The Official Publication of ITACCS - International Trauma ...

TraumaCare 

Volume 13 Number 2 

Spring 2003 

The Official Publication of ITACCS 

International Trauma Care 


now available at 

www.ITACCS.com 

During a Weapons of Mass 

Destruction drill firefighters/ 

paramedics from the Dallas 

Fire-Rescue Department 

decontaminate the 

unconscious victim of a 

chemical attack, September 

19th, 2002. The team is 

wearing Level B splash 

suits for protection. 

(Photo by Jon Freilich, 

www.firerescuephotos.com) 

CME 

Questions! 

See Pages 

69-71 

➤ Special Symposium Issue 

Program and Abstracts 

Trama Care 2003 

16th Annual Trama Anesthesia and 

Critical Care Symposium 

Dallas, Texas, USA 

➤ In this issue: 20 CME Credit Hours 

SOCÍETÉ INTERNATIONALE D ANESTHÉSIE - REANIMATION EN TRAUMATOLOGIE 

INTERNATIONALE GESELLSCHAFT FÜR ANÄSTHESIE UND INTENSIVMEDIZIN IM TRAUMA 

SOCIEDAD INTERNACIONAL DE ANESTHESIE Y REANIMACION EN TRAUMATOLOGIA

PRESIDENT’S MESSAGE 


33 • Trauma Care in Times of Trouble 

Michael J.A. Parr, MB BS MRCP FRCA 

FANZCA FJFICM 

33 • Special Message From the 

U.S. Surgeon General 

Richard Carmona, MD, MPH, FACS 

PROGRAM 

35 • Schedule for 16th ATACCS 

ABSTRACTS 

39 • Opening Plenary Session 

39 • Presidents’ Forum 

41 • Thursday Afternoon Sessions 

Session A: New Dimensions in Trauma 

and Critical Care 

Session B: Disaster Medicine and 

Emergency Medicine 

Session C: Scientific Free Paper 

Presentations 

The Official Publication of ITACCS 

International Trauma Care 

47 • Friday Morning Sessions 

Session A: Trauma Airway Management 

Session B: Critical Care in the Age 

of Terrorism 

Session C: Trauma Education, 

Simulation, and Patient Safety 

52 • Friday Afternoon Sessions 

Session A: Update on New Drugs, 

Equipment, and Techniques in 

Trauma Care 

Session B: Ethics: Organ Donation, End 

of Life Issues 

Session C: Trauma Airway Management: 

Hands-On Skills Station 

56 • Saturday Morning Sessions 

Session A: Pediatrics 

Session B: Prehospital Care 

Session C: CRNA Session 

65 • Sponsors and Exhibitors 

CME QUESTIONS 

69 • 35 Questions for 20 Credit Hours in 

AMA Category 1 

Publication Date: May 2003 

Credit Expiration Date: May 31, 2004 

CONTENTS 

Copyright 2003 © by the International 

Trauma Anesthesia and Critical Care Society 

ISSN 1094-1126 

Co-Editors-in-Chief 

Adolph H. Giesecke, MD 

Department of Anesthesiology 

UT Southwestern Medical Center 

Dallas, TX 75390-9068 USA 

Tel: 214-590-7254; Fax: 214-590-6945 

e-mail: Adolph.Giesecke@UTSouthwestern.edu 

John K. Stene, MD, PhD 

Department of Anesthesiology 

Milton S. Hershey Medical Center 

Hershey, PA 17033 USA 

Tel: 717-531-8434; Fax: 717-531-4110 

e-mail: jstene@psu.edu 

Managing Editor 

Linda J. Kesselring, MS, ELS 

ITACCS 

P.O. Box 4826 

Baltimore, MD 21211 USA 

Tel: 410-328-7449; Fax: 410-328-3699 

e-mail: lkessel112@aol.com 

Guidelines for Authors available at 

www.itaccs.com 

Send address changes and general 

inquiries to TraumaCareMail@aol.com 

ITACCS World Headquarters 

P.O. Box 4826, Baltimore, MD 21211 USA 

Fax: 410-235-8084 • www.ITACCS.com 

The opinions expressed in TraumaCare 

are those of the authors and not necessarily 

those of ITACCS. 

The drug and dosage information presented 

in this publication is believed to be 

accurate. However, the reader is urged to 

consult the full prescribing information on 

any product mentioned in this publication 

for recommended dosage, indications, 

contraindications, warning, precautions, 

and adverse effects. This is particularly 

important for drugs that are new or prescribed 

infrequently. 

Volume 13 Number 2 Spring 2003 

BOARD OF DIRECTORS 

PRESIDENT 

Michael J. A. Parr, MB, BS, MRCP, FRCA, FANZCA, FJFICM 

VICE PRESIDENTS 

Walter Mauritz, MD, PhD 

Jorge G. Plaza, MD 

EXECUTIVE DIRECTOR 

Christopher M. Grande, MD, MPH 

ASSOCIATE EXECUTIVE DIRECTOR 

James G. Cain, MD 

GENERAL MEMBERS 

Jeffrey M. Berman, MD 

Pierre A. Carli, MD 

Yves Lambert, MD 

Freddy Lippert, MD 

Jerry P. Nolan, MB, BS FRCA 

Eldar Soreide, MD 

Keiichi Tanaka, MD, PhD 

PAST PRESIDENTS 

Enrico M. Camporesi, MD 

Elizabeth A.M. Frost, MD 

Peter J. F. Baskett, MB, BCh, FRCA, MRCP 

John K. Stene, MD, PhD 


COMMITTEE CHAIRPERSONS 

EDUCATION AND TRAINING 



RESEARCH: Trauma and Resuscitation International 

Group for Experimentation and Research (TRIGER) 

Steering Committee: 



Lewis J. Kaplan, MD 

Charles E. Smith, MD 

JOURNAL: TRAUMACARE 

Adolph H. Giesecke, MD (Co-Editor) 

John K. Stene, MD, PhD (Co-Editor) 

DISASTER/MASS CASUALTY 

Andreas Thierbach, MD 

PEDIATRIC TRAUMA 

Calvin Johnson, MD 

PREHOSPITAL/EMS 

Charles Deakin, MD 

CRITICAL CARE 

Maureen McCunn, MD 

SPECIAL EQUIPMENT/TECHNIQUES 

Charles E. Smith, MD, FRCPC 

FINANCE OF TRAUMA CARE 

Anne J. Sutcliffe, MB, BCh, FRCA 

PAIN MANAGEMENT/REGIONAL ANESTHESIA 

Andrew D. Rosenberg, MD 

TOXIC TRAUMA/HAZMAT 

David J. Baker, M. Phil, DM FRCA 

MILITARY TRAUMA 

Matthias Helm, MD 

TRAUMA SURGERY 

Lewis J. Kaplan, MD, FACS 

EMERGENCY MEDICINE 

Dario Gonzalez, MD, FACEP 

CRNA 

Charles R. Barton, CRNA, MEd 

RESPIRATORY THERAPIST 

Rusty Reid, RRT 

OPERATIONAL PROJECTS 

DEVELOPING NATIONS PROGRAM (DNP) 


COMPREHENSIVE APPROACH TO TRAUMATOLOGY (CAT) 

Peter J. F. Baskett, MB, BCh, FRCA, MRCP 

TRAUMA/EMS TERMINOLOGY 

Wolfgang F. Dick, MD, PhD 

JOURNAL: TRAUMACARE 

Linda J. Kesselring, MS, ELS, Managing Editor 

REFRESHER COURSES/WORKSHOPS 

Paul Hilliard, CRNA, Manager 

SPECIAL AD HOC ADVISORS 

Bruce F. Cullen, MD 

Robert L. Fila, Esq. 

Ake N. A. Grenvik, MD, PhD 

Douglas G. Hicks, CPA 

Irene H. Impellizzeri, PhD 

John D. Lupiano, MD, MPH 

Peter Safar, MD 

31

THE INTERNATIONAL TRAUMA 

ANESTHESIA & CRITICAL CARE SOCIETY 

PRESENTS 

2003-2004 Special CME Courses: 

TRAUMA: The Team Approach 

To The Clinical Challenge 

While each program title is the same, the content varies. 

Request the individual brochure for complete details. 

June 15-20, 2003 

Grand Tetons National Park, WY 

July 21-24, 2003 

Hilton Head South Carolina 

August 7-10, 2003 

Seattle, Washington 

August 3-15, 2003 

European Cruise: London>Oslo>Arhus 

Warnemunde>Gotland > Tallin> St. 

Petersburg>Helsinki>Stockholm >Copenhagen 

2003 

August 23-30, 2003 Alaska Cruise 

Seattle>Ketchikan>Juneau>Sitka>Glac 

ier Bay>Victoria> Seattle 

September 6-10, 2003 

Yosemite National Park, California 


Las Vegas, Nevada 

October 7-14, 2003 Fall Foliage Cruise 

NYC>Newport, RI> Boston, MA>Bar 

Harbor, ME>Halifax, NS> Sydney, NS> 

Charlottetown, PEI >Quebec City> 

Montreal, Canada 

2004 

(Preliminary Schedule) 

October 19-24, 2003 

Bonaire Island 

November 2-7, 2003 

Puerto Vallarta, MX 

November 20-23, 2003 

Key West, Florida 

December 1-5, 2003 

St Thomas, Virgin Islands 

February 15-22, 2004 

Western Caribbean Cruise 

February 22-27, 2004 

Punta Cana, Dominican Republic 

March 1-4, 2004 

Whistler, BC, Canada 

April 25-30, 2004 

Cozumel, Mexico 

June 10-13, 2004 

Boston, MA 

June 16-20, 2004 

Longboat Key, FL 

July 12-15, 2004 

Cape Cod, MA 

August 15-22 

Alaska Cruise 


Las Vegas, NV 


Rome to Barcelona Cruise 


Turks & Caicos, BWI 

December 5-10, 2004 

Aruba 

for Additional Information Visit Our Web Site www.nwas.com/itaccs email info@nwas.com 

POB 2797, Pasco, WA. USA 99302 

PH (509) 547-7065, (800) 222-6927; FAX (509) 547-1265

ITACCS Spring 2003 

PRESIDENT’S MESSAGE 

Trauma Care in Times of Trouble 

Michael J.A. Parr, MB BS MRCP FRCA 

FANZCA FJFICM 

President, International Trauma Care 

Intensive Care Specialist 

University of New South Wales 

Locked Bag 7103 

Sydney NSW 1871 

m.parr@unsw.edu.au 

Despite a war, threats of terrorism, and an epidemic of a 

new viral severe acute respiratory syndrome (SARS), 

TraumaCare 2003 will come to fruition in Dallas on May 15th. 

Dedicated heathcare workers involved in the management of 

trauma patients in many nations will meet to discuss and hear 

of advances in the management of trauma victims. The educational 

benefit from these interactions is enormous and translates 

to a potential benefit for future patients. The value of the 

multidisciplinary and international input for TraumaCare 2003 

should not be underestimated. Given the relative lack of high 

quality scientific research in the field of trauma, it is not surprising 

that we rely on the consensus of the multidisciplinary 

approach seen at TraumaCare meetings. 

So many questions in relation to trauma management 

remain to be answered or studied in an objective scientific 

manner that allows critical assessment. The enthusiasm of the 

delegates and their commitment to improving trauma care will 

continue to drive this area of medical science. ITACCS is committed 

to improved trauma research in the future. Trauma has 

long been the “poor cousin” in terms of attracting research 

interest. Perhaps clinicians are too busy looking after patients 

to apply time to critical assessment and study of what really 

makes a difference. Perhaps the healthcare industry has not 

seen the potential benefits of innovation and advances in trauma 

management. This needs to change. Increasingly we recognize 

that the end result for a trauma victim may only be as 

good as the quality of care received at any stage of the trauma 

management process. The complexities and impacts of prehospital 

resuscitation, in-hospital trauma resuscitation, definitive 

care, intensive care, and rehabilitation are only too clear for 

those of us involved in managing these patients. 

During TraumaCare 2003 we will hear about innovations 

in trauma practice as diverse as alternatives for fluid management, 

prehospital ventilation management, control of coagulopathy, 

and optimizing sedation and minimizing complications 

in the ICU. There will be a significant focus on less conventional 

forms of trauma, including terrorism and weapons of 

mass destruction. There will be interactive hands-on sessions 

and ample time to discuss presentations and topics with presenters. 

The Dallas meeting will pave the way and see the presentation 

of the plan for TraumaCare 2004 in Sydney, Australia, 

where we will meet to continue to improve the care of trauma 

patients across all nations. The Sydney meeting will realize 

many innovations for ITACCS that are currently in preparation. 

Details can be found at www.traumacare2004.com and via the 

recently updated www.ITACCS.com. We will proceed, as 

always; through collaboration, good communication, mutual 

respect, and dedication to a goal that is realistic. These ITACCS 

meetings and other initiatives will hopefully generate renewed 

and revitalized interest in driving improved trauma patient 

care. The politicians will not drive this and we need to. 

Special Message from the Surgeon 

General of the United States 

Richard Carmona, MD, MPH, FACS 

On the occasion of this educational 

meeting, I wish to extend well wishes to this 

important gathering of trauma care experts, 

and indeed to the greater community of 

trauma care providers worldwide. 

In the context of current events, the care 

of the injured has assumed even greater importance. 

Throughout most of my adult life, I have had a close personal 

experience with the various dimensions of trauma: first, in the 

Vietnam War, serving as part of the U.S. Army Special Forces, 

and then, after returning home, as a paramedic, registered 

nurse, physician’s assistant, and police officer. Subsequently, 

after graduating medical school and completing residency 

training in surgery and a trauma fellowship, I chose to focus 

my practice on the care of trauma patients, while maintaining 

an active interest in practical field applications as a member of 

the PIMA County Sheriff ’s Department SWAT team (of which I 

was a team leader). These varied experiences have given me a 

unique perspective, having been one of the injured in several 

instances, and providing care for the wounded in others. In 

fact, the topic of tactical medicine has been one focus of my 

medical career and the subject of many of my published works. 

From the standpoint of “conventional” trauma, great 

strides have been made in the public health aspects of care of 

the injured, with improvements in traffic/road safety, automobile 

design, and other injury prevention systems, leading to 

increased survivability from crashes. At the same time, 

upgrades in training, equipment, and emergency medical systems 

have enabled more of the injured to receive better prehospital 

care sooner, and arrive at the trauma center alive. 

This, in turn, has presented ever greater challenges to trauma 

teams receiving these patients. Thus, from this vantage point, 

educational and scientific initiatives such as this are of critical 

importance in pushing back the barriers to improved trauma 

care for all injured patients, and raising the standard of care, 

not only in the United States, but around the world. 

More recently, lesser known “unconventional” types of 

trauma have come to the forefront. The concept of mass casualty 

management has long been a subject of discussion and 

study, and an area of specialization for some trauma care professionals; 

but previously these incidents dealt with situations 

such as war, natural disasters, industrial mishaps, and spectator 

events. The new realities brought to us by the surge in 

international terrorism, and the profound threats now represented 

by “weapons of mass destruction” (WMD), encompassing 

various biological and chemical agents, gives new meaning 

to the concept. Educational programs that further the understanding 

of terrorism, weapons of mass destruction and prevention, 

preparedness, and response are much needed for all 

health-related disciplines. Our new world order demands that 

we be prepared for “all hazards” we may face. 

At the Department of Health and Human Services, we are 

and have been engaged in numerous clinical and basic science 

endeavors to prevent trauma as well as improve care for the 

trauma patient. 

In closing, I salute trauma care providers and their continued 

dedication to the management of the injured. I also recognize 

the important work of many professional organizations, 

and encourage all of you to continue to improve the 

care of trauma patients across the globe. 

33

A joint meeting between THE AUSTRALASIAN TRAUMA SOCIETY 

(ATS) AND TRAUMA CARE INTERNATIONAL (ITACCS) 

SYDNEY CONVENTION & EXHIBITION CENTRE, DARLING HARBOUR, SYDNEY, AUSTRALIA 15-17 OCTOBER, 2004 

The premier trauma meeting for 2004 for all disciplines involved in trauma care from pre-hospital setting through to rehabilitation. 

• Paramedics • Intensive care nurses & physicians • Operating department assistants 

• Pre-hospital physicians & nurses • Rehabilitation physicians & nurses • Surgeons, theatre nurses & ward nurses 

• Emergency physicians & nurses • Physiotherapists • Hospital administrators 

• Anaesthetics & nurse anaesthetists • Medical & nursing students 

Plenary sessions on state of the art trauma care and concurrent sessions featuring – ‘Update’ and ‘Guideline’ sessions, Trauma Master 

classes with panel discussions and ‘Pro:Con’ debates. With emphasis on: 

• Pre-hospital trauma care • Management of biological & chemical • Technological advances in trauma care 

• Principles of intensive care for weapon injuries • Paediatric trauma 

major trauma • Reducing complications for trauma • Trauma rehabilitation 

• Initial resuscitation for major trauma patients • Blast injuries 

• Resuscitative surgery• International perspectives 

• Resuscitative anaesthesia for major trauma • Neurotrauma 

Workshops on: 

• Trauma simulation • Trauma audit as a learning tool • Difficult airway management 

• FAST 

• Organ donation 

Please send me further details on: 

■ Abstract submissions 

■ Registration document – including provisional program & costs 

■ Sponsorship & trade exhibition opportunities 

Name: _____________________________________________________________________________________________ 

Position: ________________________________________ Organisation: __________________________________________ 

Organisation Address: __________________________________________________________________________________ 

Suburb: _________________________ State: _________________ Country: ___________________ Postcode: ___________ 

Telephone: ( ) ____________________________________ Facsimile: ( ) ____________________________________ 

Email: _____________________________________________________________________________________________ 

TraumaCare 2004 Secretariat, Conference Action Pty Ltd, PO Box 576, Crows Nest, NSW, 1585, AUSTRALIA 

Tel: +61 2 9437 9333 Fax: +61 2 9901 4586 Email: confact@conferenceaction.com.au Website: www.traumacare2004.com


PROGRAM 

TraumaCare 2003 16th Annual Trauma Anesthesia and Critical Care Symposium 

DALLAS, TEXAS, USA 

Dallas skyline. (Photo courtesy of Dallas Convention and Visitors Bureau.) 

Thursday, May 15, 2003 

COMMITTEE MEETINGS (by invitation only) 

0630–0745 TraumaCare Editorial Board Meeting, Bel-Air Room I 

Chairs: Adolph H. Giesecke, MD, and John K. Stene, MD, PhD 

0700–0745 Disaster/Mass Casualty Committee, Bel-Air Room VI 

Chair: Andreas Thierbach, MD 

0700–1200 Registration, Garden Court III 

0700–0800 Continental Breakfast, Garden Court III 

OPENING PLENARY SESSION, Malachite Showroom 

0800 Welcome 

Christopher Grande, MD, MPH, Executive Director, ITACCS 

Co-Chair, TraumaCare 2003 Program 

0805 Introductions 

James G. Cain, MD, Associate Executive Director, ITACCS 

Co-Chair, TraumaCare 2003 Program 

0810–0845 JFK in Dallas, A Trauma Care Prospective 

Adolph H. Giesecke, MD, University of Texas Southwestern 

Medical Center, Dallas, Texas, USA 

PRESIDENTS’ FORUM, Malachite Showroom 

0845–0915 President’s Address: What’s New in Trauma 

Michael J.A. Parr, MB BS MRCP FRCA FANZCA FJFICM 

University of New South Wales, Sydney, NSW 

0915–1000 Break, Garden Court III 

Exhibits Open 

0915–1000 TRAUMA: Resuscitation, Anesthesia, Surgery, & 

Critical Care (book edited by W.C. Wilson, C.M. Grande, 

D.B. Hoyt). Dr. Wilson will be available to answer 

contributors’ questions. 

