Transport of the patient with trauma: a narrative review.

Trauma and injury place a significant burden on healthcare systems. In most high-income countries, well-developed acute pre-hospital and trauma care systems have been established. In Europe, mobile physician-staffed medical teams are available for the most severely injured patients and apply a wide variety of lifesaving interventions at the same time as ensuring patient comfort. In trauma systems providing pre-hospital care, medical interventions are performed earlier in the patient journey and do not affect time to definite care. The mode of transport from the accident scene depends on the organisation of the healthcare system and the level of hospital care to which the patient is transported. This varies from 'scoop and run' to a basic community care setting, to advanced helicopter emergency medical service transport to a level 4 trauma centre. Secondary transport of trauma patients to a higher level of care should be avoided and may lead to a delay in definitive care. Critically injured patients must be accompanied by at least two healthcare professionals, one of whom must be skilled in cardiopulmonary resuscitation and advanced airway management techniques. Ideally, the standard of care provided during transport, including the level of monitoring, should mirror hospital care. Pre-hospital care focuses on the critical care patient, but the majority of injured patients need only close observation and pain management during transport. Providing comfort and preventing additional injury is the responsibility of the whole transport team.

Analgesic efficacy of the Pecs II block: a systematic review and meta-analysis.

Surgery is the primary therapeutic intervention for breast cancer and can result in significant postoperative pain. We searched the current literature and performed a meta-analysis in order to compare the analgesic efficacy of the pectoral type-2 (Pecs II) block with systemic analgesia alone and with a thoracic paravertebral block for breast cancer surgery. Primary outcome was postoperative opioid consumption in the first 24 h after surgery. Secondary outcomes were pain scores at 0, 3, 6, 9 and 24 h after surgery, intra-operative opioid consumption, time to first analgesic request and incidence of postoperative nausea and vomiting. We identified 13 randomised controlled trials that included 815 patients. The Pecs II block significantly reduced postoperative opioid consumption (standardised difference in means: -13.64 mg oral morphine equivalents; 95%CI: -21.22 to -6.05; p < 0.01) and acute postoperative pain at all intervals in the first 24 h after surgery compared with systemic analgesia alone. Compared with the thoracic paravertebral block, the Pecs II block resulted in similar postoperative opioid consumption (standardised difference in means: -8.73 mg oral morphine equivalents; 95%CI: -18.16 to 0.69; p = 0.07) and postoperative pain scores after first measurement. In conclusion, the Pecs II block offers improved analgesic efficacy compared with systemic analgesia alone and comparable analgesic efficacy to a thoracic paravertebral block for breast cancer surgery.

Which ultrasound transducer type is best for diagnosing pneumothorax?

BACKGROUND: An accurate physical examination is essential in the care of critically ill and injured patients. However, to diagnose or exclude a pneumothorax, chest auscultation is unreliable compared to lung ultrasonography. In the dynamic prehospital environment, it is desirable to have the best possible ultrasound transducer readily available. The objective is to assess the difference between a linear-array, curved-array, and phased-array ultrasound transducer in the assessment for pneumothorax and to determine which is best. METHODS: In this double-blinded, cross-sectional, observational study, 15 observers, experienced in lung ultrasonography, each assessed 66 blinded ultrasound video clips of either normal ventilation or pneumothorax that were recorded with three types of ultrasound transducers. The clips were recorded in 11 adult patients that underwent thoracoscopic lung surgery immediately before and after the surgeon opened the thorax. The diagnostic accuracy of the three transducers, elapsed time until a diagnosis was made, and the perceived image quality was recorded. RESULTS: In total, 15 observers assessed 990 ultrasound video clips. The overall sensitivity and specificity were 98.2% and 97.2%, relatively. No significant difference was found in the diagnostic performance between transducers. A diagnosis was made slightly faster in the linear-array transducer clips, compared to the phased-array transducer (p = .031). For the linear-, curved-, and phased-array transducer, the image quality was rated at a median (interquartile range [IQR]) of 4 (IQR 3-4), 3 (IQR 2-4), and 2 (IQR 1-2), relatively. Between the transducers, the difference in image quality was significant (p < .0001). CONCLUSIONS: There was no difference in diagnostic performance of the three transducers. Based on image quality, the linear-array transducer might be preferred for (prehospital) lung ultrasonography for the diagnosis of pneumothorax.

Ultrasound-guided approach to nerves (direct vs. tangential) and the incidence of intraneural injection: a cadaveric study.

