Ejection as a key word for the dispatch of a physician staffed helicopter: the Swiss experience.

We evaluated the type and severity of injuries and the possible influence of a helicopter staffed by a physician on the outcome of 71 consecutive occupants ejected from a four-wheel vehicle ejected occupants who were cared for by the Swiss Air Rescue Helicopter team from January 1994 to February 1999. The investigation and the data collection were planned prospectively. The following data were collected for each patient ejected from a four wheel vehicle: (1) demographic information; (2) type of injury; (3) vital signs on scene, in flight and at hospital; (4) hospital diagnosis; (5) injury severity score; (6) secondary transfer; (7) length of stay in hospital and on intensive care; and (8) outcome at hospital discharge. A control group included consecutive patients cared for by the same rescue team during the same period but who were not ejected out of their vehicle. Forty-four percent of the ejected patients had a GCS < or = 8, 21% were hypotensive and 22% had respiratory problems. Nine patients died at the scene. A total of 53% of the 62 ejected patients who were transported had an ISS > or = 16. The median ISS was 17. A total of 37% of the patients were intubated at the scene, needle chest decompression was performed in 5% and major analgesia was used in 27% of the cases. A total of 38% of the patients needed surgery in the first 4 h, 34% needed intensive care. No patient needed secondary transfer to the Trauma Centre if they were not brought there in the first instance. The outcome was poor in 27 cases (38%): 17 died and 10 needed transfer to specialised institutions. Non-ejected patients suffered mostly from head and neck injuries (50%) of which 9% were severe (head and neck AIS > or = 4, P < 0.05). Thoracic injuries were less frequent (35%) of which 13% were severe (thorax AIS > or = 4, P < 0,05). The median ISS was 9 for the non-ejected patients, P < 0.05. In conclusion, ejection from a four-wheel vehicle causes more severe injuries and requires a high number of advanced life support manoeuvres. Based on the mechanism of injury alone, patients ejected from four-wheel vehicles should automatically receive a response from the best available pre-hospital team. In our system, this means the dispatch of a physician staffed helicopter.

Penetrating thoracic trauma in arrow injuries.

Arrow wounds are very rare. We present herein a case of hilar penetrating thoracic trauma caused by an arrow, and a review of the literature, to clarify the management of these cases and their indications for surgery. Depending on the type of arrowhead, the tissue elasticity can narrow the wound track around the shaft of the arrow, sometimes causing a tamponade effect. In the mediastinal or hilar area, an arrow should not be removed before an injury to the major blood vessels or the heart has been ruled out.

Acute opiate overdose: characteristics of 190 consecutive cases.

AIMS: To characterize the population of drug users consulting the Emergency Room (ER) of a university hospital with acute opiate overdose (AOO) and to assess rate of referral to specialized treatment programme. DESIGN: Survey of a 12-month sample of AOO patients. MEASUREMENTS: Medical and psychosocial features of the drug users, details of emergency treatment and referral by a mobile resuscitation team (SMUR) and the ER of our hospital (CHUV-Lausanne, Switzerland). In addition fatal AOO cases were collected by the Institute of Forensic Medicine (IFM) during the same period. FINDINGS: One hundred and eighty-four cases of AOO (134 patients) were treated. The files of the IFM detailed six additional deceased cases. This population of drug users was characterized by an over-representation of men (73%), by young age (27.4 years), by a high rate of multi-drugs use (90%) and by a high rate of multiple previous overdoses (2.6). Average length of stay was 20.1 hours but 41% of cases stayed less than 8 hours. Only one patient was readmitted within an 8-hour period. When discharged, 78% returned home. Unexpectedly, 67% of patients were not referred to any therapeutic programme for drug addiction. CONCLUSION: This study shows the low mortality of AOO when treated but also demonstrates the need to improve psychosocial evaluation and referral of drug addicts admitted with AOO.

[Cerebral hemodynamics and intracranial hypertension]. / Hémodynamique cérébrale et hypertensions intracrâniennes.

Various cerebral aggressions, either primary or secondary, can lead to the development of raised intracranial pressure. The presence of an elevated intracranial pressure often results in cerebral ischaemia/hypoxia and, eventually, neuronal death. In face of this cascade of events, several therapeutic approaches have been suggested. Two management concepts for patients with raised intracranial pressure have retained the most attention in recent years: the first suggests a therapeutic increase in cerebral perfusion pressure with the objectives to improve perilesional collateral perfusion and decreased cerebral blood volume, and consequently intracranial pressure in areas where autoregulation is preserved. The second concept supports the diminution in perilesional capillary pressure with the aim of decreasing vasogenic oedema. Although these two concepts are antagonistic and cannot be used simultaneously, they are probably complementary in the sequence of therapeutic events of patients experiencing severe head injury. This article reviews these therapeutic concepts and their clinical applications.