1000–1030 Applications of Dexmedetomidine in the Trauma Patient 

Michael A. E. Ramsay, MD, FRCA 

Baylor University Medical Center, Dallas, Texas, USA 

1030–1100 Stress Management for Care Providers 

in the Trauma Setting 

Jessie A. Leak, MD, University of Texas, MD Anderson 

Cancer Center, Houston, Texas 

1100–1130 Emergency Ventilatory Management of the Trama 

Patient: Elemental or Detrimental? 

Paul E. Pepe, MD, MPH, UT Southwestern Medical Center, 


1130–1200 Fluid Management in Trauma 

Richard P. Dutton, MD, R Adams Cowley Shock Trauma 

Center, Baltimore, Maryland, USA 

1200–1315 Lunch (on your own) 


1300–1700 Registration, Garden Court III 

SIMULTANEOUS AFTERNOON SESSIONS (1315–1715) 

SESSION A 

New Dimensions in Trauma 

and Critical Care, Bel-Air Room I-III 

Co-Chair: James G. Cain, MD 

Co-Chair: Christopher M. Grande, MD, MPH 

1315–1345 Sedation for the Critically Injured Trauma 

Patient: Precedex®, a Novel Alternative 

James Gordon Cain, MD 

Allegheny General Hospital, Pittsburgh, Pennsylvania, USA 

West Virginia University, Morgantown, West Virginia, USA 

1345–1415 The Hazards of Nutraceuticals in the 

Management of the Trauma Patient 

Jessie A. Leak, MD, University of Texas, MD Anderson 

Cancer Center, Houston, Texas 

1415–1445 Controversies in Blunt Aortic Trauma 


MetroHealth Medical Center, Cleveland, Ohio, USA 

1445–1515 Beverage Break, Garden Court III 

35




D.B. Hoyt). Dr. Wilson will be available in the Malachite 

Board Room to answer contributors’ questions. 

1515–1545 What’s New in Neurotrauma 

Anne J. Sutcliffe, MB ChB, FRCA, Queen Elizabeth Hospital 

and University of Birmingham, Birmingham, UK 

1545–1615 Pathophysiological Processes Following Toxic Trauma 

David J. Baker, DM, FRCA, University of Paris, Paris, France 

1615–1645 End Tidal CO2: From Airway to Cardiac Output 

Marvin A. Wayne, MD, FACEP 

University of Washington and Emergency 

Medical Services, Bellingham, Washington, USA 

1645–1715 A New Approach to Monitoring Early 

Hemodynamic Performance: Transesophageal 

Echo Doppler Ultrasound 

Yves Lambert, MD 

Versailles Hospital, Le Chesnay, France 

SESSION B 

Disaster Medicine and Emergency Medicine 

Bel-Air Room IV-VI 

Co-Chair: Dario Gonzalez, MD, New York, New York, USA 

Co-Chair: Andreas Thierbach, MD, Mainz, Germany 

1315–1345 International Chief Emergency 

Physician Training Course 

Freddy Lippert, MD, Rigshospitalet, Copenhagen 

University Hospital, Copenhagen, Denmark 

1345–1415 The Effect of Select Drugs on the 

Presentation of Shock in the Trauma Patient 

Joanne Williams, MD, FAAEM, FACFM 

Martin Luther King, Jr./Charles R. Drew 

Medical Center, Los Angeles, California, USA 

1415–1445 Lessons Learned 911 

Dario Gonzalez, MD, FACEP, Office of Emergency 

Management, City of New York, and Albert Einstein 

College of Medicine, New York, New York, USA 

1445–1515 Beverage Break, Garden Court III 



D.B. Hoyt). Dr. Wilson will be available in the Malachite 

Board Room to answer contributors’ questions. 

1515–1545 Organization of Medical Systems Under 

Repeat Terror Attacks 

Eran Tal-Or, MD, Rambam Medical Center, Haifa, Israel 

1545–1615 Triage: Do We Need New Concepts? 

Kristi Koenig, MD, FACEP, George Washington University 

School of Medicine and Health Sciences; National 

Director, Emergency Management Strategic Healthcare 

Group Department of Veterans Affairs, Martinsburg, 

West Virginia, USA 

1615–1645 Databases for Storing Prehospital and 

Intrahospital Data 

Dr. Peter A. Oakley, North Staffordshire Hospital, 

Stoke-on-Trent, UK 

1645–1715 Panel Discussion 

SESSION C 

Scientific Free Paper Presentations, Le Gala Room 

Moderators: Enrico Camporesi, MD, SUNY Health Science 

Center, Syracuse, New York, USA; Adolph Giesecke, MD, UT 

Southwestern Medical Center, Dallas, Texas, USA; John 

Stene, MD, PhD, Hershey Medical Center, Hershey, 

Pennsylvania, USA 

1315–1445 Scientific Presentations 

1445–1515 Beverage Break 

1515–1715 Scientific Presentations 

1800-2000 Board of Directors Meeting and 

Faculty Dinner, Mayfair Room 

Friday, May 16, 2003 

COMMITTEE MEETING (by invitation only) 

0630–0745 Critical Care Committee Meeting, Baccarat Room 

Chair: Maureen McCunn, MD 

0700–0800 Continental Breakfast, Garden View III 

0700–1200 Registration, Garden View III 

0700–1200 Exhibits Open, Garden View III 

SIMULTANEOUS MORNING SESSIONS (0800–1200) 

SESSION A 

Trauma Airway Management, Bel-Air Room I-III 

Chair: Andreas Thierbach, MD, Mainz, Germany 

0800–0830 The ASA Difficult Airway Algorithm as 

It Pertains to Trauma Patients 

William Charles Wilson, MD 

University of California, 

San Diego School of Medicine, 

San Diego, California, USA 

0830–0900 Controversies and Obstacles to Airway Training for 

Paramedics: What Are the Options? 


University of Texas Southwestern Medical School, Dallas, 

Texas, USA 

0900–0930 Airway Management with Penetrating Neck Trauma 

Vance E. Shearer, MD, University of Texas Southwest 

Medical Center, Dallas, Texas, USA 

0930–1000 Beverage Break, Exhibit Hall, Garden Court III 

Exhibits Open 

1000–1030 The Difficult Airway and Failed Intubation 

Jeffrey M. Berman, MD, University of North Carolina, 

Chapel Hill, North Carolina, USA 

1030–1100 The Role of the Combitube and the EasyTube (EzT) 

Andreas R. Thierbach, MD 

University of Mainz, Mainz, Germany 

1100–1130 SLAM Emergency Airway Flowchart 

James M. Rich, MA, CRNA 


1130–1200 Flexible Fiberoptic Intubation 

Freddy Lippert, MD, Rigshospitalet, Copenhagen University 

Hospital, Copenhagen, Denmark 

SESSION B 

Critical Care in the Age of Terrorism, 


Chair: Maureen McCunn, MD, R Adams Cowley Shock 

Trauma Center, Baltimore, Maryland 

0800–0830 Trauma Care Around the World: How We Are 

Different and How We Are the Same 

Maureen McCunn, MD, R Adams Cowley Shock Trauma 


0830–0900 Wartime Civilian Injuries: An Epidemiological Shift 

in Terrorism and Complex Disasters 

Michel Badih Aboutanos, MD, MPH 

Medical College of Virginia, Richmond, Virginia, USA 

0900–0930 Suicide Bombings in Israel: Injuries Never Seen Before 

Itamar Ashkenazi, MD, and Ricardo Alfici, MD 

Hillel Yaffe Medical Center, Hadera, Israel 


Exhibits Open 

36


1000–1030 Rapid Evacuation and Transport of the 

Critically Injured Patient 

William Beninati, MD, Air Force Coalition for 

Sustainment of Trauma and Readiness Skills (C-STARS) 

University of Maryland School of Medicine, 

Baltimore, Maryland, USA 

1030–1100 Organization of the Nurses Working with Terror 

Victims in the ED and the Wards 

Gila Hyams, RN, MA 

Rambam Medical Center, Haifa, Israel 

1100–1130 Damage Control Surgery: Principles of Care 

for Critical Injury 

Thomas M. Scalea, MD, R Adams Cowley Shock Trauma 



SESSION C 

Trauma Education, Simulation, and 

Patient Safety, Le Gala Room 

Co-Chair: James G. Cain, MD, Pittsburgh, 

Pennsylvania, USA 

Co-Chair: Michael J.A. Parr, MB BS MRCP FRCA FANZCA 

FJFICM, University of New South Wales, Sydney, NSW 

0800–0830 Human Crisis Simulation for Rural Medical Education 


Allegheny General Hospital, Pittsburgh, Pennsylvania, USA 

West Virginia University, Morgantown, West Virginia, USA 

0830–0930 The Role of Microsimulators in Training 

Trauma Professionals 

Ulrik Juul Christensen, MD 

Sophus Medical A/S, Copenhagen, Denmark 


Exhibits Open 

1000–1045 Rapid Preparation of Reserve Military Medical Teams 

Using Human Patient Simulation 

Guy Lin, MD, Israeli Defense Forces, West Galile, Israel 

1045–1130 Drills: Are They the Best Way to Prepare for Mass 

Casualty Incidents? 

Moshe Michaelson, MD 

Techjion Haifa, Haife, Israel 

1130–1200 Trauma Education Through Audit: Simulation 

Session (Laerdal Equipment) 

Michael J.A. Parr, MRCP FRCA, James G. Cain, MD, 


1200–1345 Lunch, Exhibits Open 

1200–1245 Pediatric Trauma Committee Meeting, Malachite 

Board Room (by invitation only) 

Chair: Calvin Johnson, MD 

1215–1315 Exhibits Open, Garden View III 

SPECIAL LUNCHEON PRESENTATION: “Uncontrolled 

Hemorrhagic Trauma: Progressive Treatments to 

Manage Massive Bleeding” 

1215–1220 Opening Remarks 

W. Keith Hoots, MD 

1220–1240 Redefining the Coagulation Cascade 

W. Keith Hoots, MD, The University of Texas, M.D. Anderson 

Cancer Center, and the Gulf States Hemophilia and 

Thrombophilia Center, Houston, Texas 

1240–1300 Catastrophic Trauma and Massive Hemorrhage Care 

Richard P. Dutton, MD 

R Adams Cowley Shock Trauma Center, University of 

Maryland Medical Systems, Baltimore, Maryland 

1300–1315 Questions and Answers 

1315–1345 Desserts and Beverage, Exhibit Hall 


SIMULTANEOUS AFTERNOON SESSIONS (1345–1745) 

SESSION A 

Update on New Drugs, Equipment, and 

Techniques in Trauma Care, Bel-Air Room I-III 

Chair: Charles E. Smith, MD, Cleveland, Ohio, USA 

1345–1415 What’s New in Pulse Oximetry 

Steven J. Barker, PhD, MD 

University of Arizona, Tucson, Arizona, USA 

1415–1445 Capnography in Trama 



1445–1515 Neuromuscular Relaxant Pharmacology: An Update 

Charles E. Smith, MD 

MetroHealth Medical Center, Cleveland, Ohio, USA 

1515–1545 Break (Scientific Awards), Garden Court III 

Exhibits Open 

1545–1615 Acid-Base Balance in Trauma Resuscitation 


Yale University School of Medicine, New Haven, 

Connecticut, USA 

1615–1645 The Management of Massive Bleeds in Trauma by an 

Injury Site-Specific Agent (Recombinant Activated 

Factor VII) 

Uri Martinowitz, MD, Prof. 

Sackler School of Medicine, Tel Aviv University, Tel 

Hashomer, Israel 

1645–1715 Damage Control Orthopedics 

James C. Duke, MD 

University of Colorado, Denver, Colorado, USA 

1715–1745 Emerging Pathogens: Practical and Evidenced-Based 

Interventions 

Lewis J. Kaplan, MD, FACS, Yale University School of 

Medicine, New Haven, Connecticut, USA 

SESSION B 

Ethics: Organ Donation, End of Life Issues, 


Chair: Anne J. Sutcliffe, MB ChB, FRCA, Queen Elizabeth 

Hospital and the University of Birmingham, 

Birmingham, UK 

1345–1415 Managing Death and Dying 

Anne J. Sutcliffe MB ChB, FRCA 

Queen Elizabeth Hospital and the University of 

Birmingham, Birmingham, UK 

1415–1445 Diagnosing Brain Stem Death: After 30 Years 

Couldn’t We Do Better? 

Gerlinde Francisca Mandersloot, MB ChB, FRCA 

The Royal London Hospital, London, UK 

1445–1515 Improving Organ Donation Rates 

Walter Mauritz, Prof., MD 

Trauma Hospital Lorenz Boehler, Vienna, Austria 

1515–1545 Break (Scientific Awards), Garden Court III 

1545–1615 Managing the Donor 

Linda E. Pelinka, MD 

Lorenz Boehler Trauma Center, Vienna, Austria 

1615–1645 Non-Heart-Beating Donors 


R Adams Cowley Shock Trauma Center, Baltimore, 

Maryland, USA 

1645–1715 Living Donors 

Jane McNeill, MB ChB, FRCA 



37


SESSION C 

Trauma Airway Management: Hands-On Skills Station 

Le Gala Room 


Co-Chair: Jeffrey M. Berman, MD, Chapel Hill, North 

Carolina, USA 

Co-Chair: James M. Rich, MA, CRNA, Dallas, Texas, USA 

Co-Chair: Freddy Lippert, MD, Copenhagen, Denmark 

Co-Chair: Marvin Wayne, MD, Bellingham, 

Washington, USA 

Co-Chair: William C. Wilson, MD, San Diego, 

California, USA 

1345–1745 35 minutes at each station / 5 participants per station 

Laryngoscopes, blades, and intubation aids 

Bonfils and Bullard 

Flexible fiberoptic intubation 

Combitube, EasyTube, LT, LMA 

Surgical airway: cricothyrotomy 

Decision training (Airman, SimMan) 

King LT 

1745–1900 Glad-You-Joined-Us-in-Texas Reception, 

Garden Court III 

Saturday, May 17, 2003 

0700-0800 Continental Breakfast 

SIMULTANEOUS MORNING SESSIONS (0800–1200) 

SESSION A 

Pediatric Trauma, Bel-Air Room I-III 

Co-Chair: Gail E. Rasmussen, MD, Meridian, Mississippi, USA 

Co-Chair: Jeffrey M. Berman, MD, Chapel Hill, North 

Carolina, USA 

0800–0830 Emergency Airway Management in the Pediatric 

Trauma Patient 

Gail E. Rasmussen, MD 

University of Mississippi Medical Center, Meridian, 

Mississippi, USA 

0830–0900 Sedation/Analgesia/Anesthesia for Diagnostic Studies 

and Treatment Outside the Operating Room 

James E. Fletcher, MB BS 

University of North Carolina at Chapel Hill, Chapel Hill, 

North Carolina, USA 

0900–0930 Pediatric Prehospital Care 

Charles D. Deakin, MA MD MRCP FRCA 

Southhampton University Hospital, Southampton, UK 


1000–1030 Pediatric Head Injury: Where Have We Been; Where 

Are We Going? 


University of North Carolina, Chapel Hill, 

North Carolina, USA 

1030–1100 Fluid Management of the Injured Child 


Charles R. Drew University of Medicine, Los Angeles, 

California, USA 

1100–1130 Early Care of the Pediatric Burn Patient 

Gary F. Purdue, MD 

UT Southwestern Medical Center, Dallas, Texas, USA 


SESSION B 

Prehospital Care, Bel-Air Room IV-VI 

Co-Chair: Charles Deakin, MA MD MRCP FRCA, 

Southampton, UK 

Co-Chair: Marvin Wayne, MD, Bellingham, Washington, USA 

0830–0900 Selective Cervical Immobilization 


University of Washington and EMS Medical Director, 

Bellingham, Washington, USA 

0900–0930 Pre-Operative Fluid Resuscitation for Trauma 

Patients: Elemental or Detrimental? 

Paul E. Pepe, MD, MPH, FACEP, FACCP, FACP, FCCM 

University of Texas Southwestern Medical Center at Dallas, 



1000–1030 Prehospital Use of Hypertonic Saline Derivatives 

Pierre Carli, MD, PhD 

Hôpital Necker – Enfants Malades, Paris, France 

1030–1100 Prehospital Analgesia and Anesthesia 

Caroline Telion, MD, and Pierre Carli, MD, PhD 


1100–1130 The Role of the Anesthesiologist in Civil Chemical 

and Biological Weapon Attacks 

Dr David Baker M Phil DM FRCA 


1130–1200 Terror-Induced, Multiple Casualty Events: Injury 

Patterns and Emergency Department Response 

Amir Blumenfeld, MD 

Tel Aviv University, Tel Aviv, Israel 

SESSION C 

CRNA Session, Addison Hospitality Suite 

Chair: James M. Rich, MA, CRNA, Dallas, Texas, USA 

0800–0815 Vascular Access for Trauma Anesthesia: Options, 

Risks, Benefits, and Complications 

Deborah B. Latham, MHS, CRNA-P 

Texas Wesleyan University, Cedar Hill, Texas, USA 

0815–0830 Massive Volume Replacement 

Charles R. Barton, CRNA, MSN, MEd 

Akron, Ohio, USA 

0830–0900 Applying ATLS Guidelines to Trauma Care 

Wendell Dean Spencer, CRNA, MHS 

NCAS, O’Neill, Nebraska, USA 

0900–0930 Anesthetic Management of the Patient Sustaining 

Thoracic Trauma 




1000–1030 Anesthetic Management of the Trauma Patient in the 

Rural Health Care Setting 

Wendell Dean Spencer, CRNA, MHS 

NCAS, O’Neill, Nebraska, USA 

1030–1100 Airway Management in Trauma Patients 



1100–1130 Anesthesia Management of Patients with Abdominal 

Trauma 


Texas Wesleyan University, Cedar Hill, Texas, USA 

1130–1200 Anesthestic Management of the Acute 

Spinal-Cord-Injured Patient 



1200 ALL SESSIONS ADJOURN 

0800-0830 Use of Capnography in Prehospital Trauma Care 

Charles D. Deakin, MA MD MRCP FRCA 

Southhampton University Hospital, Southampton, UK 

38


ABSTRACTS 


— Opening Plenary Session — 

JFK in Dallas, a Trauma Care Perspective 


Former Jenkins Professor of Anesthesiology and Chairman 

Department of Anesthesiology and Pain Management 

University of Texas Southwestern Medical Center, Dallas, Texas, USA 

The management of patients following injury continues to evolve as our understanding 

of the physiology of injury improves. Technology advances are providing better diagnostic 

options, allowing earlier diagnosis and selective intervention. Noninvasive or minimally 

invasive techniques are providing new methods of intervention, and therapeutic advances 

are providing more options for the management of difficult cases and complications. 

We have a greater understanding of the economic consequences of trauma care and 

this is driving more selective management for specified patients. Trauma care dogma is 

increasingly challenged in the light of sound science, and investigation or review of unproven 

beliefs that govern treatment decisions should be a priority. 

At the time of writing, we once again face the potential for major armed conflict and 

perhaps never before has the treat of nuclear, biological, and chemical weapons been so 

great. The challenges and concerns these raise affect us all. 

We all have potential roles at local, national, and international levels to improve the 

management and outcome for the victims of trauma. These improvements will be driven by 

the enthusiasm and commitment of those involved in trauma care. 

Applications of Dexmedetomidine in the Trauma Patient 

Michael A.E. Ramsay, MD, FRCA 

Baylor University Medical Center 


Learning Objectives: 

• To understand the pharmacology of α2-adrenoceptor agonists. 

• To learn how the properties of sedation and analgesia without respiratory 

depression may be applied to the management of the trauma patient. 

• To predict the effect on the hemodynamic profile of the patient. 

I was at Parkland Hospital on November 22, 1963, and assisted in the unsuccessful 

attempt to resuscitate the president and gave anesthesia to Governor Connally. I shall 

describe the events of that day, emphasizing the roles of doctors at Parkland, the conclusions 

of the Warren Commission, the controversy surrounding the conspiracy theories, the conclusions 

of the Select Committee, the movie “JFK,” and the evidence that closed the case in 

1992. The lecture is dedicated to Pepper Jenkins, Jim Carrico, and Paul Peters, valued colleagues 

who were there and who have subsequently died. 