This study evaluated the incidence of nerve puncture and intraneural injection based on the needle approach to the nerve (direct vs. tangential). Two expert operators in regional anaesthesia performed in-plane ultrasound-guided nerve blocks (n = 158) at different levels of the brachial plexus in cadavers, aiming either directly for the nerve (n = 77) or tangentially inferior to the nerve (n = 81). After reaching the outer limit of the nerve, the needle was intentionally advanced approximately 1 mm in both approaches, and 0.2-0.5 ml of saline was injected. Each operator classified (in real time) the needle tip and injectate as intraneural or not. Video clips showing the final position of the needle and the injection were evaluated in the same manner by seven independent expert observers who were blinded to the aims of this study. In addition, 20 injections were performed with ink for histological evaluation. Intraneural injections of saline were observed by the operator in 58% (45/77) of cases using the direct approach and 12% (10/81) of cases using the tangential approach (p < 0.001). The independent observers agreed with the operator in a substantial number of cases (Cohen's kappa index 0.65). Histological studies showed intraneural spread in 83% (5/6) of cases using the direct approach and in 14% (2/14) of cases using the tangential approach (p = 0.007). No intrafascicular injections were observed. There was good agreement between the operators' assessment and subsequent histological evaluation (Cohen's kappa = 0.89). Simulation of an unintentional/accidental advancement of the needle 'beyond the edge' of the nerve suggests significantly increased risk of epineural perforation and intraneural injection when a direct approach to the nerve is used, compared with a tangential approach.

Correlation of bupivacaine 0.5% dose and conversion from spinal anesthesia to general anesthesia in cesarean sections.

BACKGROUND: Failed spinal anesthesia for cesarean sections may require conversion to general anesthesia. The aim of this study was to determine whether the administered spinal bupivacaine dose for performing a cesarean section under spinal anesthesia was related to the conversion rate to general anesthesia. METHODS: Retrospective analysis was performed on 1252 electronic data and file of patients who underwent a cesarean section under spinal anesthesia between 2004 and 2011. RESULTS: In 15 patients, spinal anesthesia was converted into general anesthesia due to block failure. Patients in whom a bupivacaine dose of 8 mg or smaller was administered had significantly higher conversion rate (3/61 (4.9%) patients and 12/1191 (1.0%) patients, respectively; p < 0.05.). The relative risk of conversion with a 8 mg dose or lower is 4.88 (95% CI 1.41 - 16.85). CONCLUSION: This retrospective study shows that a low dose administration a bupivacaine 0.5% for spinal anesthesia in cesarean section patients elicits significantly more frequent conversion to general anesthesia.

Soft tissue landmark for ultrasound identification of the sciatic nerve in the infragluteal region: the tendon of the long head of the biceps femoris muscle.

BACKGROUND AND OBJECTIVES: The sciatic nerve block represents one of the more difficult ultrasound-guided nerve blocks. Easy and reliable internal ultrasound landmarks would be helpful for localization of the sciatic nerve. Earlier, during ultrasound-guided posterior approaches to the infragluteal sciatic nerve, the authors recognized a hyperechoic structure at the medial border of the long head of biceps femoris muscle (BFL). The present study was performed to determine whether this is a potential internal landmark to identify the infragluteal sciatic nerve. METHODS: The depth and the thickness of this hyperechoic structure, its relationship with the sciatic nerve and the ultrasound visibility of both were recorded in the proximal upper leg of 21 adult volunteers using a linear ultrasound probe in the range of 7-13 MHz. The findings were verified by an anatomical study in two cadavers. RESULTS: The hyperechoic structure at the medial border of the BFL extended in a dorsoventral direction between 1.4+/-0.6 cm (mean+/-SD) and 2.8+/-0.8 cm deep from the surface, with a width of 2.2+/-0.9 mm. Between 2.6+/-0.9 and 10.0+/-1.5 cm distal to the subgluteal fold, the sciatic nerve was consistently identified directly at the ventral end of the hyperechoic structure in all volunteers. The anatomical study revealed that this hyperechoic structure corresponds to tendinous fibres inside and at the medial border of the BFL. CONCLUSION: The hyperechoic BFL tendon might be a reliable soft tissue landmark for ultrasound localization of the infragluteal sciatic nerve.

A prospective randomised controlled trial of ultrasound guided versus nerve stimulation guided distal sciatic nerve block at the popliteal fossa.

The direct visualisation of nerves and adjacent anatomical structures may make ultrasonography the preferred method for nerve localisation. In this prospective randomised study, we investigated whether, for distal sciatic nerve block in the popliteal fossa, an ultrasound guided technique would result in the use of less local anaesthetic without changing block characteristics and quality. Using electrical nerve stimulation or ultrasound guidance, the nerve was identified in two groups of 20 patients scheduled for lower limb surgery. Hereafter lignocaine 1.5% with adrenaline 5 microg/ml was injected. The attending anaesthesiologist assessed the injected volume. Significantly less local anaesthetic was injected in the ultrasound group compared to the nerve stimulation group (17 vs. 37 ml, P < 0.001), while the overall success rate was increased (100% vs. 75%; P = 0.017). We conclude that the use of ultrasound localisation for distal sciatic nerve block in the popliteal fossa reduces the required dose of local anaesthetic significantly, and is associated with a higher success rate compared to nerve stimulation without changing block characteristics.

Visualization of the course of the sciatic nerve in adult volunteers by ultrasonography.

