal fluid, spinal cord, epidural space, and systemic circulation after intrathecal injection. METHODS: Equal doses of morphine and alfentanil, fentanyl, or sufentanil were administered intrathecally (L3) to anesthetized pigs. Microdialysis probes were used to sample cerebrospinal fluid at L2, T11, T7, T3, and the epidural space at L2 every 5-10 min for 4 h. At the end of the experiment, spinal cord and epidural fat tissue were sampled, and each probe's recovery was determined in vitro. Using SAAM II pharmacokinetic modeling software (SAAM Institute, University of Washington, Seattle, WA), the data were fit to a 16-compartment model that was divided into four spinal levels, each of which consisted of a caternary arrangement of four compartments representing the spinal cord, cerebrospinal fluid, epidural space, and epidural fat. RESULTS: Model simulations revealed that the integral exposure (area under the curve divided by dose) of the spinal cord (i.e., effect compartment) to the opioids was highest for morphine because of its low spinal cord distribution volume and slow clearance into plasma The integral exposure of the spinal cord to the other opioids was relatively low, but for different reasons: alfentanil has a high clearance from spinal cord into plasma, fentanyl distributes rapidly into the epidural space and fat, and sufentanil has a high spinal cord volume of distribution. CONCLUSIONS: The four opioids studied demonstrate markedly different pharmacokinetic behavior, which correlates well with their pharmacodynamic behavior.

[ATLS (advanced trauma life support) in Switzerland]. / ATLS (Advanced Trauma Life Support) in der Schweiz.

We analysed the ATLS courses organized in Switzerland since 1998. At the students courses the surgeons exceed the participants with a percentage of 45.7%, followed by the anaesthesiologist with 36.3%. The senior residents dominate with 49.1%, followed by the residents with 42.3%. The chief surgeons come only to a per cent of 4.1%. The statistics of the instructors show about the same pattern, the percentage of senior residents is even more impressive. The aim of ATLS is the same concept, the idea of ATLS in all emergency units throughout the whole country of Switzerland.

Effect of Staphylococcus aureus bacteria and bacterial toxins on meningeal permeability in vitro.

BACKGROUND AND OBJECTIVES: Epidural catheterization is associated with a significant bacterial colonization rate and occasionally frank infection. During epidural space infection, decreased analgesia despite increased epidural opioid doses has been described. One possible explanation for this observation is that bacterial infection decreases meningeal permeability. The purpose of the study was to determine whether Staphylococcus aureus bacteria, the most common organism causing epidural space infection, or S. aureus toxins alter meningeal permeability. METHODS: Spinal meninges of M. nemestrina monkeys were mounted in a previously established in vitro diffusion cell model and exposed to S. aureus toxins A, B, and F. Simultaneous transmeningeal fluxes of mannitol and sufentanil were measured before and after toxin exposure and compared to controls. In a second series of experiments, diffusion cells were inoculated with live S. aureus bacteria in suspension and the permeability of sufentanil was investigated. RESULTS: Staphylococcus aureus toxin-A increased the transmeningeal flux of mannitol but not sufentanil. Toxins B and F did not alter the meningeal permeability of either drug. Inoculation with live S. aureus bacteria increased the transmeningeal flux of sufentanil by 115+/-21% (P = .032). CONCLUSIONS: These data demonstrate that S. aureus alpha-toxin and live S. aureus bacteria can increase meningeal permeability. Thus, clinical observations of decreased epidural analgesia in the face of bacterial infection cannot be explained by decreased meningeal permeability.

What is the future of advanced trauma life support training?

Within the past 20 years, advanced trauma life support has developed from a regional to an international educational programme, with 31 participating countries. Notwithstanding the general acknowledgement of the effectiveness of advanced trauma life support procedures for improving early hospital trauma management and the specific knowledge and skills of participants, some criticism has come from the community of British anaesthetists, regarding course contents, the possibility of participating, the significance of skills for trained anaesthetists, team-related concerns and, of course, costs. Now that we have 10 years' experience from European advanced trauma life support courses, we want to take the opportunity to assess the advantages and possible deficiencies of this programme.