JFK came to Texas to try to heal a rift between Lyndon Johnson, his vice president, and 

John Connally, the Governor of Texas. While riding past the School Book Depository in his 

open-topped limousine, he was shot through the neck and head. Governor Connally, who was 

riding in front of the president, was shot through the chest, wrist, and thigh. JFK was brought 

to Parkland Hospital for an attempted resuscitation, which lasted 25 minutes. The doctors who 

were primarily involved in the resuscitation were Jim Carrico, Pepper Jenkins, Mac Perry, and 

Charles Baxter, assisted by Kemp Clark, Paul Peters, Bob McClelland, and myself. 

Lyndon Johnson ordered the body removed to Bethesda, took the oath of office aboard 

Air Force One, and ordered Chief Justice of the Supreme Court Earl Warren to investigate the 

crime. The Warren Commission concluded that the shots were fired from one rifle held by one 

man, Lee Harvey Oswald, who was perched in the sixth floor window of the School Book 

Depository. The public was not satisfied and conspiracy theories flourished. The 

Congressional Select Committee repeated the investigation in 1979 and concluded that 

Oswald was not the only gunman, and the conspiracy included figures from organized crime. 

Oliver Stone’s movie, “JFK” staring Kevin Costner released in 1991, was based on the discredited 

conspiracy theory proposed by Jim Garrison, the District Attorney of New Orleans. 

Dennis Breo published the evidence, which convinced me that no conspiracy existed.1 

He interviewed the pathologists who did the autopsy; reviewed the films, photographs, drawings, 

and microscope slides; and interviewed the key players in the resuscitation_Carrico, 

Jenkins, Perry, and Baxter. Based on Breo’s article, GD Lundberg,2 editor of JAMA, concluded 

that we now have “unequivocal forensic evidence, without reservation that JFK was struck by 

two bullets fired from behind, from one high velocity rifle…one gunman.” His conclusion was 

confirmed in a carefully researched and written book by GL Posner, called Case Closed.3 All participants 

in this congress should visit the Sixth Floor Museum, dedicated to the story of the 

assassination and housed in the old School Book Depository. 

References 

1. Breo DL. JFK’s death, the plain truth. JAMA 1992; 267:2794–802. 

2. Lundberg GD. Closing the case in JAMA on the John F. Kennedy autopsy. JAMA 

1992; 268:1736–8. 

3. Posner GL. Case Closed. Random House, New York, 1993. 

— Presidents’ Forum — 

President’s Address: What’s New in Trauma 

Michael J.A. Parr, MB BS MRCP FRCA FANZCA FJFICM 

Intensive Care Specialist, University of New South Wales, Liverpool Hospital, 

Sydney, Australia 

Learning Objective: To summarise some recent advances in trauma management 

and to identify topics for future initiatives. 

The α2-adrenoceptors are located in the central nervous system, peripheral nervous system, 

vascular smooth muscle, and a variety of other organs. Presynaptic activation of the α2- 

adrenoceptor modulates the release of norepinephrine, resulting in a reduction in the stress 

response. In many instances, this reduction can be very beneficial and cardioprotective. In a 

shock situation, it could be deleterious when the production of catecholamines may be essential 

to supporting the circulation. The activation of the α2-adrenoceptor in the spinal cord and 

locus ceruleus in the brain produces analgesia and sedation without respiratory depression. 

The quality of sedation produced is different from most other sedatives that act on GABA receptors. 

Dexmedetomidine has a sedative profile that resembles non-REM sleep, and patients 

roused from sedation can be assessed neurologically without evidence of being obtunded. 1 

Dexmedetomidine is the most selective α2-adrenoceptor agonist available and is an 

imidazole compound, but without the steroid suppression action seen with etomidate. It is 

metabolized by the liver into inactive metabolites excreted in the urine. The redistribution 

half-life is approximately 8 minutes, and it has a terminal half-life of 3.5 hours; therefore, it is 

a readily controlled sedative when administered as an infusion. 

The dosing is labeled to allow up to 0.7 mcg/kg/h for 24 hours in initially intubated 

patients undergoing mechanical ventilation. Venn et al reported dexmedetomidine use in the 

medical ICU for up to 7 days without the development of tolerance or dependence and without 

any rebound hypertension on discontinuing the drug. They also found that doses as high 

as 2.5 mcg/kg/h were required to properly control sedation in this patient group. 2 

Dexmedetomidine’s analgesic effect has been shown to reduce the need for opioids 

by 50% in postoperative cardiac surgery patients. 3 

The lack of respiratory depression has been demonstrated by Hall et al from measurements 

of end-tidal CO2, by Ebert et al from arterial blood gas analysis, and from CO2 

response curves by Ramsay et al. 4–6 This combination of sedation and analgesia with no respiratory 

depression lends itself to the management of the trauma patient. Controlled sedation 

can be maintained while facilitating weaning from mechanical ventilation. Sedation and 

pain management can be provided for the head injury patient without risk of CO2 retention. 

The effect of dexmedetomidine on cerebral blood flow has been examined in human volunteers. 

7 It reduces cerebral blood flow, probably as a result of reduced cerebral metabolic rate. 

This reduction may be an advantage in the management of many head injury patients, particularly 

if mechanical ventilation can be avoided. 

The success in using dexmedetomidine in “fast-track” cardiac surgery patients offers 

the potential that chest trauma patients may be managed effectively without the need for 

mechanical ventilation or thoracic epidural analgesia. 

Dexmedetomidine allows us an opportunity to re-evaluate how we provide sedation 

and analgesia to the trauma patient. 

References 

1. Nelson LE, Lu J, Guo T, et al. The alpha2-adrenoceptor agonist dexmedetomidine 

converges on an endogenous sleep-promoting pathway to exert its sedative effects. 

Anesthesiology 2003; 98:428-36. 

2. Venn M, Newman J, Grounds M. A phase II study to evaluate the efficacy of 

dexmedetomidine for sedation in the medical intensive care unit. Intensive Care 

Med 2003; 29:201–7. 

3. Venn RM, Bradshaw CJ, Spencer R, et al. Preliminary UK experience of dexmedetomidine, 

a novel agent for postoperative sedation in the intensive care unit. 

Anaesthesia 1999; 54:1136–42. 

4. Hall JE, Uhrich TD, Barney JA, et al. Sedative, amnestic, and analgesic properties of 

small-dose dexmedetomidine infusions. Anesth Analg 2000; 90:699–705. 

5. Ebert TJ, Hall JE, Barney JA, et al. The effects of increasing plasma concentrations 

of dexmedetomidine in humans. Anesthesiology 2000; 93:382–94. 

6. Ramsay MAE, Jones CC, Knorpp HC, et al. Dexmedetomidine does not depress the 

CO2 response curve in postoperative patients. Anesthesiology 2002; 96:A1335. 

7. Prielipp RC, Wall MH, Tobin JR, et al. Dexmedetomidine-induced sedation in volunteers 

decreases regional and global cerebral blood flow. Anesth Analg 2002; 

95:1052–9. 

39


[Dr. Ramsay receives grant/research support from Abbott Laboratories (the manufacturer 

of Precedex®) and is a consultant and member of the speakers bureau for that company. 

In regard to “off-label” uses, Dr. Ramsay will present clinical trial data related to the longterm 

use of dexmedetomidine (Precedex®).] 

Stress Management for Care Providers in the Trauma Setting 

Jessie A. Leak, MD 

Associate Professor of Anesthesiology, University of Texas, MD Anderson Cancer Center, 

Houston, Texas 

What do you want to have? Where do you want to go? Who do you want to go with? How 

the hell do you plan to get there? Write it down. Go do it. Enjoy it. Share it. It doesn’t get 

much simpler or better than that. 

—Lee Iacocca 

Stress management is a ubiquitous subject that many think about but few actively practice. 

Many of us want to reduce stress, particularly in the workplace, but fail to realize that 

stress does not occur in a vacuum. If we are feeling stress at work, chances are that we have 

stress in other areas of our life; these may include personal relationships, anger issues, issues 

involving our physical environment at home or at work, financial issues, and, most importantly, 

loss of opportunities to address our individuality: mind, body, and spirit. Without attention 

to all these areas of our life, we bring this excess baggage to work and perceive an undesirable 

or unpleasant work environment. 

What is Stress? Webster’s dictionary describes stress as “any mental or physical tension 

or strain.” Russ Hanlin, CFO, Sunkist, says that “it’s always appeared to me that stress is within 

the individual and not manufactured by the situation.” 

Hans Selye discussed the scientific theory of General Adaptation Syndrome that 

describes a built-in ability that our bodies have to adapt to situations to a certain extent. 

Beyond this point, stress occurs. However, stress can be cumulative and therefore insidiously 

destructive when homeostasis is no longer possible because of internal resource depletion. 

Why am I Feeling Resource Depleted or Experiencing Burnout? Loss of control (particularly 

in the workplace), the outward manifestation of which is stress, can be intensified 

for anesthesiologists because of the exaggerated loss of a doctor-patient reciprocal relationship 

that other physician specialists enjoy with their patients. In other words, the loss of 

receiving positive strokes from our patients in conventional doctor-patient relationships may 

intensify a chronic depersonalization. 

Anesthesiologists may have little or no interaction with their patients, except in the 

immediate perioperative period. The loss of a reciprocal relationship with our patients is 

intensified in an oncology or burn ward-type setting (areas with many suffering patients). 

Additional factors that can contribute to loss of control (stress) may include 1) the constant 

need to suppress symptoms of fatigue and exhaustion; 2) economic factors that compel 

the physician to perform in the dual role of physician and business manager/CEO; 3) difficult 

relationships with colleagues; 4) increased severity of illness of patients; 5) liability concerns 

(“every patient is a potential law suit” mentality); 6) night call/sleep deprivation; or 7) 

compliance issues, e.g., HIPPA, Medicare. 

You are not alone. A 1994 study in Anesthesiology reported that nearly half of the anesthesiologists 

surveyed felt they were under chronic pressure at work. Female physicians 

between the ages of 45 and 55 without a partner, with full-time hospital work and the attendant 

administrative responsibilities in an understaffed area are at greatest risk to experience 

chronic pressure or stress. This group also commits suicide at six times the rate of the general 

population. 

Chassot described the triad of burnout as emotional exhaustion, depersonalization 

(loss of empathy), and a lack of personal accomplishment. If you are not sure if you are 

burned or burning out, see if you recognize any of the following burnout symptoms: feeling 

tired even with adequate sleep, work dissatisfaction, forgetfulness, sadness, irritability, 

increased incidence of illness, subpar job performance, substance abuse, decreased concentration, 

avoidance of interaction with others, increased boredom with work, decreased work 

accomplishment despite seeming hard work, dreading going to work, avoiding social activities, 

feeling like work is a dead-end (“why bother”), and the perception that what you were 

hired to do is not meeting with reality. 

Where Do I Go From Here? It is important not to compare yourself to others. What 

may drain one individual may be a breeze for another. Simply honor what you know is draining 

you and address the issue. You have a right to be the final judge of your stress issues and 

to accept them as legitimate. Barbara Larrivee tells us in Moving Into Balance that “the journey 

toward personal fulfillment and true transformation requires major restructuring that 

cannot be prescribed with an intervention formula…The pathway cannot be preplanned. 

Each of us has our own internal gauge for when we are ready to deal with a critical life issue.” 

Once you have identified that you are burned out/stressed out, it is imperative to reestablish 

some control in your life. Ironically, when we are burned out, the last thing that we 

want to do is change because change is work. What we want is less work, but avoidance of 

change can become a fear of change (which causes increased stress). 

It is not unusual to find that you have stressors in one or more areas in your life: work, 

relationships (including issues with anger management or toxic relationships), dysfunction in 

your physical environment, financial woes, and most importantly no time or imbalance in 

your body, mind, and/or spiritual life. This may include medical issues or a disconnect with 

our spiritual life, which may or may not include our religious practices or beliefs. 

It is important to take inventory as soon as possible. During this process, it is quite 

helpful to establish what your life purpose may be and what makes your life meaningful. 

Once you discover what is draining you the most, you have three options: 1) Take care of the 

issue by yourself and do it! 2) Delegate the task to someone else or hire someone to do it!; 

or 3) Throw it out and let it go! 

Now is the time which is the borderline between going up and going down; now is the 

time when by slipping into laziness even for a moment you will endure constant suffering; 

now is the time when by concentrating for an instant you will enjoy constant happiness. 

Focus your mind single-mindedly; strive to prolong the results of good karma. 

—The Tibetan Book of the Dead 

Bibliography 

1. Odette Pollar. 365 Ways to Simplify Your Work Life: Ideas That Bring More Time, 

Freedom and Satisfaction to Daily Work. Chicago: Dearborn Financial Pub, 1996. 

2. Chassot P. Stress in European operating room personnel. World Congress of 

Anesthesiologists, 2000 Proceedings 2000, 63–5. 

3. Gaba DM, Howard SK, Jump B. Production pressure in the work environment. 

California anesthesiologists’ attitudes and experiences. Anesthesiology 1994; 

81:488–500. 

4. Heim E. Stressors in health occupations. Do females have a greater health risk? New 

Zealand Psychosom Med Psychoanal 1992; 38:207–26. 

5. Leak JA. Stress management: communicating with the lion and the lamb. ASA 

Newsletter 2002; 66(11): 33–4. 

6. Leak JA. Stress management: finding your purpose in the Ark. ASA Newsletter 2001; 

65(11):27–8. 

7. Leak JA. Stress management: slaying the dragon. ASA Newsletter Part I. 2000; 

64(10):27–8. 

8. Leak JA. Stress management: slaying the dragon. ASA Newslette. Part II. 2000; 

64(11):21–2. 

9. Leak JA. Stress management: calming the lion. ASA Newsletter 1999; 63(8):21–2. 

Emergency Ventilatory Management of the Trauma Patient: 

Elemental or Detrimental? 

Paul E. Pepe, MD, MPH, FACEP, FCCP, FACP, FCCM 

Professor of Surgery, Medicine, and Public Health and Riggs Family Chair in Emergency 

Medicine. The University of Texas Southwestern Medical Center andParkland Health and 

Hospital System, Dallas 

Medical Director, Dallas Metropolitan Medical Response System (MMRS) and Medical 

Director, Dallas Metropolitan Bio Tel (EMS) System 

Learning Objectives: 1) To understand the differences in ventilatory techniques 

used during normal hemodynamic conditions versus those required during circulatory 

arrest/compromise, 2) To appreciate the potential detrimental effects of airway and ventilatory 

techniques commonly used by emergency care providers for cases of cardiac and 

trauma resuscitation, 3) To recognize the rationale and appropriate circumstances for recommended 

ventilatory strategies/adjuncts, both basic and advanced and 4) to learn 

improved strategies for delivering appropriate ventilatory techniques during cardiac and 

trauma resuscitations. 

Emergency care providers have been trained to make airway management a priority in 

cardiac, respiratory, and trauma resuscitation. Nevertheless, most providers of emergency 

care, both in and out-of-hospital, often lack a fundamental understanding of ventilatory physiology 

during circulatory arrest/compromise. Furthermore, texts and guidelines for emergency 

respiratory care traditionally have been somewhat generic, generally emphasizing 

“hyperventilation,” a concept that is also not well understood. The purpose of this talk is to 

review the physiology of ventilation in the unusual circumstances of circulatory arrest/compromise. 

The discussion will describe how both basic and advanced airway techniques can be 

life-saving if used properly, but can also be detrimental when traditional training techniques 

are followed too zealously. The lecturer will conclude with updated recommendations for the 

management of both cardiac and trauma resuscitation and will also review the value of each 

of the various airway adjuncts currently available to emergency care providers. 

References 

1. American College of Surgeons Committee on Trauma. Shock. In Advanced Trauma 

Life Support Program for Physicians. Instructor Manual. Chicago: ACS, 1993, pp 

75–110. 

2. Noc M, Weil MH, Tang W, et al. Mechanical ventilation may not be essential for initial 

cardiopulmonary resuscitation. Chest 1995; 108:821–7. 

3. Idris AH, Staples ED, O’Brien DJ, et al. Effect of ventilation on acid-base balance and 

oxygenation in low blood-flow states. Crit Care Med 1994; 22:1827–34. 

4. Pepe PE. Acute respiratory insufficiency. In Harwood-Nuss A et al, eds. The Clinical 

Practice of Emergency Medicine. Philadelphia, Lippincott, 1996, chapter 140; pp 

636–40. 

5. Pepe PE, Marini JJ. Occult positive end-expiratory pressure in mechanically-ventilated 

patients with airflow obstruction - the auto-PEEP effect. Am Rev Resp Dis 1982; 

126:166–70. 

6. Franklin C, Samuel J, Hu TC. Life-threatening hypotension associated with emergency 

intubation and the initiation of mechanical ventilation. Am J Emerg Med 

1994; 12:425–8. 

7. Durham LA, Richardson RJ, Wall MJ, Pepe PE, Mattox KL. Emergency center thoracotomy: 

impact of prehospital resuscitation. J Trauma 1992; 32:775–9. 

8. Marion DW, Firlik A, McLaughlin MR. Hyperventilation therapy for severe traumatic 

brain injury. New Horizons 1995; 3:439–47. 

9. Pepe PE. Resuscitation of the patient with major trauma. Curr Opin in Crit Care 

1995; 1:479–86. 

10. Pepe PE. Preoperative fluid resuscitation for post-traumatic hemorrhage: elemental 

or detrimental? In Lawin P, Peter K, Prien T, eds. Intensivmedizin. New York, 

Stuttgart, Georg Thieme Verlag, 1995, pp 72–7. 

11. Pepe PE. Controversies in resuscitation: to infuse or not to infuse (2). Resuscitation 

1996; 31:7–10. 

12. Bickell WH, Wall MJ, Pepe PE, et al. Immediate versus delayed fluid resuscitation for 

hypotensive patients with penetrating torso injury. N Engl J Med Oct. 27, 1994; 

331:1105–9. 

13. Pepe PE, Mattox KL, Fischer RP, Matsumoto CM. Geographical patterns of urban 

trauma according to mechanism and severity of injury. J Trauma 1990; 30:1125–32. 

14. Cobb LA, Alvarez H, Copass MK. A rapid response system for out-of-hospital cardiac 

emergencies. Med Clin North Am 1976; 60:283–90. 

15. McManus WF, Tresch DD, Darin JC. An effective prehospital emergency system. J 

Trauma 1977; 17:304–10. 

16. Curka PA, Pepe PE, Ginger VF, et al. Emergency medical services priority dispatch. 

Ann Emerg Med 1993; 22:1688–95. 

17. Applebaum D. Patient selection for advanced prehospital care in a two-level emergency 

medical system. Prehosp Disast Med 1989; 4:36. 

18. Sanders AB, Kern KB, Berg RA, et al. Survival and neurologic outcome after cardiopulmonary 

resuscitation with four different chest compression-ventilation 

ratios. Ann Emerg Med 2002; 40:553–62. 

19. Pepe PE, Raedler C, Lurie K, Wigginton J. Emergency ventilatory management in 

hemorrhagic states: elemental or detrimental? J Trauma 2003 (in press). 

20. Pepe PE, Mosesso VN, Falk JL. Prehospital fluid resuscitation of the patient with 

major trauma. Prehosp Emerg Care 2002; 6(1):81–91. 

40


Fluid Management in Trauma 

Richard P. Dutton, MD 

R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, Maryland, USA 

Learning Objective: To better understand the anesthesiologist’s role in controlling 

life-threatening hemorrhage. 

Fluid resuscitation is a rapidly evolving area of trauma practice, particularly in early 

hemorrhagic shock (while the patient is still actively bleeding). The surgeons have brought 

new diagnostic and therapeutic options to the table, including FAST, angiography, and damage 

control techniques. What has anesthesia contributed? 