BACKGROUND: The sciatic nerve block by the posterior approaches represents one of the more difficult ultrasound-guided nerve blocks. Our clinical experiences with these blocks indicated a point slightly distal to the subgluteal fold as an advantageous position to allow good ultrasonic visibility. In this study, we systematically scanned the sciatic nerve from the subgluteal fold to the popliteal crease, to determine an optimal point for ultrasonographic visualization. METHODS: After institutional approval and written informed consent, we recruited 15 volunteers to visualize the sciatic nerve from the subgluteal fold to the popliteal crease using a linear ultrasound probe in the range of 7-13 MHz. The ultrasonographic visibility of the sciatic nerve, nerve diameter (width and thickness), and skin-to-nerve distance at 20 equidistant points between the subgluteal fold and the popliteal crease were recorded. RESULTS: The sciatic nerve could be successfully visualized in cross-section as a hyperechoic structure on ultrasound in all volunteers. In the course from subgluteal to the popliteal area, the shape of the sciatic nerve changed from flat to round, while the skin-nerve distance varied with the smallest skin-nerve distances at the popliteal crease and at 5.4 cm (on average) distal to the subgluteal fold. The best ultrasonographic visibility scores were found between 7.2 and 10.8 cm (on average) distal to the gluteal fold. CONCLUSION: Between 5.4 and 10.8 cm from the subgluteal fold seems to be the best area to scan the sciatic nerve in terms of superficial nerve position and good ultrasonic visibility.

A needle guidance device compared to free hand technique in an ultrasound-guided interventional task using a phantom.

In this in vitro study, a needle guidance device and a 'free hand' technique for ultrasound guided needle insertion were compared in a simulated ultrasound-guided interventional task using a porcine phantom. Residents inexperienced in using ultrasonography were asked to insert a needle, using an in-plane techniques, and to make contact with metal rods at a depth of 2 and 4 cm in the phantom. The transducer made angles of 90 degrees, 60 degrees and 45 degrees with the surface of the phantom. The times to perform the procedures were significantly shorter and the needle visualisation was significantly better when using the needle guidance device. The residents ranked their satisfaction with the needle-guidance device significantly better than the 'free-hand' technique. This device may be beneficial when performing ultrasound guided peripheral nerve blocks, especially by inexperienced operators.

Ultrasound-guided training in the performance of brachial plexus block by the posterior approach: an observational study.

The application of ultrasonography in guiding and controlling the path of the stimulating needle to the brachial plexus via the posterior approach (Pippa technique) was studied. In 21 ASA physical status 1 and 2 patients, scheduled for surgery of the shoulder or upper arm, needle insertion was monitored by ultrasonography and the interaction between needle, surrounding structures and brachial plexus was followed. During injection, the spread of local anaesthetic was visualised and a prediction of block success was made. One failure was predicted. Complete block was achieved in 20 (95%) patients. One potential complication, puncture of the carotid artery, was prevented using ultrasound. Ultrasound is a useful tool in the training and performance of a neurostimulation-guided brachial plexus block by the posterior approach. Ultrasonographic guidance may prevent serious complications associated with this approach to the brachial plexus.

Ultrasound-guided bilateral continuous sciatic nerve blocks with stimulating catheters for postoperative pain relief after bilateral lower limb amputations.

The performance of continuous bilateral sciatic nerve blocks under ultrasonographic control using stimulating catheters is described in a 4-year-old child with VACTERL syndrome. Ultrasound showed an abnormal vascular and nerve supply to the lower limbs. The use of ultrasound guidance made successful continuous sciatic nerve blocks possible in a child in whom the traditional method of nerve localisation was unlikely to succeed for anatomical reasons.

Clinical experience with percutaneous dilatational tracheostomy: report of 150 cases.

OBJECTIVE: To report our experience with percutaneous dilatational tracheostomy. DESIGN: Retrospective study. SETTING: Teaching hospital. The Netherlands. SUBJECTS: 147 patients. INTERVENTIONS: 150 percutaneous dilatational tracheostomies, 95 (63%) for prolonged ventilation, 37 (25%) for pulmonary toilet, and 18 (12%) for upper airway obstruction. MAIN OUTCOME MEASURES: Morbidity and mortality. RESULTS: The success rate of the procedure was 99%. Operative complications occurred in 16 (11%) and were usually minor. During a total duration of cannulation of 5212 days four complications were recorded. Haemorrhage was the most common early complication (n = 14). Late complications (five to 53 months after decannulation) included tracheal stenosis (n = 1), tracheomalacia (n = 2), tracheocutaneous fistula (n = 2) and an ugly scar (n = 1). CONCLUSION: Percutaneous dilatational tracheostomy is a simple, safe and cost effective technique for inserting a tracheal cannula.

Percutaneous subcricoid minitracheostomy: report of 50 procedures.

A minitracheostomy is a small cannula in the trachea that allows permanent access to the tracheal lumen and that is used for the evacuation of bronchial secretions. It generally is performed through the cricothyroid membrane. We used a Seldinger technique in 50 patients to insert a minitracheostomy cannula in the subcricoid position. This technique proved to be easy to perform in translaryngeally intubated patients, both under local anesthesia and under general anesthesia. Operative complications occurred in 5 patients (10%), all of which were minor. The pros and cons of a minitracheostomy in the subcricoid position are discussed.