General anaesthesia for surgery can influence circulating melatonin during daylight hours.

BACKGROUND: Both melatonin and anaesthetics have been shown to affect sleep and behaviour. The effect of general anaesthesia on circulatory melatonin has not been reported, but anaesthetic-related alterations in hormone profiles are known. We hypothesize that differences in recovery from anaesthesia may be associated with differences in circulatory melatonin levels because of melatonin's sedative effect in humans. METHODS: The influences of general anaesthesia and surgery on circulating melatonin, prolactin, and cortisol concentration were investigated in 32 female patients scheduled for elective gynaecological surgery to study differences in hormone profiles and responses during anaesthesia and the recovery period. Patients were randomly assigned to one of two groups. General anaesthesia was induced with either thiopentone/fentanyl (Group 1: n = 16) or propofol/fentanyl (Group 2: n = 16). Maintenance of anaesthesia was achieved with either isoflurane (0.8-1.0 vol%)/fentanyl (Group 1) or propofol (6 mg.kg-1.h-1)/fentanyl (Group 2) with a N2O/O2 flow ratio of 2:1 in both groups. During anaesthesia, patients' eyes were carefully taped shut to prevent light effects. Blood samples were taken before and after premedication, immediately before induction of anaesthesia, every 15 min during anaesthesia, and hourly in the recovery room for 8 h. The control group consisted of 6 healthy women who were not subjected to surgery, but who were in a similar environment, including light conditions, as the study groups. RESULTS: Isoflurane and propofol anaesthesia as well as darkness elicited elevated plasma melatonin levels that persisted in the recovery period in patients anaesthetized with isoflurane, but gradually decreased during the recovery of patients anaesthetized with propofol. Circulating prolactin and cortisol values were also elevated during anaesthesia and had similar decreases during the recovery period. CONCLUSION: Higher plasma levels of melatonin during the recovery period following isoflurane anaesthesia may, in part, explain increased sedation in these patients compared with patients who received propofol anaesthesia. However, the relationship between recovery from anaesthesia and plasma melatonin levels may not be simple and straightforward.

Propofol reduces succinylcholine induced increase of masseter muscle tone.

PURPOSE: Succinylcholine is known to increase the tone of the masseter muscles. As excessive jaw tension may complicate rapid sequence induction, we investigated three induction techniques, all including the use of succinylcholine, with respect to masseter muscle tone, neuromuscular blockade, intubation conditions, and time course of intubation. METHODS: Sixty adult patients were allocated to one of three induction groups: Group THIO received 5 mg.kg-1 thiopentone, Group THIO/ATR received 5 mg.kg-1 thiopentone plus 0.05 mg.kg-1 atracurium for precurarization, and Group PROP received 2.5 mg.kg-1 propofol. All patients received 3 micrograms.kg-1 fentanyl and 1.5 mg.kg-1 succinylcholine. Time for induction of anaesthesia was recorded, and, after inserting a Grass Force Transducer between upper and lower incisors, jaw tone and the time course of jaw tension was recorded before and after the administration of succinylcholine. RESULTS: No differences in the onset of sleep were observed among the three groups (Group THIO 33 +/- 2 sec: THIO/ATR 30 +/- 2 sec: PROP 35 +/- 2 sec, mean +/- SE). Masseter preloads following induction of anaesthesia were similar in all three groups (THIO 16.4 +/- 2.1 N: THIO/ATR 15.1 +/- 2.0 N: PROP 12.7 +/- 1.6 N). However, after administration of succinylcholine, the increase in masseter tone was less in Groups PROP (5.0 +/- 1.1 N) and THIO/ATR (6.4 +/- 2.1 N) than in Group THIO (12.4 +/- 3.0 N; P < 0.05). CONCLUSION: Jaw tension after administration of succinylcholine is influenced by the choice of induction agent. The increase of masseter muscle tone is lower following propofol or thiopentone/atracurium induction than with thiopentone alone.