I will briefly review the history and recent academic literature on early resuscitation, 

including the arguments for and against deliberate hypotensive management, early use of 

blood products, hypothermia, hypertonic resuscitation fluids, and pro-coagulants. The anesthesiologist 

plays a critical role in the application of each of these therapies and should be 

familiar with the evidence that supports their use. 

I will conclude with a discussion of over-the-horizon approaches to hemorrhagic 

shock, including new diagnostic modalities, new treatment options, and new approaches to 

long-term resuscitation and prevention of organ system failure. 

[Editors’ note re “off-label” use: Dr. Dutton will discuss investigational and anecdotal 

use of dry fibrin sealant bandages, hemoglobin-based oxygen carriers, and recombinant FVIIa.] 


Simultaneous Afternoon Sessions 

— Session A — 

New Dimensions in Trauma and Critical Care 

Co-Chair: James G. Cain, MD 

Co-Chair: Christopher M. Grande, MD, MPH 

Sedation for the Critically Injured Trauma Patient: Precedex®, a Novel Alternative 


Allegheny General Hospital, Pittsburgh, Pennsylvania, and West Virginia University, 

Morgantown, West Virginia, USA 

Learning Objective: To provide an introduction to dexmedetomidine, a newly 

introduced alpha 2 blocking sedative-analgesic, and its use in critically ill trauma patients. 

Dexmedetomidine (Precedex®), a lipophilic imidazole derivative, selective alpha2 

agonist (1300:1, a2:a1), is approved for use in initially intubated critically ill patients. 

Precedex® offers analgesia, sedation, inhibition of shivering, decreased sympathetic outflow, 

and decreased catecholamines without significantly decreasing respiratory drive. With this 

decrease in sympathetic outflow, mild to moderate hypotension and bradycardia may occur. 

Precedex® does not have a direct myocardial effect. A novel aspect of Precedex® is that, 

compared with an equal level of baseline sedation with standard agents, it allows easy arousability. 

This would be particularly advantageous in facilitating reproducible, serial neurologic 

examinations at will in patients with TBI while avoiding the drastic swings in sedation with 

volatile hemodynamics associated with the current propofol-based technique. 

Dexmedetomidine reduced propofol and morphine requirements and improved hemodynamic 

stability during bispectral (BIS) index-guided intensive care unit sedation. Additional 

benefits of Precedex® may be a modest decrease in cerebral blood flow, along with additional 

neuroprotective properties in its own right. 

Bibliography 

Hall JE, Uhrich TD, Barney JA, et al. Sedative, amnestic, and analgesic properties of 

small-dose dexmedetomidine infusions. Anesth Analg 2000; 90:699–705. 

Housmans PR. Effect of dexmedetomidine on contractility, relaxation, and intracellular calcium 

transients of isolated ventricular myocardium. Anesthesiology 1990; 73:919–22. 

Jolkkonen J, Puurunen K, Koistinaho J, et al. Neuroprotection by the alpha2-adrenoreceptor 

agonist, dexmedetomidine, in rat focal cerebral ischemia. Eur J Pharmacol 

1999; 372:31–6. 

Kuhmonen J, Pokorny J, Miettinen R, et al. Neuroprotective effects of dexmedetomidine 

in the gerbil hippocampus after transient global ischemia. Anesthesiology 

1997; 87:371–7. 

Prielipp RC, Wall MH, Tobin JR, et al. Dexmedetomidine-induced sedation in volunteers 

decreases regional and global blood flow. Anesth Analg 2002; 95:1052–9. 

Takrouri MS, Seraj MA, Channa AB, et al. Dexmedetomidine in the intensive care unit: 

a study of hemodynamic changes. Middle East J Anesthesiol 2002;16:587–95. 

Talke P, Li J, Jain U, et al. Effects of perioperative dexmedetomidine infusion in patients 

undergoing vascular surgery. The Study of Perioperative Ischemia Research Group. 

Anesthesiology 1995; 82:620–33. 

Triltsch AE, Welte M, von Homeyer P, et al. Bispectral index-guided sedation with 

dexmedetomidine in intensive care: a prospective randomized, double blind, placebo-controlled 

phase II study. Crit Care Med 2002; 30:1007–14. 

Venn RM, Bradshaw CJ, Spencer R, et al. Preliminary UK experience of dexmedetomidine, 

a novel agent for postoperative sedation in the intensive care unit. 

Anaesthesia 1999; 54:1136–42. 

Venn RM, Bryant A, Hall GM, Grounds RM. Effects of dexmedetomidine on adrenocortical 

function, and the cardiovascular, endocrine and inflammatory responses in 

post-operative patients needing sedation in the intensive care unit. Br J Anaesth 

2001; 86:650–6. 

Venn RM, Hell J, Grounds RM. Respiratory effects of dexmedetomidine in the surgical 

patient requiring intensive care. Crit Care 2000; 4:302–8. 

The Hazards of Nutraceuticals in the Management of the Trauma Patient 

Jessie A. Leak, MD 

Associate Professor of Anesthesiology 

University of Texas, MD Anderson Cancer Center, Houston, Texas, USA 

Learning Objectives: 1) To outline the herbs and dietary supplements (nutraceuticals) 

that are most commonly used in the preoperative phase; 2) to discuss the various 

preparations in which these products are available; 3) to broadly cover the state of government 

regulation of these products; and 4) most importantly, to target some of the more 

important potential drug-nutraceutical interactions and hazards, particularly as they 

may relate to the care of the patient receiving anesthesia. 

Because of the paucity of government regulation regarding purity, contents, manufacturing, 

and health claims as well as pharmacologic and physiologic predictability, it is difficult 

to fund and perform double-blind, placebo-controlled studies on these products. For this 

reason, much of the material concerning potential hazards and adverse drug interactions is 

based on extrapolation, anecdote, and/or uncontrolled case studies on active ingredients that 

are not consistently available in the products that we purchase in our local pharmacies, grocery 

stores, and gyms. 

SUMMARY OF POTENTIAL INTRAOPERATIVE COMPLICATIONS 

Untoward cardiovascular effects Ephedra 

Ginseng 

Licorice 

St. John’s Wort (potential indirect effect) 

Vitamin E 

Triiodothyroacetic acid 

GBL, BD, GHB 

Enhanced bleeding potential 

Potential for prolongation 

of anesthesia 

Possible renal insufficiency 

or hepatotoxicity 

Possible abnormal thyroid functions 

Potential for electrolyte disturbances 

Risk of decreased effectiveness of 

HIV protease inhibitors 

Ginseng 

Ginkgo 

Ginger 

Garlic 

Feverfew 

Vitamin E 

Valerian 

Kava-kava 

St. John’s Wort (anecedotal only) 

Licorice (renal) 

Creatine (renal) 

Echinacea (hepatic) 

Kava-kava (hepatic) 

Triiodothyroacetic acid 

Vitamin E 

Goldenseal 

Licorice 

St. John’s Wort 

SUMMARY OF INDIVIDUAL HERBS AND SUPPLEMENTS 

Name Common Uses Potential Side Effects 

Echinacea Common cold, bronchitis Possibly hepatotoxic. May decrease 

effectiveness of corticosteroids 

Ephedra Diet aid; antitussive Death. Cardiovascular instability. Multiple 

drug interactions 

Feverfew Migraine prophylactic May inhibit platelet activity and increase 

bleeding. Avoid use in pts on anticoagulants. 

Garlic Lipid & BP lowering; May potentiate warfarin and increase 

Antiplatelet, antioxidant, bleeding; affects platelet aggregation. 

anithrombolytic qualities 

Ginger Antinauseant May be a potent inhibitor of thromboxane 

synthetase and may increase bleeding time. 

Use with caution with warfarin. 

Ginkgo Circulatory stimulant May enhance bleeding in pts on 

anticoagulant or antithrombotic therapy. 

Ginseng “Adaptogenic” Avoid use with other stimulants—may 

Energy level enhancer experience tachycardia or hypertension. 

Antioxidant 

May increase bleeding, especially in patients 

on anticoagulant or antithrombotic therapies. 

Known to have anti-platelet properties. 

Goldenseal Diuretic; anti-inflammatory Functions as aquaretic, not as diuretic; see 

no sodium excretion, just free water 

excretion. May worsen edema or 

hypertension. 

Kava-kava Anxiolytic May potentiate barbiturates and prolong 

anesthesia. 

Licorice Gastric and duodenal ulcers Glycyrrhizic acid in licorice may cause high 

blood pressure, low potassium, and edema. 

Contraindicated in renal insufficiency, liver 

conditions, hypertonia. 

St. John’s Wort Mild to moderate depression May prolong effects of anesthesia (anecdotal 

Anxiety 

only). May decrease effectiveness of all HIV 

protease inhibitors as well as all nonnucleo 

side reverse transcriptase inhibitors. May 

decrease blood levels of digoxin. 

Valerian Sedative May potentiate barbiturates. 

41


Triiodothy- Diet aid May cause heart attacks or strokes due to its 

roacetic acid 

potent thyroid hormone content. May also 

see abnormal thyroid function tests along 

with severe diarrhea, fatigue, lethargy, 

weight loss. 

GHB, BD, GBL Body building, Coma, seizures, vomiting, slowed breathing 

weight loss aid, 

requiring intubation, slowed heart rate, or 

sleep inducement 

death. Being investigated as a treatment for 

narcolepsy. Implicated as a “date-rape” drug. 

Vitamin E Slow aging process May increase bleeding, especially when used 

Prevention of stroke and PE with anticoagulant and/or anti-thrombotic 

Promotes wound healing drugs. May affect thyroid function in 

Effective against fibrocystic otherwise healthy patients. May enhance 

breast syndrome 

HTN in predisposed patients in doses 

greater than or equal to 400 IU/day. 

Bibliography 

1. McLeskey C, Meyer TA, Baisden CE, Gloyna DF, Roberson R. The incidence of 

herbal and seleted nutraceutical use in surgical patients. Anesthesiology 1999; 

91(34):A1168. 

2. Tsen LC, Segal S, Pothier M, Bader A. Alternative medicine use in presurgical 

patients. Anesthesiology 2000; 93(1):148–51. 

3. Leak JA, Hogervorst SL, Roach P, Arbuckle R, Palmer L. Anesthesiology 2002; A-1129. 

4. Eisenberg D, Davis RB, Ettner SL, Appel S, Wilkey S, Rompay M, Kessler RC. Trends 

in alternative medicine use in the United States, 1990-1997: results of a follow-up 

national survey. JAMA 1998; 280:1569–75. 

5. Leak JA. Herbal medicines: what do we need to know? ASA Newsletter 2000; 

5(2):5–7,11. 

6. Eisenberg DM, Kessler RC, Van Rompay M, Kaptchuk TJ, Wilkey SA, Appel S, Davis 

RB. Perceptions about complementary therapies relative to conventional therapies 

among adults who use both: results from a national survey. Ann Intern Med 2001; 

135(5):344–51. 

7. O’Hara MA, Kiefer D, Farrell K, Kemper K. A review of 12 commonly used medicinal 

herbs. Arch Fam Med 1998; 7:523–36. 

8. Leak JA. Perioperative considerations in the management of the patient taking 

herbal medicines. Current Opinion in Anaesthesiology 2000; 13:321–5. 

9. Miller HI, Longtin D. Death by dietary supplement. Policy Review 2000; 102:15–25. 

10. American Society of Anesthesiologists. What you should know about your patients’ 

use of herbal medicines. Pamphlet, American Society of Anesthesiologists, 520 N. 

Northwest Highway, Park Ridge, Illinois, 60068; 1999. 

11. Gruenwald J, Brendler T, Jaenicke C. PDR for Herbal Medicines, ed. 2. Montvale: 

New Medical Economics Company; 2000, pp 469–74. 

12. Leak JA. Herbal medicine: is it an alternative or an unknown? A brief review of popular 

herbs used by patients in a pain and symptom management practice setting. 

Current Review of Pain 1999; 226–36. 

13. Durr D, Stieger B, Kullak, Ublick GA, Rentsch KM, Steinert HC, Meier PJ, Fattinger 

K. St. John’s wort induces intestinal P-glycoprotein/MDR1 and intestinal and hepatic 

CYP3A4. Clin Pharmacol Ther 2000; 68:598–604. 

14. US Food and Drug Administration, Medwatch, Important Message for Health 

Professionals. Report serious adverse events associated with dietary supplements 

containing GBL, GHB, BD. August 25, 1999. 

15. Leak JA, Feather SM, DeMonte F. A case of multiple and significant postoperative 

bleeds in a single patient felt to be attributable to chronic preoperative Panax ginseng 

use. Anesthesiology 2001; 95(3):A-1134. 

Controversies in Blunt Aortic Trauma 


Professor of Anesthesia, MetroHealth Medical Center, Case Western Reserve University, 

Cleveland, Ohio, USA 

Learning Objectives: 1) to review the incidence, pathophysiology, and diagnosis of 

blunt aortic injury and 2) to discuss the anesthetic considerations for patients with blunt 

aortic trauma. 

Cardiothoracic trauma includes injury to the chest wall, trachea, bronchus, lungs, 

pleura, thoracic great vessels, diaphragm, heart, and esophagus. The practical points of providing 

safe and efficient anesthesia for patients with blunt aortic trauma will be stressed. 

The diagnosis of blunt aortic trauma should be suspected based on mechanism of 

injury and widened mediastinum on chest radiograph. .Aortic angiogram is the gold standard 

of diagnosis of aortic injury, although TEE may be an excellent alternative according to the 

experience in each institution, especially for the unstable patient. Chest computed tomography 

is rapid and noninvasive and may be the test of choice to confirm or rule out the existence 

of mediastinal widening. 

The spectrum of blunt cardiac trauma ranges from asymptomatic myocardial contusion 

to cardiogenic shock, arrhythmias, free wall or septal wall rupture, valvular tears, and coronary 

artery thrombosis. Echocardiography is the diagnostic method of choice in patients with ECG 

abnormalities or unexplained cardiovascular instability following blunt chest trauma. 

Major considerations for anesthetic management of patients undergoing aortic surgery 

include location and extent of aortic injury and timing of surgery. Delaying surgery is recommended 

in many instances for stabilization and workup of other injuries. Strict control of 

blood pressure with beta blockers and/or vasodilators is essential. Hemodynamic monitoring 

is recommended to optimize blood pressure, cardiac output, and tissue perfusion. 

Ascending aorta and aortic arch tears require cardiopulmonary bypass and single lung 

anesthesia. Deep hypothermic circulatory arrest is often employed. Proximal descending aortic 

tears are usually done with clamp and sew techniques and one-lung anesthesia. Partial left 

heart bypass may be utilized. Maintenance of normoglycemia improves wound healing and 

reduces wound infection and death. Cerebrospinal fluid drainage is not routinely done. Risk 

factors for developing paraplegia after aortic surgery include duration of aortic cross clamping, 

intraoperative hypotension, and surgical technique. 

A left-sided double-lumen tube is preferred for one-lung ventilation because of the 

high margin of safety and relative ease of deflating the left lung and providing CPAP to the 

atelectatic lung. Alternatively, a bronchial blocker technique may be employed. Fiberoptic 

bronchoscopy is routinely done to confirm proper position. 

Postoperative complications after aortic repair include respiratory failure, stroke, 

pneumonia, renal failure, suture line failure, and paraplegia. 

References 

1. Duan Y, Smith CE. Anesthesia for major cardiothoracic trauma. In Wilson WC, 

Grande CM, Hoyt DB, eds. Trauma: Resuscitation, Anesthesia, and Critical Care, 

chapter 25, 2003, in press. 

2. Van den Berghe G. Intensive insulin therapy in the critically ill patients. N Engl J 

Med 2001; 345(19):1359–67. 

3. Orliaguet G, Ferjani M, Riou B. The heart in blunt trauma. Anesthesiology 2001; 

95:544–8. 

Web-Based Resources 

1. Devitt JH. Blunt thoracic trauma: assessment, management, and anaesthesia. 

www.anesthesia.org/winterlude/wl95/wl95_4.html. 

2. EAST guidelines for blunt aortic trauma management. www.east.org/tpg/chap8.pdf. 

3. Pulmonary artery educational project: 

www.pacep.org/pages/start/ref.html?xin=accp. 

4. ASA guidelines for PA catheters: 

www.asahq.org/publicationsandservices/pulm_artery.pdf. 

What’s New in Neurotrauma 

Dr Anne Sutcliffe MB ChB, FRCA 

Consultant in Anaesthesia and Critical Care, Queen Elizabeth Hospital, Birmingham B15 

2TH, UK and Honorary Senior Lecturer, University of Birmingham 


• To review the scientific basis of interesting developments 

• To put these developments in clinical perspective 

These days, all of us are trying to practice evidence-based medicine. Unfortunately, 

there is a dearth of high quality research in the field of head injury management. This is 

unfortunate because mortality is still high. However, hospital outcome measurement following 

head injury is still crude compared to rehabilitation outcome measures. Attempts to link 

existing outcome registries have not been practical. Now is the time to reconsider how we 

assess outcome. 

It is well known that hypoxia, hypotension, and combined hypoxia and hypertension 

are associated with poor outcome. The original data clearly demonstrate that perfusion is the 

crucial factor. But there is debate about how cerebral swelling should be managed. Many 

believe that protocol-driven management, which includes fluid and inotropes to raise mean 

arterial pressure, is useful. In Lund, an alternative approach is equally successful and treatment 

is directed mainly to reducing vasogenic oedema. Hypertonic saline has yet to find a 

clear role in the management of head injury. 

Recent work has shown that blood glucose level in the first 24 hours after injury correlates 

more closely with outcome than even hypotension. Most doctors control blood sugar 

after head injury, but the evidence for benefit has been shown only in the general ICU population. 

Hypothermia following head injury has failed to live up to its early promise. The reasons 

for this may include delays in inducing hypothermia, practical difficulties in measuring 

brain temperature, and faults in study design. 

The successful management of spinal cord injury also depends on maintaining adequate 

perfusion. Much attention is still directed to preventing mechanical cord damage but 

there is a body of evidence suggesting that it would be better if more attention was given to 

perfusion. The value of steroids has been questioned. There is animal evidence to suggest 

that uncontrolled oxygen therapy may also be detrimental to the under-perfused spinal cord. 

In order to improve outcome after neurotrauma, it is essential that high quality 

research is done. An example of this is the European CRASH trial. Many questions remain 

unanswered but better use of existing knowledge should be our current goal. 

Further reading 

1. Copes WS, Stark MM, Lanwick MM, et al. Linking data from national trauma and 

rehabilitation registry. J Trauma 1996; 40:428–36. 

2. Rosner MJ, Rosner SD, Johnson AH. Cerebral perfusion pressure: management 

protocol and clinical results. J Neurosurg 1995; 83:949–62. 

3. Eker C, Asgeirsson B, Grande P-O, et al. Improved outcome after severe head injury 

with a new therapy based on principles for brain volume regulation and preserved 

microcirculation. Crit Care Med 1998; 26:1881–86. 

4. Walia S, Sutcliffe AJ. The relationship between blood glucose, mean arterial pressure 

and outcome after severe head injury. Injury 2002; 33:339–44. 

5. Van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in critically 

ill patients. N Engl J Med 2001; 345:1359–67. 

6. Qureshi AI, Suarez JI, Castro A, Bhardwaj A. Use of hypertonic saline/acetate infusion 

in treatment of cerebral edema in patients with head trauma: experience at a 

single center. J Trauma 1999; 47:659–65. 

7. Clifton GL, Miller ER, Choi SC, et al. Lack of effect of induction of hypothermia after 

acute brain injury. N Engl J Med 2001; 344:556–63. 

8. Perez-Pinzon MA, Alonso O, Kraydieh S, Dietrich WD. Induction of tolerance against 

traumatic brain injury by ischemic preconditioning. Neuroreport 1999; 10:2951–4. 