[Treatment of intracranial hypertension in the case of severe craniocerebral injuries]. / Traitement de l'hypertension intracrânienne en cas de traumatisme craniocérébral grave.

More than 50% of severely head-injured patients develop increased intracranial pressure, risking exacerbating ischaemic insults to the already injured brain. In approximately 10% of these cases, intracranial pressure may become unresponsive to medical or surgical treatment, with a resulting mortality of over 90%. The main emphasis should be on full intensive care, based on the prophylaxis of the devastating effects of secondary insults to the injured brain. Specific treatment should be directed towards controlling intracranial pressure and maintaining a cerebral perfusion pressure over 70 mmHg, while avoiding, where feasible, treatment modalities at risk of exacerbating cerebral ischaemia. Recently, an algorithm for treating intracranial hypertension under three different therapeutic situations has been suggested, based on the successive application of effective agents with increasing associated risks. Therapeutic modalities of this protocol are discussed.

[Concept of secondary cerebral injury of systemic origin]. / Concept d'agression cérébrale secondaire d'origine systémique (ACSOS).

The prevention and treatment of secondary insults to the brain of systemic origin in severely head injured patients remain of utmost importance. Head injury remains the leading cause of traumatic death, being responsible for 50-60% of fatalities. Head-injured patients not only suffer from the primary injury at the time of trauma, but also from the secondary, largely ischaemic, brain damage that occurs later. Some of these insults are of extracranial origin (or systemic), such as arterial hypotension, hypoxaemia, hypercarbia and anaemia. Their impact on mortality and morbidity is extremely high and requires greater efforts in improving the care of head-injured patients. Systemic insults occur either before the patient reaches hospital or during interfacility transfer or, in a surprisingly large number of cases, within hospital during emergency procedures, intrahospital transport or during their stay in intensive care units. Hypoxaemia, although quite easy to treat, is still common. This calls for better and earlier protection of the airway, more systematic administration of oxygen to trauma patients and wider use of pulse oximetry. Arterial hypotension has even more dramatic consequences in severe head injury. Recent studies indicate that short episodes of hypotension may induce severe brain ischaemia, that will be present even after complete systemic haemodynamic restoration. The treatment of hypotensive episodes should be immediate and aggressive. In some circumstances, restoration of an adequate cerebral perfusion pressure may not be obtained sufficiently rapidly with fluids alone and may require early use of vasopressors. Optimal haemodynamic resuscitation of the trauma patient with haemorrhagic hypotension and severe head injury remains a special challenge.(ABSTRACT TRUNCATED AT 250 WORDS)

[Neuro-anesthetic contribution to the prevention of complications caused by mechanical cerebral retraction: concept of a chemical brain retractor]. / Contribution neuroanesthésique à la prévention des complications de la rétraction cérébrale mécanique: le concept de l'écarteur chimique.

During most intracranial procedures, the microscope is used to allow the surgeon to work on structures which are deeply located in the brain. Under these circumstances, brain retraction is required for adequate exposure. It was rapidly suspected and later confirmed that brain retraction causes secondary brain damage. This is due not only to direct effect of the retractor on the cortical surface, but also because a pressure is generated under the retractor, on the brain tissue, which compromises local cerebral blood flow and local cerebral perfusion pressure, thus causing cerebral ischaemia. The need for retraction is increased if the lesion is located deeply and/or if the brain is tensed; thus the risk to generate ischaemic conditions is enhanced. These secondary surgical lesions are promoted and worsened by associated systemic conditions such as hypotension, hypoxaemia, hypercapnia. As an attempt to respond to the problem generated by surgical retraction, the "chemical brain retractor" concept is proposed. By compulsively rendering the brain as relaxed and compliant as possible, the chemical brain retractor should allow the surgeon to operate on without the use of a surgical brain retractor and, if such a retractor is still needed, to reduce the pressure under it. These goals are achieved with an osmotic agent like mannitol to improve brain compliance, and intravenous anaesthetic agents, moderate hypocarbia and a normal or elevated blood pressure, to minimize cerebral blood volume. In conjunction with the chemical brain retractor, two other manoeuvres should be used to enhance cerebral compliance: CSF drainage and moderate head up position during the procedure.