Acetylcholinesterase and butyrylcholinesterase are expressed in the spinal meninges of monkeys and pigs.

BACKGROUND: Acetylcholinesterase inhibition at the spinal level has been shown to produce a potent antinociceptive effect. However, the site of cholinesterase inhibition is unknown. To determine whether the spinal meninges participate in acetylcholine metabolism, the spinal meninges of monkeys and pigs were assayed for cholinesterase activity. METHODS: Spinal cord, dura mater, and arachnoid mater specimens from anesthetized pigs and monkeys were mechanically homogenized and cholinesterase activity was determined quantitatively using a commercially available colorimetric assay. The ability of neostigmine to inhibit cholinesterase activity in vitro was also measured. Finally, the reverse transcriptase polymerase chain reaction (RT-PCR) was used to identify the cholinesterase metabolizing enzymes expressed by the spinal meninges. RESULTS: All spinal cord and meningeal specimens showed cholinesterase activity. In pigs, the dura mater showed less enzyme activity (36 +/- 17.7 U/mg protein) than the arachnoid mater (73.4 +/- 30.3 U/mg protein; P < 0.05), and the arachnoid mater showed less activity than the spinal cord (131.3 +/- 55.2 U/mg protein; P < 0.05). In monkeys, the dura mater again showed less cholinesterase activity (45.8 +/- 20.1 U/mg protein; P < 0.05), whereas cholinesterase activity in the arachnoid mater (90.3 +/- 45.9 U/mg protein) and spinal cord specimens (101.9 +/- 37.5 U/mg protein) were not significantly different. There were no significant species-related differences in cholinesterase activity. Neostigmine inhibited cholinesterase activity in a log-dose-dependent manner. The RT-PCR identified mRNA for acetylcholinesterase and butyrylcholinesterase in monkey pia-arachnoid mater. CONCLUSIONS: These data show that the spinal meninges express acetylcholinesterase and butyrylcholinesterase; for monkeys, although not pigs, the level of cholinesterase activity is comparable with that found in the spinal cord. This finding suggests that the meninges may be an important site for acetylcholine metabolism and may play a role in the analgesic effect produced by intrathecally administered cholinesterase inhibitors.

Preoperative anxiolysis with minimal sedation in elderly patients: bromazepam or clorazepate-dipotassium?

BACKGROUND: In elderly patients undergoing ophthalmic surgery the loss of co-operation due to over-sedation, induced by drugs given preoperatively, may jeopardise the success of microsurgery performed under regional anaesthesia. The aim of this study was to compare the psychotropic effects of bromazepam and clorazepate-dipotassium, two benzodiazepines with predominantly anxiolytic and only weak sedative action. METHODS: A randomised, placebo-controlled, double-blind study was designed to include 60 patients, ASA physical status II-III, older than 60 years scheduled for ophthalmic surgery under regional anaesthesia. The patients were randomised to receive either bromazepam (3 mg) or clorazepate-dipotassium (20 mg) or placebo. The study drugs were given at 10 p.m. the night before surgery and 90 min before surgery. Using the State-Trait Anxiety Inventory (STAI), the patient's anxiety was assessed at the end of the preoperative visit, on the next morning before the study drug was given and on arrival at the operating theatre. RESULTS: Bromazepam induced a marked anxiolytic effect as documented by a significant reduction in the STAI State values after both applications (P<0.01). Clorazepate did not differ from placebo at any evaluation time with regard to the STAI and haemodynamic values. Sedative effects and oxygen saturation (SpO2) were comparable in all groups. CONCLUSION: Bromazepam is superior to clorazepate in its anxiolytic action and suitable as preoperative medication in the elderly patient because of lack of overt sedative effects.