Pathophysiological Processes Following Toxic Trauma 

Dr David Baker M Phil DM FRCA 

Department of Anaesthesia and SAMU de Paris 

Hopital Necker – Enfants Malades, Paris 

Learning Objectives: To present an approach toward the management of chemical 

and biological agent injuries, which is injury rather than agent specific. 

Toxic trauma is a term used to describe the injury caused by mass release of a variety 

of toxic agents. These may be drawn from the spectrum of chemical and biological warfare 

(CBW) agents or from the many industrial hazardous materials (HAZMAT). The term may also 

be used to include the longer-term organ failure consequences of serious infection. 

Traditionally, the approach to the management of casualties from chemical agents has 

been antidote based, an approach that rests upon early identification of the noxious agent. 

While this is often possible in the military sphere, where sophisticated detection and monitoring 

systems are available, in civil life, such information may not be possible and treatment 

must then respond to presenting signs and symptoms. The concept of early life support in a 

42


toxic zone (TOXALS) introduced by ITACCS in 1996 has now been widely accepted and the 

new approach to CBW agent management is based upon life support coupled with appropriate 

antidote therapy where possible. 

Consideration of the pathophysiological processes following toxic agent exposure provides 

a rational platform for prehospital and hospital clinical management. CBW agents can 

attack all systems of the body, including the central and peripheral nervous systems, the skin 

and epithelia, and particularly the respiratory system. The latter is vulnerable to attack from 

blockage of the airways through vesication and excess secretions, from failure of central control 

and peripheral neuromuscular transmission due to disruption of the cholinergic transmission 

system, and from the development of toxic pulmonary oedema. Certain classes of 

agent are clearly associated with different processes: nerve agents and neurotoxins have a 

direct effect on synaptic and neural transmission while the classic war gases such as phosgene 

and industrial agents such as methyl isocyanate have been demonstrated to cause mass toxic 

pulmonary edema. Vesicant agents such as mustard gas are now known to have effects at all 

levels of the respiratory tree apart from causing vesication of the dermis. 

The explosion in research into the cholinergic transmission system that followed 

World War II led to a good understanding of the pathophysiology of acetylcholinesterase inhibition 

and the development of a range of antidotes that can be used in both military or civil 

exposure. There are valuable lessons to be learned from the management of pesticide poisoning, 

and the rational use of oximes has been reappraised. The interest in cholinergic 

mechanisms has been matched in recent years by work on the pathogenesis of toxic pulmonary 

edema and new treatment strategies have resulted. Work has focused on increasing 

cellular glutathione (GSH) levels as a means of preventing lipid–peroxidation induced pulmonary 

edema. There are suggestions that N-acetyl cysteine may provide protection by maintaining 

GSH levels and inhibiting production of inflammatory leukotrienes. 

Further application of knowledge gained from normal clinical research into disease 

mechanisms is likely to have a continued beneficial effect on the management of the rarer circumstances 

of mass toxic trauma. 

End Tidal CO2: From Airway to Cardiac Output 


Associate Clinical Professor, University of Washington 

Assistant Clinical Professor, Yale University 

Emergency Medical Services, Bellingham, Washington, USA 

Learning Objectives: 1) to review the physiology of CO2 production and excretion 

and 2) to describe the use of ETCO2 to monitor ventilation, tube placement, and indirect 

cardiac output. 

Principles. A capnometer projects filtered infrared light at a wavelength of 4.28 um 

across a sample chamber to a semiconductor detector. The detector generates an electrical 

signal inversely proportional to the light absorbed by CO2 in the sample chamber, which ultimately 

is translated into a capnometer value (CO2 concentration). Capnography is the realtime 

graphic depiction of CO2 concentration throughout the respiratory cycle. 

Gas sampling may be by “sidestream” or “mainstream” technique. Mainstream technique 

incorporates the sensor into the ventilation circuit. Sidestream technique samples 

exchanged gases through a small branch tube from the ventilation circuit or breathing 

patient. Sidestream sampling is more susceptible to clogging with water or mucus and results 

in a slower response time compared with mainstream capnometry. 

Applications. Carbon dioxide is a by-product of cellular metabolism, constantly produced 

in proportion to the cellular metabolic rate. Because CO2 is transported via the bloodstream 

for elimination by the lungs, measurement of end-tidal CO2 (ET CO2) may reflect the 

cellular metabolic rate, vascular system intactness, cardiac function, and ventilation. 

Capnometry and capnography enjoy widespread use in anesthesia and the ICU. Similar technology 

appears transferable to the emergency department and prehospital setting. 

Decreased CO2 concentrations, detected by capnometry or capnography, are indicative 

of endotracheal tube disconnection, extubation, obstruction, or misplacement. ETCO2 

was found more reliable than direct visualization, auscultation, or observation of chest wall 

motion. Capnometry/capnography can confirm esophageal intubation within one respiratory 

cycle, whereas pulse oximetry may not detect desaturation for several minutes in the preoxygenated 

patient. For these important reasons, capnometry is strongly advocated in the 

emergency department and prehospital arena, where physical diagnosis is difficult at best 

and patient motion increases the risk of endotracheal tube displacement. 

Capnometry and capnography may be useful for assessing the effects of cardiopulmonary 

resuscitation (CPR). During cardiopulmonary arrest, CO2 is neither efficiently transported 

to, nor expired from the lungs, resulting in decreased ETCO2. A rising ETCO2 may be 

the first sign of improved patient status during CPR. CO2 concentrations as measured by capnometry 

have been shown to correlate well with coronary perfusion pressure during CPR. 

These data may suggest prognostic application of capnometry. Capnogram waveform analysis 

enhances the specificity of capnometric ETCO2 measurements. Baseline changes may indicate 

CO2 rebreathing, while slope changes may indicate resistance that occurs with endotracheal 

tube kinking or expiratory obstruction. “Staircase effects” in the capnogram descending limb 

may be seen in situations such as pneumothorax. These applications of capnography and capnometry 

are important in the emergency department and prehospital setting. 

Recently a new dimension has been added with the introduction of noninvasive cardiac 

output. This system utilizes a CO2 Fick principle to simulate the equivalency of an O2 

Fick application. Initially usable only on intubated patients, this has now been expanded to 

those spontaneously breathing. This system combines ETCO2, flow, and differential dead 

space rebreathing to non-invasively accomplish this. 

Limitations. While highly accurate, in certain clinical situations the ability of capnometric 

measurement to estimate arterial CO2 tension (PaCO2) is hampered. In healthy 

patients with well-matched alveolar ventilation and perfusion, ET CO2 estimates PaCO2 within 

2 or 3 mmHg. When expired gas is from poorly or nonperfused alveoli (ventilation-perfusion 

ratio, or V/Q, mismatching), ETCO2 underestimates PaCO2. V/Q mismatching has multiple 

etiologies, including body position changes, acute and chronic pulmonary disease, and 

adult respiratory distress syndrome. While absolute values of CO2 concentration may be inaccurate 

in these circumstances, trend information may remain valuable. Also, the arterial-alveolar 

CO2 difference may be calculated in these patients. The arterial-alveolar difference, a- 

ADCO2, is the difference between arterial CO2 and end tidal CO2 (ET CO2). Normally this 

difference is small (2–3 mmHg) in patients with normal physiology and without cardiovascular 

or pulmonary disease. The a-ADCO2 difference may be elevated due to incomplete emptying, 

shunt perfusion, or dead space ventilation. 

In shunt perfusion, a particular lung unit is underventilated relative to the amount of 

perfusion (normal 5L blood flow to 4L ventilation). Here the a-ADCO2 difference will be 

slightly elevated in the range of 5 to10 mmHg. This small difference is related to the efficiency 

of the lung and the excellent diffusability of CO2. 

In dead space ventilation, a particular lung unit is underperfused relative to the 

amount of ventilation. Dead space ventilation widens the a-ADCO2 much more than does 

shunt perfusion alone. This difference may be 10 to 20 mmHg or more. Further, dead space 

ventilation and shunt perfusion are not mutually exclusive and may both occur to some 

degree in the same patient. 

Conclusion. Capnometry/capnography are of confirmed value in the hospital setting, 

and their applications continue to broaden. Situations unique to the out-of-hospital environment 

invite their rapid extrapolation to the prehospital setting. Their ultimate value will 

depend upon the training, level of understanding, and clinical acumen of emergency care 

providers. New application to allow noninvasive cardiac output will provide a viable alternative 

to invasive systems. 

A New Approach to Monitoring Early Hemodynamic Performance: 

Transesophageal Echo Doppler Ultrasound 

Yves Lambert, Olivier Richard, Pascal Renoux 

Service d’Aide Médicale Urgente (SAMU 78) & Service Mobile d’Urgence et de 

Réanimation 

Versailles Hospital, Le Chesnay, France 

Early resuscitation of severe trauma is first based on physical examination like heart 

rate and arterial blood pressure. These parameters are not accurate enough to give a reliable 

circulatory status of the patient. Therapeutic adjustments based on these clinical parameters 

are thus difficult to implement and control, even after an initial aggressive therapy. The outcoming 

of the Transesophageal Echo Doppler system, which is a new noninvasive or light 

invasive hemodynamic monitor, could lead to an interesting approach in the rapid management 

of severe trauma patients. Early detection of cardiocirculatory disorders and prompt 

adequate treatment in order to prevent serious complication like organ failure are required 

during the very first hours after trauma. 

Transesophageal Echo Doppler monitoring is easy to use and reproducible. On the 

trauma field or in the emergency room, the rapid settlement of the TEE is a major asset which 

allows to obtain a hemodynamic profile in just a few minutes. Its logical first use gives the 

chance, in clinical practice, to adjust the therapy based on the displayed hemodynamic 

parameters: aortic blood flow, stroke volume in the aorta and total systemic vascular resistance 

of the aortic circuit. 

• For severe head trauma patients with no active bleeding, in order to maintain a 

mean arterial blood pressure (MABP) of 90 mmHg and avoid a secondary cerebral ischemia, 

we highly suggest a continuous measurement of MABP. Thus, interpreting the arterial blood 

pressure data correlated to ABF, Sva and TSVRa, the therapy can be orientated either toward 

fluid loading or toward the use of catecholamines, i.e., when vascular resistances are low with 

a normal flow (neurogenic hypotension). In all cases, continuous monitoring and trends 

allow to assess a real time hemodynamic status and help to adjust treatment. 

• For polytrauma patients (penetrating or blunt trauma), with an unstable hemodynamic 

condition, the arterial blood pressure and heart rate are useless in estimating the right 

amount of blood loss. Keeping in mind that treatment should not delay surgery, monitoring Sva 

and ABF will help guiding the vascular fluid loading. Increase of ABF or Sva will reflect more 

accurately efficacy of initial treatment than any increase of arterial blood pressure. 

Another challenge provided by Transesophageal Echo Doppler is the possibility to determine 

factors able to predict occurrence of MOF. Continuous measurement of ABF and Sva as 

early as possible after the trauma could help to quantify early low flow and poor tissue perfusion 

states. Correlation betwin those variation and occurrence of MOF have to be determined. 

Minimally invasive, hemodynamic monitoring using the Transesophageal Echo 

Doppler approach opens very enthusiastic perspectives. Earlier diagnosis and continuous 

monitoring of circulatory deficiencies must be very useful for the trauma physician to start 

adequate resuscitation and minimize tissue ischemia. 

— Session B — 

Disaster Management and Emergency Medicine 

Co-Chair: Dario Gonzalez, MD, New York, New York, USA 


The International Chief Emergency Physician Training Course 


Trauma Center and Major Incident Command Centre, 

H:S Rigshospitalet, Copenhagen University Hospital, Denmark 

Learning Objectives: To review the development, content, and importance of The 

International Chief Emergency Physician Training Course. 

Education and training are essential in handling major incidents and disasters. It is an 

obligation of any medical system to meet these challenges. Guidelines for education and 

training in disaster medicine have been proposed. 1 

The International Chief Emergency Physician Training course on Command Incident 

Management and Mass Casualty Disasters (ICEP) is one of the international courses with a 

well-established curriculum. 

The first CEP course was set up in 1998 by The International Trauma Anesthesia and 

Critical Care Society (ITACCS) in cooperation with a group of leading chief emergency physicians 

in Mainz and based on experiences from national German CEP courses. 2 

The international faculty consists of experienced chief emergency physicians and 

experts in different fields from various parts of the world to cover all issues. Participants make 

up an international forum of physicians with experiences within prehospital care, trauma 

care, emergency medicine, and command incident management. This constellation facilitates 

international exchange of experiences and ideas. 

The CEP course has an intensive 40 hours curriculum with lectures, discussions of case 

reports, excursions, and in-field training. Subjects include epidemiology of mass casualty incidents 

and disasters, responsibilities and duties of the CEP, command and control, triage concepts, 

personal protection and equipment, communication devices and techniques, evacuation 

and long-range transport, planning for mass gatherings, VIP protection, hostage situations, 

counter terrorism, HazMat, bio-threats and chemical warfare, medical relief, and media 

contact and management. 

Lectures are interactive and most are accompanied by practical training sessions or 

tabletop discussions. Theory and practical training result in full-scale disaster exercises in 

cooperation with all local authorities. 3 

This international concept facilitates post-course exchange of knowledge and experiences 

based on the network established during the 5-day intensive curriculum of chief emer- 

43


gency physicians. 

The ICEP courses are announced at www.ITACCS.com. 

References 

1. Handbook of Disaster Medicine International Society of Disaster Medicine 2000. 

Education and Training, pp 481–95. 

2. Müller R, Lipp MDW. The First International Chief Emergency Physician Training 

Course. TraumaCare 1998; 8:29–30. 

3. Thierbach AR, Lippert FK, Grande CM. The International Chief Emergency 

Physician Training Course on Command Incident Management and Mass Casualty 

Disasters. TraumaCare, in press. 

The Effect of Select Drugs on Shock in the Trauma Patient 

Joanne (“Dr. J”) Williams, MD, FAAEM, FACFM 

Department of Emergency Medicine, Martin Luther King, Jr./Charles R. Drew Medical 

Center, Charles R. Drew University of Medicine & Science, Los Angeles, California, USA 

“He takes a little white heart pill in the morning!” 


• To understand the effects of prescribed medications, herbal supplements, and 

illicit drugs on the clinical presentation of shock. 

• To review the effects of prescription medications and their potential influence 

on the assessment of trauma patients. 

• To appreciate the risk of adverse drug reactions, especially in elderly patients 

with preexisting conditions. 

Many prescribed medications, over-the-counter drugs, social “drugs,” and “herbal 

medicinals” may camouflage the clinical presentation of the shock syndrome in the trauma 

patient. For example, beta blockers may blunt the compensatory tachycardia in hypovolemia. 

Alcohol is a central nervous system depressant and vasodilator, potentially affecting Glasgow 

Coma Scale assessment or potentiating hypotension. A detailed history of prescribed medications, 

over-the-counter drugs, herbal supplements, and social “drug” activity must be 

sought if the “typical” presentation of shock is not consistent with the injury pattern or clinical 

appearance of the patient. 

A working knowledge of the pharmacokinetics and pharmacodynamics of commonly 

prescribed medications and other drugs on various organ systems will aid the clinician in the 

overall assessment and management of the trauma patient. 

Drugs used for the management of pre-existing disease may be solely or partially 

responsible for inciting cause of events leading to injury. Chief “culprits” are insulin and/or 

oral hypoglycemics, antihypertensives, and antiarrhythmics. 

Many adverse drug effects may be treated expeditiously and effectively if it is recognized 

that the drug effect exists. For example, naloxone will reverse the effect of opiateinduced 

respiratory depression, and 50% dextrose in water will reverse hypoglycemia 

induced by insulin and oral hypoglycemics. 

More than 35 million Americans are 65 years of age or older. There is a high incidence 

of diabetes mellitus and cardiovascular disease in the elderly. Many in this patient population 

are dependent on prescribed drugs for maintenance of health and, as a result, the elderly are 

more at risk for an adverse drug reaction. 

Unfortunately, most herbal medications and supplements are not yet regulated by the 

Food and Drug Administration and may be purchased readily without prescription. 

Consumption of these “natural drugs” has increased significantly with the popularity of 

Internet sales and distribution. 

Lessons Learned 911 

Dario Gonzalez, MD, FACEP 

Medical Director, Office of Emergency Management, City of New York, Brooklyn, New 

York, and Albert Einstein College of Medicine, Bronx, New York, USA 


1. Student will be presented three core issues related to the problems associated 

with the 911 disaster. 

2. The student will be presented with basic lessons learned from the discussed 

problems. 

3. The student will be able to appreciate the need for pre-planning and policy 

development for disaster response. 

At 0845 on September 11, 2001, hijacked commercial airliners crashed into World 

Trade Center (WTC) Complex. This resulted in the collapse of the North and South Towers 

(each 110 stories). Fire Department City of New York (FDNY) and other New York City emergency 

responders initiated building evacuation, rescue, and fire suppression activities. The 

collapse of the towers killed 450 responders, including much of the top leadership of the Fire 

Department of New York City, who were operating within the towers as the on-scene incident 

command. 

Incident Command Structure. The collapse and subsequent death of these key 

personnel resulted in a command void within the fire department. An effective command 

structure is essential to resolve four critical issues: scene control, event mitigation, resource 

coordination, and site safety. 

The command structure did develop with time, but the delays encountered in reestablishing 

a command and control structure had significant operational, health, and safety consequences. 

The development of a cohesive incident command structure allowed the transition 

from victim rescue operations to body recovery operations and site mitigation. 

Lessons Learned: 

1. Fire command location must be based on the uniqueness of a disaster. 

2. Coherent command authority is necessary to coordinate resources. 

3. Incident command structure is necessary for the transition and development of a 

coordinated operational plan. 

Hazard Analysis. The environment contained hazardous materials, such as jet fuel, 

battery acid, asbestos, lead paint, silica, explosives (munitions), radioactive debris, and products 

of combustion. Traditional site environmental risk-assessment activities had technical 

problems. The ever-present WTC dust was composed of silica (windows), concrete, smoke, 

cremated/shredded human remains, and unknown irritants. Its prolonged inhalation ultimately 

led to the “World Trade Center cough.” Loss of the incident command and the nature 

of the event resulted in an overall poor personal protective equipment (PPE) compliance rate. 

Efforts were made to qualitatively and quantitatively define the Ground Zero atmospheric 

environment. The environmental readings that were eventually obtained were confusing, 

contradictory, and difficult to correlate with human health risk analysis. 

Lessons Learned: 

1. Environmental data are difficult to interpret and quantify. Numbers in a vacuum 

only serve to confuse and alarm the public and emergency responders. 

2. Policies for the appropriate use of PPE during disaster responses must be enforced. 

3. Incident site hazard information must be collected rapidly and accurately. 

4. Technologies that can provide rescuers real-time information about their environment 

(e.g., sampling and pluming models) are needed. 

Volunteerism. Volunteerism after the WTC attack resulted in increased death rate for 

FDNY and police, due to the self-assignment by off duty personnel. Civilian volunteers arrived 

without appropriate protective equipment and worked in some of the most hazardous locations, 

outside the direction of the incident commander. Their presence added to the confusion 

and increased the safety and rescue responsibilities of the command structure. The massive 

outpouring of volunteer involvement in the response was heartwarming but became 

problematic. 

Conclusion. The events surrounding September 11 posed unique challenges for the 

City of New York. Its uniqueness required emergency responders to assume new roles and 

responsibilities. The events surrounding large-scale disasters have a wide range of hazards. 

The more complicated the event, the greater the potential for multiple complex environmental 

threats. The World Trade Center incident began as an urgent response (days) and 

transitioned into a sustained recovery campaign (18 months). 

There should be procedures in place to ensure 1) appropriate use of PPE, 2) timely 

and accurate hazard assessment, and 3) site management. 