[Techniques for intubation when head and neck cannot be moved]. / Techniques d'intubation lorsque tête et cou ne peuvent être mobilisés.

The inability to extend the head may be due to a blocked cervical spine or to any cervical instability imposing to maintain the head straight. Exposure of the glottis during intubation may be difficult and can be ameliorated by a stable general anesthesia, some pressure on the larynx and by charging the epiglottis. When mouth aperture is superior to 40 mm, a lighted stylet, a laryngoscope with a prism, a fiberoptic laryngoscope (Bullard) or the PCV laryngoscope represent a possible alternative to the Mac Intosh laryngoscope. If mouth aperture is superior to 20 mm but inferior to 40 mm, a ENT or PCV laryngoscope or a fiberoptic intubation are recommended. One should remember that the intubation is easier if the diameter of the ET tube is small. If the mouth aperture is inferior to 20 mm, nasal intubation (if intubation is indicated) is mandatory using fiberoptic intubation or a retrograde technique or even nasal blind intubation. In case of failure of intubation in a hypoxic patient, the anterior percutaneous route should always be kept in mind and transtracheal ventilation should be ready in case of failure, or even tracheotomy.

[Relaxation and protection of the brain on the operating table]. / Détente et protection cérébrales au bloc opératoire.

Cerebral protection combines techniques aimed 1) to avoid death of neurones which sustained primary ischemic of traumatic insults and 2) to prevent secondary insults to the brain. The chemical brain retractor concept includes the use of a total intravenous anesthesia technique, mild hypocapnia and mannitol with strict monitoring and maintenance of the global cerebral homeostasis. This contributes to decrease brain volume and intracranial pressure and allows the best possible access to the operating site, while avoiding excessive pressure under the surgical brain retractors. Neuronal protection is based on a better understanding of the biological basis of secondary brain damage; therapeutic or prophylactic techniques include the use of specific pharmacological agents, hypothermia, hemodilution and maintenance of an elevated cerebral perfusion pressure. In short, although the favourable effects of such techniques are nor easy to demonstrate in man, their use in today's clinical practice, in association with the concept of the chemical brain retractor, is an effective way to prevent ischemic cerebral insults during neurosurgical procedures.

[Prehospital air ambulance and systemic secondary cerebral damage in severe craniocerebral injuries]. / Médicalisation préhospitalière héliportée et agressions cérébrales secondaires d'origine systémique chez les traumatisés craniocérébraux graves.

Advanced supportive therapy at the site of the accident, associated with direct transfer to a trauma centre increases survival and reduces morbidity rates. Patients with severe head injury, especially those with multiple injuries, often arrive in the emergency department with potentially causes of serious secondary systemic insults to the already injured brain, such as acute anemia (Hematocrit < or = 30%), hypotension (systolic arterial pressure (Pasys) < or = 95 mmHg, 12.7 kPa), hypercapnia (Paco2 > or = 45 mmHg, 6 kPa) and/or hypoxemia (Pao2 < or = 65 mmHg, 8.7 kPa). The incidence of such insults and their impact on mortality were studied in a group of 51 consecutive adults suffering from non penetrating severe head injury (Glasgow score < or = 8, mean age 31 +/- 17 yrs) rescued by a medicalized helicopter. Each patient received medical care on the site of the accident by an anaesthesiologist of a university hospital (UH) complying with an advanced trauma life support protocol including intubation, hyperventilation with FiO2 = 1, restoration of an adequate Pasys and direct transportation to the UH. Mean delay from call to arrival of the rescue team on the site was 15 +/- 5 min. Mean scene time was 32 +/- 10 min in cases not requiring extrication. Nineteen patients (Group I) were admitted without secondary systemic insults to the brain, 13 with isolated head injury, and 6 with multiple injuries, with a low Glasgow Outcome Score (GOS 1-3) of 42% at 3 months. In 32 patients (Group II), despite advanced supportive measures at the scene of the accident and during transportation, one or more secondary systemic insults to the brain were detected upon arrival at the emergency room, one with isolated head injury, 31 with multiple injuries, with a bad GOS of 72% at 3 months. We conclude that: 1) advanced trauma life support prevents from secondary systemic insults in the great majority of isolated severe head injured patients. 2) secondary systemic insults to the already injured brain are frequent in patients with multiple injuries and are difficult to avoid despite rapid aeromedical trauma care, 3) secondary systemic insults to the brain have a catastrophic impact on the outcome of severely head injured patients.