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.

Controlled mechanical ventilation to detect regional lymph node metastases in esophageal cancer using USPIO-enhanced MRI; comparison of image quality.

BACKGROUND: Artifacts caused by respiratory motion or ventilation-induced chest movements are a major problem for thoracic MRI, as they can obscure important anatomical structures such as lymph node metastases. We compared image quality of routine breathhold with intermittent apnea during controlled mechanical ventilation of patients under general anesthesia as the ideal situation without respiratory motion in the detection and characterization of regional lymph nodes in esophageal cancer. METHODS: In this prospective study, 10 patients treated for esophageal cancer underwent ultrasmall superparamagnetic iron oxide (USPIO) enhanced MRI scans. Before neoadjuvant therapy, MRI scans were acquired with a routine breathhold technique. After neoadjuvant therapy, patients were scanned under general anesthesia immediately prior to surgery with controlled mechanical ventilation. The image quality was compared using a Likert scale questionnaire based on visibility of anatomical structures and image artifacts. RESULTS: MRI with controlled mechanical ventilation and prolonged controlled apnea of 4 min was safe and feasible. All cardio-respiratory monitoring parameters remained stable during the apnea phases. Mediastinal and upper abdominal lymph nodes down to 2 mm in size could be visualized with all sequences. All image quality criteria, including visibility of thoracic structures and regional lymph nodes were scored higher using the controlled ventilation sequences compared to the routine breathhold phase. CONCLUSION: USPIO-enhanced MRI with controlled mechanical ventilation is superior to routine breathhold MRI in visualizing lymph nodes, which warrants new motion reduction techniques to use MRI for the detection of lymph node metastases in patients with esophageal cancer.

Accuracy and precision of non-invasive cardiac output monitoring by electrical cardiometry: a systematic review and meta-analysis.

Cardiac output monitoring is used in critically ill and high-risk surgical patients. Intermittent pulmonary artery thermodilution and transpulmonary thermodilution, considered the gold standard, are invasive and linked to complications. Therefore, many non-invasive cardiac output devices have been developed and studied. One of those is electrical cardiometry. The results of validation studies are conflicting, which emphasize the need for definitive validation of accuracy and precision. We performed a database search of PubMed, Embase, Web of Science and the Cochrane Library of Clinical Trials to identify studies comparing cardiac output measurement by electrical cardiometry and a reference method. Pooled bias, limits of agreement (LoA) and mean percentage error (MPE) were calculated using a random-effects model. A pooled MPE of less than 30% was considered clinically acceptable. A total of 13 studies in adults (620 patients) and 11 studies in pediatrics (603 patients) were included. For adults, pooled bias was 0.03 L min-1 [95% CI - 0.23; 0.29], LoA - 2.78 to 2.84 L min-1 and MPE 48.0%. For pediatrics, pooled bias was - 0.02 L min-1 [95% CI - 0.09; 0.05], LoA - 1.22 to 1.18 L min-1 and MPE 42.0%. Inter-study heterogeneity was high for both adults (I2 = 93%, p < 0.0001) and pediatrics (I2 = 86%, p < 0.0001). Despite the low bias for both adults and pediatrics, the MPE was not clinically acceptable. Electrical cardiometry cannot replace thermodilution and transthoracic echocardiography for the measurement of absolute cardiac output values. Future research should explore it's clinical use and indications.

Systematic review of uncalibrated arterial pressure waveform analysis to determine cardiac output and stroke volume variation.

UNLABELLED: The FloTrac/Vigileo™, introduced in 2005, uses arterial pressure waveform analysis to calculate cardiac output (CO) and stroke volume variation (SVV) without external calibration. The aim of this systematic review is to evaluate the performance of the system. Sixty-five full manuscripts on validation of CO measurements in humans, published in English, were retrieved; these included 2234 patients and 44,592 observations. RESULTS: have been analysed according to underlying patient conditions, that is, general critical illness and surgery as normodynamic conditions, cardiac and (post)cardiac surgery as hypodynamic conditions, and liver surgery and sepsis as hyperdynamic conditions, and subsequently released software versions. Eight studies compared SVV with other dynamic indices. CO, bias, precision, %error, correlation, and concordance differed among underlying conditions, subsequent software versions, and their interactions, suggesting increasing accuracy and precision, particularly in hypo- and normodynamic conditions. The bias and the trending capacity remain dependent on (changes in) vascular tone with most recent software. The SVV only moderately agreed with other dynamic indices, although it was helpful in predicting fluid responsiveness in 85% of studies addressing this. Since its introduction, the performance of uncalibrated FloTrac/Vigileo™ has improved particularly in hypo- and normodynamic conditions. A %error at or below 30% with most recent software allows sufficiently accurate and precise CO measurements and trending for routine clinical use in normo- and hypodynamic conditions, in the absence of large changes in vascular tone. The SVV may usefully supplement these measurements.

Fatal aspiration of polyethylene glycol solution.

Endoscopy of the colon requires adequate cleansing of the entire bowel. Several laxative regimens have been propagated, but bowel preparation with polyethylene glycol (PEG) solution is popular because of the easy application and good cleansing results. Although very safe in daily use, complications of this bowel-cleansing procedure have been reported and aspiration of the PEG solution is a possible and serious hazard. A case report is presented of a patient who aspirated the PEG solution and ultimately died because of respiratory failure.

A retrospective analysis of the intubations performed during 5 years of helicopter emergency medical service in Amsterdam.

INTRODUCTION: Different skilled personnel perform prehospital airway management, by far one of the most challenging skills with major consequences upon failure. SETTING: The setting for this study was the helicopter emergency medical service at the Vrije Universiteit Medical Center, Amsterdam, the Netherlands. METHODS: We conducted a retrospective analysis of all medical charts of intubated trauma patients in the period from May 1995 to May 2000. We focused on intubation reasons and conditions. RESULTS: In 43 of 653 patients (7%) the process of intubation was recorded as being difficult, leading to 5 failed intubations (11.6%). In 432 of 653 trauma victims (66%), general anaesthesia was required before intubation. Forty (9%) of these patients died, most soon after arrival in the hospital. The clinical condition of 221 (34%) patients was so poor that they did not require additional drugs for intubation; 73% of those patients died, with two-thirds dying at the accident site. CONCLUSION: The rate of difficult intubation in this analysis is low (7%). The overall airway failure (11.6%) is the same as seen in the literature when sedation and relaxation are used. An adult trauma victim with a Revised Trauma Score of 0 has a very poor prognosis of survival.