Organization of Medical Systems Under Repeat Terror Attacks 

Eran Tal-Or, MD, 1 Gila Hyams, RN, MA, 1 Guy Lin, MD,2 Amitai Ziv, MD, 3 Zvi Feigenberg, 

MD, 4 Moshe Michaelson, MD 1 

1 

Rambam Medical Center, Haifa, Israel; 2 Medical Corps, Israel Defense Forces; 3 National 

Medical Simulation Center, Tel Aviv, Israel; 4 Magen David Adom, Tel Aviv, Israel 

From the start of the ‘El-Aksa Intifada’ on 29.09.2000 until 13.03.2003, Israel suffered 

753 dead and 5,152 injuries from terror attacks. 523 of the dead and 3,844 of the injured were 

civilians. The incidents were bomb attacks in buses, hotels, and clubs and shooting at civilians’ 

cars. After the first few attacks, the Israeli medical system began to change itself to deal 

with these terror incidents. The prehospital system, Magen David Adom (MDA), changed its 

way of working by adding on-call ambulances, creating a debriefing protocol after every incident, 

and building a feedback system with the hospitals. Emergency wards reviewed the trauma 

practice of their staff by using smart simulators in the ‘National Medical Simulation 

Center’, and the Israeli Trauma Association sent volunteers to help community hospitals get 

ready to deal with these injuries and to deal with mass casualties situations (MCS). The 

national MCS committee reviewed and updated MCS protocols to match the new situation. 

The army found new ways to prepare reserve physicians and medics in a short period of time 

for the new conditions at work. Out of all this, we built an international course for managing 

trauma systems and MCS. 

Triage: Do We Need New Concepts? 

Kristi L. Koenig, MD, FACEP 

National Director, Emergency Management Strategic Healthcare Group, 

Department of Veterans Affairs; 

Clinical Professor of Emergency Medicine, George Washington School of Medicine and 

Health Sciences, Washington, DC, USA 


1. Participants will gain an understanding of the differences between traditional 

triage and triage of mass casualties when health care resources are exceeded. 

2. Participants will become familiar with the indications for and methodology of 

Simple Triage and Rapid Treatment (START). 

The goal of standard triage is to identify the sickest patients who require the most 

immediate care. Clinicians expend the greatest resources on the most critical patients. 

However, in a situation in which health care resources are overwhelmed, patients will die if 

standard triage methods are applied. The focus of triage must shift from treating patients 

who are gravely ill or injured to “doing the most good for the most people.” 

There currently exists no single “correct” method of triage. Varying triage methods 

should be applied depending on the type or magnitude of the event. Is there a scene? Is the 

incident static, or are there likely to be additional casualties over time? Is there access to standard 

definitive medical care, or must patients be managed under austere field conditions or 

triaged to alternate care sites? 

A common method for sorting multiple patients at a disaster scene is Simple Triage and 

Rapid Treatment (START). All patients who can walk are directed to move to a location away 

from the site. Next, patients are divided into green (“walking wounded”), yellow (“delayed”), 

red (“immediate”), and black (“deceased”) groups, based on a quick assessment of respirations, 

pulse, and mental status. Assessment of each patient takes only seconds; the sole treatments 

performed are opening an airway or placing direct pressure on external hemorrhage. 

Under conditions in which immediate transport to definitive care is unavailable, 

Secondary Assessment of Victim Endpoint (SAVE) triage may be used. SAVE assumes a local 

cadre of trained health care providers and decentralized equipment. Triage is a dynamic 

process and periodic patient reassessment is crucial. 

Traditional triage methods presume a static event that occurs at a single point in time. 

However, in a catastrophic setting, there may be multiple pockets of casualties spread across 

a geographic region. Transportation and communication systems may be disrupted, EMS systems 

could be nonfunctional, and definitive care facilities could be unavailable. Traditional 

triage tags are inadequate for medical documentation during a dynamic event; secondary 

examinations and treatment will be necessary. 

In non-military settings, mass casualty triage training is limited. Health care providers 

are taught to apply resources to the most critically ill or injured patients. It is challenging for 

a trained health care professional to allow a patient to die, even if this means saving many 

other lives. Fortunately, the capacity of the U.S. health care system has not been exceeded 

since the influenza pandemic of 1918. However, many current threats, including a massive 

earthquake, pandemic influenza, and some types of terrorist attacks would produce more 

casualties than could be treated. Surge capacity in the United States is currently lacking for 

such a situation; thus, new concepts in triage must be implemented. 

44


References 

1. Koenig KL, Schultz CH. Disaster medicine: advances in local catastrophic disaster 

response. Acad Emerg Med 1994; 1:133–6. 

2. Schultz CH, Koenig KL, Noji EK. A medical disaster response to reduce immediate 

mortality following an earthquake. N Engl J Med 1996; 334(7):438–44. 

3. Benson M, Koenig KL, Schultz CH. Disaster triage: START, then SAVE–a new method 

of dynamic triage for victims of a catastrophic earthquake. Prehosp Disaster Med 

1996; 11(2):117–24. 

4. Koenig KL, Dinerman N, Kuehl AE. Disaster nomenclature–a functional impact 

approach: the PICE system. Acad Emerg Med 1996; 3:723–7. 

5. Schultz CH, Koenig KL, Noji E. Disaster planning and response. In Marx J, 

Hockberger R, Walls R, eds. Rosen’s Emergency Medicine: Concepts and Clinical 

Practice, 5th edition. St. Louis, Mosby, 2002. 

Databases for Storing Prehospital and Intrahospital Data 

Peter A. Oakley, MA, FRCA, MRCGP 

Consultant in Anaesthesia and Trauma, North Staffordshire Hospital, Stoke-on-Trent, 

UK; Senior Research Fellow, Keele University 

Databases for Storing Pre-hospital and Intra-hospital Data 

Dr. Peter A. Oakley 

Consultant in Anaesthesia and Trauma 

University Hospital of North Staffordshire 

Stoke-on-Trent, Staffordshire, UK 

Learning Objectives: To understand the changing requirements for data collection 

in trauma care and to appreciate the influences affecting data accuracy. 

In a cost-constrained, evidence-based, and digitally competent world, data is precious. 

We need it to justify our actions and to point out improvements or pitfalls in care. Its very 

necessity creates a tension between unbiased accuracy and the desire to bolster our own 

practice. The more we are judged on our performance as demonstrated by the data, the higher 

the stakes become and the greater the need for transparency. These pressures are further 

confounded by the difficulty of recording real-time data in an emergency situation and the 

inherent uncertainty in the information at the time. Without cost constraints, we would 

employ extra scribes to record events while others deliver patient care or we would invest in 

labor-intensive media recordings with analytical replay to extract data. 

Despite these conflicting constraints, many worthy data systems have been developed 

and they have played a pivotal role in trauma care. In its heyday, the Major Trauma Outcome 

Study (MTOS) allowed an overall comparison of mortality in different centres, adjusting for 

the variation in anatomical injury and physiological response using the TRISS methodology. 

Database development was relatively naïve at the time, leading to data structures that were 

somewhat clumsy and were extended ‘by accretion’ as extra variables were added piecemeal 

to the whole. In addition, the early focus was on pre-hospital and emergency department 

care, neglecting the important contribution of definitive care and rehabilitation to outcome 

(measured in terms of morbidity and disability rather than just mortality). 

With the lessons we have learned and the seemingly limitless potential of new digital 

technology, we are developing new systems. We demand standardization and are keen to 

agree on universal data sets. Our greed for completeness haunts us as the list of variables 

grows ever larger and the problems of error, omission, and ‘noise’ remain with us. 

Commercial systems such as Collector(, while not inexpensive, have allowed professional 

software developers to enhance the way in which the data is handled. Over 200 centers 

worldwide have signed up to Collector’s flexible system. The American College of Surgeons 

has developed its own system, offering the ability to import data from other commercial systems 

(including Collector). Its NTRACS( trauma registry, launched in 1992, and the associated 

national trauma data bank NTDB( offer national recognition, although only 20-25% of 

Level I-II trauma centers currently subscribe. 

In Europe, the demand for unity and standardization is equally strong. After an international 

workshop coordinated by the Trauma Research and Audit Network (TARN), a 

European consensus on the minimum data set for trauma is being established, using the 

Delphi technique. TARN, the surviving UK sister of MTOS, has commissioned a new webbased 

data management system to facilitate remote input of and access to data. Although it 

incorporates new thinking on the generic nature of trauma data as the patient moves from 

one location to another (e.g. scene to ER to OR to ICU), other developments await the anticipated 

technological surge to allow real-time observations and decision-making to be incorporated 

into our trauma data systems. 

Bibliography 

American College of Surgeons Trauma Registry: http://www.facs.org/dept/trauma. 

Dick WF, Baskett PJ, Grande C, et al. Recommendations for uniform reporting of data 

following major trauma – the Utstein style. Br J Anaesth 2000; 84:818–9. 

Trauma Research and Audit Network: http://www.tarn.ac.uk. 

Wynn A, Wise M, Wright MJ, et al. Accuracy of administrative and trauma registry databases. 

J Trauma 2001; 51:464–8. 

— Session C — 

Scientific Free Paper Presentations 

Moderators: Enrico M. Camporesi, MD, Syracuse, New York; Adolph H. Giesecke, MD, 

Dallas, Texas; John K. Stene, MD, PhD, Hershey, Pennsylvania, USA 

Battle Field Anaesthesia: How Different Is It? 

Dr. Ankit Sarin and Major Manish Mehrotra 

The provision of anesthesia and critical care is always a big challenge in trauma victims. 

It, however, becomes broadly redefined when working in field conditions due to inadequate 

logistic support and non-availability of optimal working conditions. This is exemplified while 

working in a combat zone trauma center. 

Military anesthesia has been instrumental in providing care to the wounded since the 

discovery of anesthesia in 1846 and has made significant progress over the years. Each war 

and conflict has required anesthesiologists working in service hospitals to adapt to new challenges 

in different environments. This paper provides an insight into the working of a forward 

military trauma care center located in insurgency-rife Jammu and Kashmir sector. This 

part of India is at high altitude with extreme cold climate and high wind velocity. Besides the 

shelling, altitude, and cold, the area is heavily mined. The steep gradient and loose rocky surface 

make it prime avalanche territory. 

The team comprises a single anesthesiologist and a surgeon with necessary ancillary 

staff. The main operation theatre is inside an underground bunker. We managed 767 casualties 

over a period of two and a half years (November 1999 to June 2002), out of which 587 

patients underwent surgery. This included 209 splinter injuries, 191 gunshot wounds, 118 

landmine injuries, and 69 grenade injuries. 

A standardized protocol using the basics of trauma anesthesia was followed. Adequate 

wound treatment was given prime importance. Radical primary wound debridement and foreign 

body removal accounted for three fourths of the procedures. The choice of anesthesia 

was dependent on the site of involvement. DA was used for all 23% of cases and GA for 19%. 

The remaining cases were done under regional block anesthesia. 

Military experience has shown that the presence of expert care in the vicinity of a forward 

post is a very big moral booster for troops employed in warfare. Prompt optimal care 

gives the trauma patient a chance to return to functional life. The future challenge for anesthesiologists 

involved in trauma care in an advance field surgical unit is to provide tertiary 

level care within the available resources and to minimize morbidity and mortality. 

Cervical Spine Management in Unconscious Adult Trauma Patients: Survey of 

Practice in UK Specialist Centres 

Dr. Phil Jones, Mr. John Wadley, Dr. Marie Healy 

Royal London Hospital, London, United Kingdom 

Learning Objective: To determine how the cervical spine is assessed before discontinuation 

of immobilisation in unconscious adult trauma patients in UK neurosurgical 

centres. 

Purpose of study: a) to establish if each unit had a written protocol or guidelines to 

screen for cervical spine injury, b) to determine the radiological screening tests used routinely 

in all unconscious patients, and c) to ascertain whether cervical spine immobilisation 

was normally continued until the patient regained consciousness and could be examined 

clinically. 

Method Used. A postal questionnaire was sent to all neurosurgical centres in the United 

Kingdom. Follow-up telephone contact was made if a reply was not received within 6 weeks. 

Results. 27 of 32 centres responded (84% response rate). The following results refer 

to the units from whom replies were received: 9% had written guidelines for the radiological 

screening tests used routinely in unconscious adults, 6% had a written policy for discontinuing 

immobilization, 56% of centres used fewer than three plain radiographs (over half of 

these centres did not use computed tomography [CT] routinely). CT scanning was used in 

10 centres (37%). Two centres (7%) used dynamic fluoroscopy routinely. One centre used 

magnetic resonance imaging (MRI) routinely. 

If all radiological investigations were normal, 44% of centres discontinued immobilisation 

before the patient was awake and could be assessed clinically. 

Seven centres (26%) had experience in dynamic flexion-extension fluoroscopy. Three 

of these believed it was unsafe. 

Conclusion. There is little consistency in how the cervical spine is assessed before 

the removal of immobilisation precautions in UK neurosurgical centres. Although the use of 

plain radiography is ubiquitous, there is wide variation in the number of films taken. Routine 

use of CT is surprisingly low for specialist centres dealing with unconscious trauma victims. 

Clinicians in these centres have little experience, and less faith, in the safety of dynamic fluoroscopy. 

Clinically Relevant Hyperventilation of First Aid Providers 

Results from Artificial Ventilation 

B. Kleine-Weischede, T. Piepho, MD, C. Jaenig, B. B. Wolcke, MD, A. R. Thierbach, MD 

Clinic of Anesthesiology, Johannes Gutenberg-University, Mainz, Germany 

Learning Objective: To investigate the hypothesis that rescuer ventilating an apneic 

victim during basic life support (BLS) performing mouth-to-mouth or mouth-to-nose ventilation 

suffers from clinically relevant and statistically significant hyperventilation. 

Purpose of Study. The “Guidelines 2000 for Cardiopulmonary Resuscitation and 

Emergency Cardiovascular Care–International Consensus on Science” recommend a ventilation 

volume of 10 mL/kg body weight (equivalent to a tidal volume of 700 to 1000 mL) without 

the use of supplemental oxygen in adults during isolated respiratory arrest and two-rescuer 

cardiopulmonary resuscitation (CPR). 1 Additionally, a deep breath is recommended 

before each ventilation to increase the end-expiratory oxygen concentration of the air 

exhaled by the first aid provider. 

Methods. To investigate the effects of these recommendations in healthy volunteers, 

test persons were asked to perform isolated artificial ventilation and two-rescuer CPR in a 

lung model connected with a BLS mannequin. The tidal volume was fixed to 800 mL. The 

breathing rate was set to 12/min for isolated respiratory arrest. In the two-rescuer cardiopulmonary 

resuscitation model, it depended primarily on the rate of chest compressions (set to 

100/min). Therefore, a breathing rate between 8 and 9/min could be achieved by the test persons. 

End-tidal carbon dioxide, oxygen saturation (measured by pulse oximetry), and heart 

rate were recorded continuously. Capillary blood gas samples (including capCO 2 ) were collected 

before and after the ventilation periods. 

Results. Clinically and statistically significant hyperventilation results in first aid 

providers performing artificial ventilation during isolated respiratory arrest 2 and two-rescuer 

CPR according to the Guidelines 2000. The ventilation was associated with a significant 

decrease in capillary and end-expiratory carbon dioxide pressure (p


with a crash airway. 

The Statoil Search and Rescue Helicopter Service 

Anders Kroken, Flight Nurse, Statoil HNO HMS, Heidrun TLP, Norway 

Jørund Resell, MD, Statoil HNO HMS, Stjørdal, Norway 

Arne Bere, Flight Nurse, Statoil Tampen HMS, Statfjord B, Norway 

Guttorm Brattebø, MD, Anestesi- og intensivavd., Haukeland sykehus, Norway 

Eva Shammas, MD, Statoil Tampen HMS, Statfjord B, Norway 

Learning Objective: To describe and demonstrate the use of offshore stationed SAR 

helicopters in emergency situations at offshore oil installations. 

Oil companies operating in the North Sea and Norwegian Ocean are obliged to have 

their own medical aid and health service on board their platforms, even though a national 

coast guard service covers all the coast line. The quality of the service shall be comparable to 

onshore primary health care, and even requires the ability of qualified transportation of 

injured or critically ill patients. 

Supplying oil installations with competent and immediate medical aid requires a helicopter 

based service. The low frequency of emergencies makes it possible to combine the 

service of ambulance transportation with tasks concerning surveillance of oil spills as well as 

search and rescue operations. 

The crew consists of five members. The nurse on board is supposed to be able to handle 

emergency medical situations with the help of the rescue-man. 

Statoil commenced the service at the Statfjord B platform in 1982. Since June 2001, the 

Statoil SAR operations include a new service based at the Heidrun platform in the Norwegian 

Ocean. 

The method used is retrospective investigation of medical files and flight records. 

The services in the Norwegian Ocean and the North Sea are demonstrated through 

pictures and tables. Descriptions of personal qualifications and equipment in use will be 

given. The main categories of tasks will be reviewed and discussed. 

The efficiency of the service is demonstrated by referring a medical case, including 

serious trauma to extremities. First aid was given at the platform, and treatment was continued 

by the SAR nurse arriving at the installation. Scramble time and flight time was half the 

time compared with using an onshore based helicopter. 

Results. Diagnoses are summarized and counts are reviewed for the year 2002. The 

counts show a total of 78 patients treated at Statfjord and 59 at the Heidrun services. Traumas 

counted for 22 and 12 of the cases, respectively. SAR operations, including hoisting from vessels, 

were performed in 6 and 2 cases each. In the other cases, the SAR helicopters where able 

to land on the helideck. 

Fourteen percent of all treated patients were suggested to have an MI. In comparison, 

all traumas accounted for 25% of total. Major trauma counted for just 3 of these 34 cases, 

while the major part of traumas were distal fractures and soft tissue wounds. Counts show an 

increasing number of cases with coronary heart disease, while trauma cases are becoming 

fewer and less serious than in the early days of oil business offshore. 

Conclusion. The combination of helicopter ambulance with a full SAR service in offshore 

industry is an appropriate way of gaining a high quality medical emergency service. 

Sharing the cost with company emergency tasks like sea-rescue and oil spill surveillance 

makes it beneficial to the oil companies. Combining these tasks gives an ambulance service 

at lower cost, higher quality, and shorter response time. 

Stand-By Intra-Aortic Balloon Occlusion in the Prevention of Cardiac Arrest Prior 

to Definitive Treatment of Traumatic Hemorrhage 

Kitoji Takuhiro, MD, Hisashi Matsumoto, MD, Toru Mochizuki, MD, Yuji Kamikawa, MD, 

Yuichiro Sakamoto, MD, Yoshiaki Hara, MD, Kunihiro Mashiko, MD, Yasuhiro Yamamoto, MD 

Department of Emergency and Critical Care Medicine, Nippon Medical School, Chiba 

Hokuso Hospital, Chiba, Japan 

Learning Objective: To understand the strategies of initial treatment for the 

patients in hemorrhagic shock due to intra-abdominal hemorrhage or retroperitoneal 

hemorrhage. 

Purpose of Study. Hemorrhagic shock due to intra-abdominal hemorrhage or 

retroperitoneal hemorrhage caused by severe liver injury or pelvic fracture may cause cardiac 

arrest. How can we prevent cardiac arrest prior to adequate blood transfusion or definitive 

treatment such as transcutaneous arterial embolization (TAE), external fixation of the pelvis, 

or laparotomy? In the present study, we show the usefulness of the concept of stand-by intraaortic 

balloon occlusion (IABO). 

Methods. In the present study, a retrospective review of trauma patients, in whom 

IABO was considered appropriate, was conducted over a 3-year period. For the trauma 

patient, prior to the use of an IABO catheter, a 9Fr introducer or 18G catheter was inserted 

percutaneously so that emergency insertion of IABO would be possible. We defined this procedure 

as “stand-by IABO”. 

Results. We reviewed trauma patients with hemorrhagic shock (BP range, 50–94 

mmHg) due to intra-abdominal hemorrhage or retroperitoneal hemorrhage at presentation 

and who were still fighting for life. Ten patients were considered to need or potentially need 

the use of IABO and in whom a 9Fr introducer or 18G catheter had been inserted. Among 

them, 7 patients were considered to need “stand-by IABO.” Three patients were considered 

to need immediate IABO. Three of the 7 “stand-by IABO” patients were non-responders or 

transient responders to the initial bolus fluid resuscitation and required later inflation of the 

IABO balloon. 

Conclusion. Stand-by intra-aortic balloon occlusion for preventing cardiac arrest 

prior to definitive treatment of traumatic hemorrhage appears to be a useful adjunct in some 

cases. We recommend preparing stand-by IABO for those patients whose initial vital signs are 

unstable and who would have intra-abdominal hemorrhage or retroperitoneal hemorrhage 

caused by severe liver injury or pelvic fracture, before their vital signs could deteriorate to the 

point where the femoral artery could not be palpated. 

Mason’s PU-92 Concept: Rapid Recognition and Treatment of the Crash Airway 

Andrew M. Mason, MB, BS, MRCS, LRCP, Suffolk Accident Rescue Service, Ipswich, Suffolk, 

United Kingdom 

James M. Rich, MA, CRNA, Staff Nurse Anesthetist, Department of Nurse Anesthesia 

Baylor University Medical Center, Dallas, TX, USA 

Michael A.E. Ramsay, MD, FRCA, Chief of Service, Department of Anesthesiology and Pain 

Management, Baylor University Medical Center, Dallas, TX, USA 

Learning Objective: To understand how to rapidly recognize and treat the patient 

Mason’s PU-92 concept 1 was designed to assist with the rapid identification of the crash 

airway 2 by combining an assessment of the level of consciousness with the patient’s SpO 2 

level. The AVPU system specifies four levels of consciousness: 1) A (Alert) – signifying that the 

patient is alert; awake; responsive to voice; and oriented to person, time, and place; 2) V 

(responsive to a Voice) – signifying the patient responds to voice but is not fully oriented to 

person, time, or place; 3) P (responsive to a Pain) – signifying that the patient does not 

respond to voice but does respond to painful stimuli such as pressure to a nail-bed or the 

supraorbital nerve; and 4) U (Unresponsive) – signifying that the patient does not respond 

to verbal or painful stimuli. An AVPU score of ‘P’ or ‘U’ corresponds to a Glasgow Coma Scale 

score of


tions such as airway assessment; oxygenation and ventilation; aspiration prophylaxis; cervical 

spine protection; and confirmation of tracheal intubation. However, it differs from other algorithms 

in the presentation of the six limbs, i.e., 1) first responder limb for providers who generally 

do not possess tracheal intubation skills and may or may not have rescue ventilation 

skills; 2) nonintubation technique limb, which allows the provider to opt out of using tracheal 

intubation if the situation dictates and to either continue with a nonrebreathing mask or bagvalve 

mask ventilation or proceed with a minimally invasive technique such as Combitube, 

COPA, Easy Tube, King LT or LMA; 3) rescue ventilation limb, which provides for rapid insertion 

of a Combitube or LMA or LMA-Fastrach in the presence of a crash airway or failed airway 

situation; 4) difficult intubation limb, which provides options for facilitating a difficult 

intubation; 5) RSI limb, which focuses on appropriate use of rapid sequence intubation; and 

6) cricothyrotomy limb for application if rescue ventilation fails. 

The flowchart assists in improving oxygenation and ventilation regardless of the 

provider’s skill level. Other contributions include use of limiting intubation attempts to avoid 

traumatizing the airway or creating a “cannot ventilate–cannot intubate”; 6 “Mason’s PU-92 

Concept” for rapid recognition of the crash airway 1 ; maxims and special considerations to 

facilitate airway safety; technique adjustment if adequate oxygenation is not being attained or 

maintained; clear criteria for application of rescue ventilation to treat a failed or crash airway; 

criteria for application of cricothyrotomy; and near-failsafe devices in all locations to confirm 

tracheal intubation. Use of color to show safe blocks, danger blocks, decision blocks, consideration 

blocks, and action blocks aids in instruction and acquisition of information. 

Conclusions. A flowchart has been developed that can be used by all practitioners 

involved in emergency airway management. It provides a platform for teaching critical decisionmaking 

skills to diverse practitioners. It is hoped that a tool can be developed to measure its 

effect on providers’ ability to apply critical decision-making skills effectively in emergency airway 

management. The flowchart is germane to that common area of emergency airway management 

where the diverse fields of anesthesiology, emergency medicine, and prehospital care coincide. 

References 

1. Mason AM. The Laryngeal Mask Airway (LMA) & Intubating Laryngeal Mask Airway 

(ILMA) in Prehospital Trauma Care. Presentation at the Royal College of 

Anaesthetists, London, May 13, 2002. 

2. ASA Task Force on Management of the Difficult Airway. Anesthesiology 1993; 78:597. 

3. Gabbott DA. Management of the airway and ventilation during resuscitation. Br J 

Anaesth 1997; 79:159–71. 

4. Walls RW. The emergency airway algorithms. In Walls RW, ed. Manual of Emergency 

Airway Management. Philadelphia: Lippincott Williams & Wilkins, 2000, pp 16–26. 

5. Smith CE, Grande CM, Wayne MA, et al. ITACCS Rapid Sequence Intubation (RSI) 

in Trauma [poster]. 10th ATACCS. Baltimore, May 1997. 

6. Benumof JL. The ASA Difficult Airway Algorithm: new thoughts and considerations. 

In Hagberg CA, ed. Handbook of Difficult Airway Management. Philadelphia: 

Churchill Livingstone, 2000, pp 31–48. 


Simultaneous Morning Sessions 


Trauma Airway Management 

Chair: Andreas Thierbach, MD, Mainz, Germany 

RECOGNIZED 

PROPER 

PREPARATION 

AWAKE 

INTUBATION 

CHOICES* + 

SUCCEED 

SURGICAL 

AIRWAY 

CANCEL CASE, 

REGROUP (e.g., 

different personnel/ 

equipment) 

DIFFICULT AIRWAY 

UNCOOPERATIVE 

PATIENT 

UNRECOGNIZED 

MASK VENT 

NONPROLEMATIC 

FAIL 

REGIONAL 

ANESTHESIA 

(if possible and 

surgery reversible) 

GENERAL 

ANESTHESIA 

+ PARALYSIS ++ 

MASK 

VENTILATION 

AWAKEN 

YES 

(non emergency 

pathway) 

INTUBATION 

CHOICES * + 

FAIL 

+ 

NO 

(emergency 

pathway) 

SUCCEED 

SURGICAL 

AIRWAY 

++ 

+ 

Always consider calling for help (e.g., technical, 

medical, surgical etc.) when difficulty with mask 

ventilation and/or tracheal intubation is encountered 

Consider the need to preserve spontaneous 

ventilation 

LMA, 

COMBITUBE, 

TTJV 

AWAKEN 

INTUBATION 

CHOICES* + 

SURGICAL 

AIRWAY 

CONFIRM 

when 

EXTUBATE 

OVER JET 

appropriate 

STYLET 

ANESTHESIA WITH 

MASK VENTILATION 

Figure 1. The ASA Difficult Airway Algorithm from References 1 and 2. 

*Non-surgical tracheal intubation choices consist of laryngoscopy with a rigid laryngoscope blade (many types), blind 

orotracheal or nasotracheal technique, fiberoptic/stylet technique, retrograde technique, illuminating stylet, rigid 

bronchoscope, percutaneous dilational tracheal entry. See Reference 2 for a complete discussion of these TI choices. 

The ASA Difficult Airway Algorithm As It Pertains to Trauma Patients 

William C. Wilson, MD 

University of California, San Diego School of Medicine, San Diego, California, USA 

Learning Objectives: 1) to review the ASA difficult airway (DA) algorithm, 2) to recognize 

that most of the important elements of the algorithm apply equally well to the elective 

setting and the emergency trauma setting, and 3) to identify special considerations 

and solutions related to trauma airway situations. 

Pre-induction Airway Evaluation. The ASA DA Algorithm (Figure 1) begins with 

recognition of airway difficulty. Whenever the patient is recognized to have a difficult airway 

(and the patient is stable and cooperative), the clinician should secure the airway awake. 

Awake Limb of the ASA Algorithm. The ASA DA algorithm does not endorse any 

particular airway technique. However, it does emphasize that the patient must be properly 

prepared (both mentally and physically) for an awake technique, and the physician must 

ensure continuation of spontaneous ventilation and adequacy of O 2 saturation. 

Stopping to Come Back Another Day (Seldom an Option with Trauma). If 

awake intubation techniques fail, one can, and should, consider stopping, maintaining spontaneous 

ventilation, allowing the patient to recover from topicalization or sedatives and 

resume management later with a better plan (other equipment/personnel). However, stopping 

is seldom an option when managing the emergency trauma airway. 

Anesthetized or Uncooperative Patient Limb of ASA Algorithm. There are three 

common conditions when the need arises to intubate the trachea of an unconscious or anesthetized 

patient with a DA: 1) The clinician fails to recognize a difficult airway in preoperative 

evaluation prior to the induction of anesthesia. 2) The DA patient who is already unconscious 

prior to being assessed by the trauma anesthesiologist. 3) The patient has an obvious DA but 

is hemodynamically unstable (i.e., following trauma) or absolutely refuses to cooperate with 

an awake intubation (child, or mentally retarded, or drugged or head-injured adult). Once 

the patient is anesthetized or is rendered apneic or presents comatose and the trachea cannot 

be intubated, O 2 -enriched mask ventilation is attempted. If adequate, a number of intubation 

techniques may be employed. Techniques allowing continuous ventilation during airway 

manipulations are favored over those requiring an interruption of mask ventilation (e.g., 

fiberoptic bronchoscope, via an LMA or an airway intubating mask, with self-sealing 

diaphragm). Alternatively, techniques requiring a cessation of ventilation (at least temporarily) 

can be employed (these techniques are relatively contraindicated for patients with large 

right-to-left transpulmonary shunt or decreased FRC). 

Three Emergency Airway Aides (LMA , Combitube, and TTJV) Assist the 

Cannot Intubate/Cannot Ventilate Patient. When confronted with this type of patient, 

three alternative ventilation methods should be considered (Combitube, LMA, TTJV). Once 

ventilation is established with one of these methods, other more definitive (and time-consuming) 

techniques of airway management may be considered. 

Confirmation of Endotracheal Tube Position. Immediately after the patient’s trachea 

is intubated, one must confirm endotracheal tube position with end tidal CO 2 measurement. 

If end tidal CO 2 measurement is unavailable, the Wee’s esophageal detector device 

is reasonably reliable (close to 100% sensitive and specific). 

Extubation or Endotracheal Tube Change of the Difficult Airway. If the conditions 

that caused the airway to be difficult to intubate still exist at the time of extubation, or 

if new DA conditions exist (e.g., airway edema, Halo), then the trachea should be extubated 

over an airway exchange catheter and/or with the assistance of a fiberoptic bronchoscope. 

References 

1. Benumof JL. Laryngeal mask airway and the ASA difficult airway algorithm.. 

Anesthesiology 1996; 84:686-99. 

2. Wilson WC, Benumof JL. Pathophysiology evaluation and treatment of the difficult 

airway. Anesthesiol Clin North Am 1998; 16(1):29-75. 

Controversies and Obstacles to Airway Training for Paramedics 


Retired Jenkins Professor and Former Chairman, Anesthesiology and Pain Management 

Univeristy of Texas Southwestern Medical School, Dallas, Texas, USA 

Medical doctors, paramedics, and educators all agree that paramedics should be taught 

management of the airway. Curriculum should include evaluation of the airway and breathing, 

airway-clearing maneuvers, bag and mask ventilation, oral and nasal airway insertion, and 

endotracheal intubation. Teaching methods should include lectures, teaching movies, 

manikin practice, and experience in an operating room supervised by an anesthesiologist or 

nurse anesthetist. Most programs require a minimum of five supervised intubations before 

the course is complete. The supervised OR experience improves the successful attempts in 

the field from 50% to 95%. 

The supervised OR experience carries proven benefits to the paramedic and to the 

patients, but it is becoming less and less available over the nation. One by one hospitals, anesthesiologists, 

and nurse anesthetists have withdrawn from offering this valuable training to 

paramedics. The reasons offered include fear of liability, advice of liability insurance carriers, 

problems with informed consent and increasing use of the LMA in routine surgery. 

I don’t have magic bullets to propose to solve the problem, except to strongly repeat the 

time honored argument, “When you have your cardiac arrest, what level of success will you 

accept from your paramedic: 50% or 95%?” Anesthesiologists and nurse anesthetists must continue 

to offer this training. Insurance companies must accept the minimal risk associated with 

this training, and we must all work on the problem of informed consent. We must also carefully 

evaluate the use of the LMA and Combitube as rescue airways in emergency medical services. 

Airway Management with Penetrating Neck Trauma 

Vance E. Shearer, MD 

Associate Professor, Department of Anesthesiology and Pain Management; University of 

Texas Southwestern Medical Center at Dallas; Dallas, Texas, USA 

Learning Objectives: 1) To understand the need for an individualized approach 

to patients with penetrating neck injuries, 2) to appreciate the indications for and utility of 

fiberoptic bronchoscopy and retrograde intubation in the management of penetrating 

neck trauma, 3) to understand the need for topical anesthesia during bronchoscopy, 4) to 

realize the dangers associated with blind intubation and direct laryngoscopy during the 

management of penetrating neck trauma, and 5) to recognize the situations in which creation 

of a surgical airway is warranted. 

The airway can be distorted significantly by a penetrating neck injury. Standard management 

algorithms do not adequately cover the establishment of a secure airway in patients 

with this type of injury. Until prospective studies are completed, the best technique for intubation 

remains controversial; meanwhile, each patient’s airway must be approached on an 

individual basis. 

47


Fiberoptic Bronchoscopy. Awake and spontaneously breathing patients can usually 

maintain a patent airway. Spontaneous ventilation avoids the potential complications of positive 

pressure ventilation, e.g., barotrauma or disruption of an injured trachea. Intubation 

over a fiberoptic bronchoscope (FOB) has the advantages of both an awake, spontaneously 

breathing patient and the ability to examine the airway distal to the glottis. In the absence of 

significant bleeding, a tracheal wound can be identified and the ETT cuff placed distal to the 

injury. If the wound is sufficiently large or is at the level of the cricoid ring, then the intubation 

can be aborted and a tracheostomy with local anesthesia performed. Few anesthesia 

providers possess proficiency in awake bronchoscopy under emergency conditions; therefore, 

alternative methods of securing an airway may be necessary. 

For an awake FOB technique, the airway must be anesthetized to avoid coughing, gagging, 

and vomiting. Transtracheal injection of local anesthetic is probably best avoided in the 

management of penetrating neck injuries, because it tends to cause significant coughing. 

Administration of a mixture of 4% lidocaine with sterile water through a nebulizer appears to 

decrease coughing and gagging during subsequent topicalization of the airway and provides adequate 

tolerance of the ETT. Others have reported that gargling with viscous lidocaine followed 

by spraying 4% lidocaine through the suction port of an advancing FOB is effective and efficient. 

However, we refrain from the use of viscous lidocaine for fear of dislodging tamponaded hemorrhage. 

Whatever technique of topicalization is utilized, it is important that the airway is anesthetized 

adequately. Topicalization of the airway can take 5 to 20 minutes, which may be too long 

for some patients, and will not be effective in patients with significant bleeding or secretions. 

Blind Intubation. Blind attempts at endotracheal intubation are contraindicated 

because they may worsen existing injury, leading to airway obstruction or passage of the ETT into 

a false passage. An awake patient may cough, buck, or vomit during the attempt, causing loss of 

the airway. The sympathetic response in an awake patient may increase heart rate and blood 

pressure, overcoming hemostasis and causing an expanding hematoma to distort the airway. 

Direct Laryngoscopy. Direct laryngoscopy after rapid sequence induction (RSI) has 

a high success rate. However, it is a blind procedure after the ETT passes the glottic opening. 

Since there is a small potential for blindly placing the ETT through a tracheal wound, initial 

breaths should be administered softly until the ETT is confirmed to be in the trachea by continuously 

expired end-tidal CO 2 . 

Fiberoptic-Assisted Direct Laryngoscopy. Although direct laryngoscopy has a high 

success rate, the author suggests combining FOB or the Shikani Seeing Stylet with direct 

laryngoscopy to decrease the possibility of blindly placing the ETT through a tracheal wound. 

This technique involves RSI, with placement of the FOB (preloaded with an ETT) through the 

vocal cords under direct laryngoscopy. The addition of the FOB allows intubation and inspection 

of the trachea and helps ensure the ETT cuff is distal to a tracheal injury. The FOB may 

also stent the airway during ETT passage, thereby avoiding additional trauma to the trachea. 

The Shikani Seeing Stylet is also ideal for visualizing the airway during intubation. Oxygen can 

be insufflated through the FOB’s suction port or the stylet’s side port. 

Although the author recommends direct laryngoscopy, especially combined with 

fiberoptics, the problem is to identify and predict those patients who will be impossible to 

intubate and will require a surgical airway as the primary choice. Therefore, each patient’s 

injuries must be evaluated and managed on an individual basis. 

Retrograde Intubation. Retrograde intubation has been successful in patients with 

severe maxillofacial injuries and therefore may be especially useful with a Zone III pharyngeal 

injury. In experienced hands, this technique can be performed rapidly and is especially useful 

with airway hemorrhage. However, excessive upper airway tissue destruction and edema 

may prevent passage of the ETT into the trachea. Much of this procedure is blind and may 

dislodge a previously tamponaded hematoma, causing massive bleeding. 

Surgical Airway. Creation of a surgical airway is the best first choice in some situations: 

• Failure to intubate 

• Cricoid ring injury 

• Significant laryngeal injury 

• Excessive hemorrhage 

• Significant tracheal deviation 

• Trauma-induced airway obstruction 

• Quadriplegia 

• Significant upper airway tissue edema and destruction 

Expectations. As anesthesia providers, we are called upon to provide airway management 

in any area of our hospital where the need arises, including critical care units and 

the emergency department. Often the circumstances are chaotic and the environment difficult. 

Moreover, we can be confronted with an obviously difficult airway–facial trauma, airway 

edema or hemorrhage, hematoma of the neck, or other anatomic abnormality. Nevertheless, 

the expectation is that we will secure the airway in a timely manner while simultaneously 

maintaining oxygenation. Though this should always be our goal, it ought be recognized that 

it is sometimes an unrealistic expectation. 

Airway Evaluation. The need and value of an adequate and accurate airway exam 

cannot be overstated. Predicting a difficult airway can and often averts catastrophic loss of 

airway control. Careful attention should be paid to predictors of difficult bag-valve mask ventilation 

as well as those stigmata that might predict difficulty for tracheal intubation. 

The Emergency Difficult Airway Algorithm. Developed by Murphy, Hagberg, 

Walls, et al, it specifically deals with the emergent difficult setting. It is a binary decision tree 

specifically designed for use in emergency situations outside the elective anesthesia setting. 

It seamlessly couples with the Failed Airway Algorithm. 

Predicted Difficult Airway. It is universally held that the best approach is to secure the 

airway with the patient awake. In the stable and cooperative trauma patient, this may not be 

problematic. However, in the unconscious and/or unstable patient, management becomes far 

more urgent and difficult often because of declining cardiovascular and/or respiratory status. 

Unpredicted Difficult Airway. This situation can easily degenerate very quickly, 

especially if bag-valve mask ventilation is impossible or difficult. If SPO 2 can be maintained 

above 90%, more options are available. However, if SPO 2 falls below 90%, time to assure adequate 

oxygenation becomes critical and the options for doing so become fewer. In this situation, 

one must have the confidence and ability to perform a needle cricothyrotomy or 

employ a commercial cricothyrotomy kit in short order. 

The Failed Airway. Recognition that the situation has become extremely time critical 

and preparations for a surgical airway must be made. Initiation of this algorithm is triggered 

by inability to maintain SPO 2 greater than 90% by bag-valve ventilation after attempt(s) 

at tracheal intubation. 

The Difficult and Failed Airway in the Trauma Patient 


University of North Carolina, Chapel Hill, North Carolina, USA 

Learning Objectives: 1) To identify the difficult airway in the trauma patient, 2) 

recognize when an intubation failure has occurred, 3) to utilize specific algorithms, 4) to 

develop personal strategies for emergency airway management. 

The Role of the Combitube (ETC) and the EasyTube (EzT) 

Andreas R. Thierbach, MD 

Consultant Anesthesiologist, University of Mainz, Mainz, Germany 

Learning Objectives: To discuss the function, uses, advantages, and disadvantages 

of the Combitube and to introduce an enhancement of the ETC, the EasyTube. 

The ETC is a double-lumen tube that is introduced blindly into the mouth, combining 

the functions of an esophageal obturator airway (EOA) and a conventional endotracheal airway. 

It is manufactured in two sizes: Combitube 37 F SA (=small adult) and Combitube 41 F. 

The device is designed to ventilate the lungs, whether the distal end enters the esophagus 

or the trachea. The longer channel has an open distal end, and the other channel has a 

blind end with multiple small openings at supraglottic level. There is a small-volume distal cuff 

and a large-volume proximal cuff designed to obliterate the hypopharynx. If the long tube 

enters the esophagus (as it does in the majority of cases), the patient is ventilated through the 

small openings above the glottic level. The tidal volume is directed toward the glottis and is 

prevented from passing elsewhere by the inflated distal and hypopharyngeal cuffs. If the tube 

enters the trachea, ventilation is performed via the open distal channel. 

The ETC has been used successfully as an artificial airway during cardiorespiratory 

arrest. The device has also been evaluated for use by ICU nurses and by paramedics in the 

prehospital setting. The ETC is an effective substitute for tracheal intubation in cases where 

there is a lack of expertise or familiarity in endotracheal intubation, or there is an inability to 

intubate caused by difficult anatomy, or when patients are trapped in unusual positions. 

A disadvantage of the ETC is that suctioning of the trachea is impossible in the 

esophageal position. Complications of the device include lacerations of the pharynx and 

hypopharynx, esophageal or tracheal perforation, and the inability to provide adequate ventilation. 

The Combitube is, however, contraindicated in the following circumstances: patients 

shorter than 4 feet; patients with intact gag reflexes irrespective of their level of consciousness; 

patients with known esophageal pathology; patients who have ingested caustic substances; 

and patients with obstruction of the upper airways, e.g., foreign bodies and tumors. 

Since May 2003, the so-called EasyTube (EzT) has been available on the European market. 

The device will be available on the U.S. market in 2003. It represents a further development 

of the ETC. Major advantages of the EasyTube include a special double-lumen design, 

including a tip resembling a standard endotracheal tube. This tip facilitates tracheal intubation, 

but still enables ventilation when positioned in the esophagus. Furthermore, the trachea 

is accessible in the esophageal and endotracheal position of the tip of the tube. The 

48


large volume proximal cuff is made of Neoprene; therefore, the device is suitable for patients 

allergic to latex. 

The EzT is available in two sizes (41 and 27 Fr), making the device applicable for 

patients from a height of 90 cm on. 

SLAM Emergency Airway Flowchart: Universal Considerations 

for the Emergency Airway 


Baylor University Medical Center, Dallas, TX, USA 

Learning Objective: To understand the need for acquisition of critical decisionmaking 

skills to effectively deal with a wide range of emergency airway situations. 

Purpose of Work. The purpose of the work was 1) to collate and organize current 

information on emergency airway management in a single flowchart that provides a clear 

strategy for effectively dealing with emergency airway situations that occur in and out of the 

hospital; 2) to teach rapid recognition and treatment of a “crash” or “failed” airway; 3) to 

assist practitioners in developing critical decision making skills for emergency airway management. 

Although it can be applied in the operating room, it was primarily developed for 

providers outside the operating room and hospital. 

Method Used. A literature review was used to collect current peer-reviewed information 

on emergency airway management. 

Results. Material was drawn from peer reviewed sources 1–5 to develop a single “all-inone” 

flowchart that provides a clear strategy for dealing with a wide array of emergency airway 

situations. It is similar to other flowcharts in its coverage of common airway considerations 

such as airway assessment; oxygenation and ventilation; aspiration prophylaxis; cervical 

spine protection; and confirmation of tracheal intubation. However, it differs from other algorithms 

in the presentation of the six limbs, i.e., 1) first responder limb for providers who generally 

do not possess tracheal intubation skills and may or may not have rescue ventilation 

skills; 2) nonintubation technique limb, which allows the provider to opt out of using tracheal 

intubation if the situation dictates and to either continue with a nonrebreathing mask or bagvalve 

mask ventilation or proceed with a minimally invasive technique such as Combitube, 

COPA, Easy Tube, King LT or LMA; 3) rescue ventilation limb, which provides for rapid insertion 

of a Combitube or LMA or LMA-Fastrach in the presence of a crash airway or failed airway 

situation; 4) difficult intubation limb, which provides options for facilitating a difficult 

intubation; 5) RSI limb, which focuses on appropriate use of rapid sequence intubation; and 

6) cricothyrotomy limb for application if rescue ventilation fails. 

The flowchart assists in improving oxygenation and ventilation regardless of the 

provider’s skill level. Other contributions include use of limiting intubation attempts to avoid 

traumatizing the airway or creating a “cannot ventilate–cannot intubate”; 6 “Mason’s PU-92 

Concept” for rapid recognition of the crash airway 1 ; maxims and special considerations to 

facilitate airway safety; technique adjustment if adequate oxygenation is not being attained or 

maintained; clear criteria for application of rescue ventilation to treat a failed or crash airway; 

criteria for application of cricothyrotomy; and near-failsafe devices in all locations to confirm 

tracheal intubation. Use of color to show safe blocks, danger blocks, decision blocks, consideration 

blocks, and action blocks aids in instruction and acquisition of information. 

Conclusions. A flowchart has been developed that can be used by all practitioners 

involved in emergency airway management. It provides a platform for teaching critical decision-making 

skills to diverse practitioners. It is hoped that a tool can be developed to measure 

its effect on providers’ ability to apply critical decision-making skills effectively in emergency 

airway management. The flowchart is germane to that common area of emergency airway 

management where the diverse fields of anesthesiology, emergency medicine, and prehospital 

care coincide. 

References 




2. ASA Task Force on Management of the Difficult Airway. Anesthesiology 1993; 78:597. 

3. Gabbott DA. Management of the airway and ventilation during resuscitation. Br J 

Anaesth 1997; 79:159–71. 

4. Walls RW. The emergency airway algorithms. In Walls RW, ed. Manual of Emergency 

Airway Management. Philadelphia: Lippincott Williams & Wilkins, 2000, pp 16–26. 

5. Smith CE, Grande CM, Wayne MA, et al. ITACCS Rapid Sequence Intubation (RSI) 

in Trauma [poster]. 10th ATACCS. Baltimore, May 1997. 




Flexible Fiberoptic Intubation 


Trauma Center and Major Incident Command Centre, H:S Rigshospitalet, Copenhagen 

University Hospital, Copenhagen, Denmark 

Learning Objectives. To understand 1) the need for a more prominent role of 

fiberoptic endotracheal intubation (FOI) in difficult airway management, 2) to know the 

indications and limitations for the use of FOI, and 3) to realize the need for acquiring the 

necessary skills and experience during daily practice of non-emergency situations. 

Difficult Airway Management. Airway management of the severely traumatized patient 

is often a challenge. The aim is to establish a secure airway. The ASA difficult airway algorithm 

provides various proposals for safe and simple procedures for solving difficult airway management. 

However, the flexible fiberoptic facilitated endotracheal intubation is down the line 

in the ASA algorithm, and the surgical airway is an early consideration in the advanced trauma 

life support (ATLS) airway algorithm. 

Fiberoptic Intubation. Various techniques have being developed. For a safe, awake FOI 

technique, the airway must be anesthetized sufficiently to avoid coughing, gagging, and vomiting. 

Various techniques have been described but time consumption might be a limitation. 

In the conscious patient, transtracheal injection of local anesthetic is easy, simple, and effective. 

Subsequent topicalization of the airway provides further tolerance of the fiberoptic 

scope, and additional spraying of lignocaine through the suction port of an advancing 

fiberoptic scope is effective and efficient. 

Advantages. The FOI is a simple, non-traumatic technique, superb to most other technique 

in the hands of the experienced person. The FOI can be used for solving most of the 

challenges presented in difficult airway management of trauma patients. In case of a suspected 

difficult airway in a spontaneously breathing patient, the fiberoptic approach reveals 

the problem, thereby avoiding an emergency “cannot intubate situation”. The cervical spine 

can be protected and movements of the C-spine minimized in case of suspected C-spine 

injuries. Injury to the airway and penetrating neck injuries can be handled with care and 

diagnosed early. Hemodynamic stability is preserved during FOI with topical anesthesia. FOI 

provides an immediate and precise confirmation of endotracheal tube position. 

Disadvantages. The major disadvantage of FOI is that, like all other emergency techniques, 

proper use requires skills and prior experience with the equipment and the procedure. 

FOI is more time consuming than successful first-time conventional direct laryngoscopy. 

Interruption of mask ventilation might be necessary in the apneic patient. Bleeding 

in the upper airway is another problem making FOI more difficult or impossible. Other limitations 

include the relatively high costs and vulnerability of fiberoptic scopes, the immediate 

availability of equipment, and cleaning and maintenance of equipment. 

Conclusion. Direct laryngoscopy after rapid sequence induction is usually the first 

approach. However, the recognition of a possible difficult airway is the main issue. If possible, 

keep the patient awake and spontaneously breathing. FOI should be considered early if 

skills are available. Nasotracheal intubation is often easier and permitted even in trauma 

patients, however, with the risk of bleeding making visualization difficult. Establishing a surgical 

airway is not always simple and easy; the FOI is a qualified alternative. Skills end experiences 

should be obtained during non-emergency situations 

The challenge is to predict and identify the patients in whom conventional intubation 

is not possible or very difficult and those who will require a surgical airway as the primary 

choice. Prospective studies need to demonstrate the future role of FOI in emergency care. 

Recommended Literature 

Ovassapian A. Fiberoptic Endoscopy and the Difficult Airway, 2nd edition. Philadelphia, 

Lippincott-Raven, 1996. 


Critical Care in the Age of Terrorism 

Chair: Maureen McCunn, MD, Baltimore, Maryland 

Trauma Care Around the World: 

How We Are Different and How We Are the Same 


Medical Director, Neurotrauma Critical Care; Physician Director, Continuous Renal 

Replacement Therapies; R Adams Cowley Shock Trauma Center 

University of Maryland, Baltimore, Maryland, and 

Graduate Candidate, Johns Hopkins University, School of Advanced International 

Studies, Washington, DC, USA 

Trauma . . . “the neglected disease of modern society” . . . 

Learning Objective: To review differences in trauma care in various countries and 

to highlight cultural differences. 

Injury is a major public health problem in the United States, developed countries, and 

developing nations. Blunt trauma due to vehicular craches, industrial equipment, and falls 

occurs across all economic strata, in addition to blast and crush injuries that may be seen in 

war-ravaged environments. Penetrating injuries from gunshot wounds, stabs, or landmines 

occur not only in combatants but more and more commonly in civilians. All populations are 

affected by this growing burden of injury. 

While published data garnered from studies of the epidemiology of injury and violence 

around the world are increasing, there are few to no data concerning how we can effectively 

intervene to implement policies or to change ineffective practices surrounding these issues. 

What is acceptable in any given society may not be effective in another due to social, cultural, 

or religious differences. Trauma care in various cultures may demand multiple paradigms 

as a result of these differences. 

Background and Significance. The World Health Organization (WHO) estimates 

that injury accounts for 16% of all disease worldwide. 1 The leading causes of death for both 

men and women between the ages of 15 and 44 years are injury related, and by 2020, injuries 

will be the third leading cause of death and disability in the world. 2 Interpersonal violence and 

war-related mortality account for approximately 5 million deaths. Based on 2000 data, 91% of 

homicides occur in low- and middle-income countries. 3 

One of every ten Americans was treated for an injury in an emergency department in 

2000. 4 Injury is also an increasingly significant health problem in most low-income countries. 

However, few studies have investigated the epidemiology of injury patterns and even fewer 

address strategies for injury prevention. Furthermore, there are no published data that investigate 

the impact that social customs, religion, or cultural differences may have on trauma care. 

In today’s less-developed countries, infectious diseases remain the leading cause of 

death, but this trend is decreasing and trauma is causing more and more deaths. According 

to the WHO report concerning the global burden of disease, road traffic craches are predicted 

to be the leading cause of death in the world by 2020. 5 Fifty percent of injured victims die 

at the scene in some countries. The preventable death rate (PDR) is about 25% in Poland, 

30% in Greece, 37% in Italy, and 43% to 62% in the United Kingdom. In the United States, the 

PDR dropped from 13% to 7% due to better and more efficient systems of trauma care. 6 

Unfortunately, there are very little data with regard to traumatic injury in developing nations. 

Recent Developments. Progress in the organization and the delivery of trauma care 

has resulted in decreased mortality. These improvements include the following: 

• More rapid prehospital transport 

• Increased capabilities for prehospital care/training 

• Growth of emergency medicine as a specialty 

• Development of trauma surgery as a specialty 

• Advanced Trauma Life Support (ATLS) course 

• Development/certification of trauma centers 

Unfortunately, many of these changes have not reached developing nations. 

Differences in Trauma Care. Previous queries into trauma system effectiveness in 

the United States and Canada concluded that studies assessing efficacy of care rely on hospital 

deaths as the primary indicator of success or failure. 7 But many patients in developing 

nations are not even treated for their injuries ,8,9 so hospital deaths may not be an indication 

of true morbidity or mortality from traumatic injury. A cluster survey of household interviews 

has shown that many injuries and deaths in poor nations are not captured by hospital data. 10 

Mortality from trauma may be directly correlated with gross national product, 11 such 

that mortality declines with increasing economic level. Implementation of low-cost improve- 

49


ments in prehospital trauma care in a developing nation has been shown to decrease mortality 

during transport by 50%, with only a 16% required increase in the ambulance service 

budget. 12 Another difference in patterns of injury in developing nations involves urban versus 

rural trauma. 13 Prevention strategies need to differ from those in developed countries and 

may need to target nonmedical providers (private citizens) to show a difference. 

Despite these recently published statistics, and an increasing recognition of injury as a 

major public health problem worldwide, limited attention and resources have been paid to 

this topic. This lack of attention is most notable in low-income countries. International 

forums to define the global burden of injury and to make recommendations regarding specific 

actions required of governments, individual researchers, and donor agencies are only 

lately forthcoming. 14,15 

This dilemma is made more difficult when injuries resulting from conflict are taken into 

account. The face of modern wars has changed dramatically; the target is no longer the destruction 

of the opposing army, but rather the destabilization of the opponent’s political, social, cultural, 

and psychological infrastructure. 16 Civilians have been the major targets in recent wars 

(Afghanistan, Lebanon, Kosovo, the Persian Gulf) and account for more than 80% of those killed 

and wounded. This represents a further burden on the effective delivery of trauma care and 

resources utilized. Today, warfare is the leading cause of traumatic deaths in the world. 

Cultural Sensitivity. Problems identified in the chain of trauma care (from injury 

through hospital discharge and rehabilitation) do not include weak links associated with ethnic 

prejudices, religious differences, cultural norms, or gender issues. It is known that there 

are social and cultural disparities in substance abuse, 17,18 in decisions regarding end-of-life 

care, 19 and in functional status measurements of health-related outcomes. 20 Studies documenting 

the presence of racial, ethnic, and socioeconomic disparities in health care have outpaced 

articles that describe effective strategies to eliminate disparities. 21 Education in the area 

of cultural competence, defined as a set of skills that allows an individual to increase his/her 

understanding of cultural differences and similarities within, among, and between groups, is 

virtually nil. 22,23 

Jean Jacques Rosseau makes the all-important point, in The Social Contract (1762), 

that “the history, character, habits, religion, economic base and education of each people 

must be taken into account before setting up machinery.” 

Eye to the Future. While technological advances and a more precise understanding 

of the pathophysiology of trauma have led to significant improvements in trauma care in 

many developed nations, there has been little attention paid to the majority of civilization. 

Trauma systems are only as effective as their ability to be accessed/utilized. We must focus on 

developing effectual programs to improve care and quality of life throughout the world. 

References 

1. World Health Organization. Injury: A Leading Cause of the Global Burden of 

Disease. Geneva: World Health Organization, 1999. 

2. Murray CJL, Lopez AD. The Global Burden of Disease. Cambridge, Massachusetts: 

Harvard University Press, 1996. 

3. Krug EG, Dahlberg LL, Mercy JA, et al (eds). World Report on Violence and Health. 

Geneva, World Heath Organization, 2002. 

4. Centers for Disease Control Data. 

5. Krug EG, Sharma GK, Lozano R: The global burden of injuries. Am J Public Health 

2000; 90(4): 523–6. 

6. Bielecki K. Trauma care for the year 2000. Przegiad Ledarski 2000; 57:S127–8. 

7. Mann NC, Mullins RJ, MacKenzie EJ, et al. Systematic review of published evidence 

regarding trauma system effectiveness. J Trauma 1999; 47:S25–33. 

8. Mock CN, nii-Amon-Kotei D, Maier RV. Low utilization of formal medical services by 

injured persons in a developing nation: health service data underestimate the 

importance of trauma. J Trauma 1997; 42:504–511. 

9. Mock CN, Forjuoh SN, Rivara FP. Epidemiology of transport-related injuries in 

Ghana. Accid Anal and Prev 1999; 31:359–370. 

10. Mock CN, Abantanga F, Cummings P, et al. Incidence and outcome of injury in 

Ghana: a community-based survey. Bull World Health Organ 1999; 77:955–64. 

11. Mock CN, Jurkovich GJ, nii-Amon-Kotei D, et al. Trauma mortality patterns in three 

nations are different economic levels: implications for global trauma system development. 

J Trauma 1998; 44:804–12. 

12. Arreola-Risa C, Mock CN, Lojero-Wheatly L, et al. Low-cost improvements in prehospital 

trauma care in a Latin American city. J Trauma 2000; 48:119–24. 

13. Mock CN, Forjuoh SN, Rivara FP. Epidemiology of transport-related injuries in 

Ghana. Accid Anal Prev 1999; 31:359–70. 

14. Forjuoh SN, Zwi AB, Mock CN. Injury control in Africa: getting governments to do 

more. Trop Med Int Health 1998; 3:349–56. 

15. World Health Organization and The Bone and Joint Decade. The burden of musculoskeletal 

conditions at the start of the new millennium: Scientific Group 

Meeting, Geneva, January 2000. 

16. Aboutanos MB, Baker SP. Wartime civilian injuries: epidemiology and intervention 

strategies. J Trauma 1997; 43:719–25. 

17. Leischow SJ, Ranger-Moore J, Lawrence D. Addressing social and cultural disparities 

in tobacco use. Addic Behav 2000; 25:821–31. 

18. Rossow I. Alcohol and homicide: a cross-cultural comparison of the relationship in 

14 European countries. Addic 2001; 96:S77–9. 

19. Vincent JL. Cultural differences in end-of-life care. Crit Care Med 2001; 29:S52–5. 

20. Custers JW, Hoijtink H, van der Net J, et al. Cultural differences in functional status 

measurement: analyses of person fit according to the Rasch model. Qual Lif Res 

2000; 9:571–8. 

21. Horowitz CR, Davis MH, Palermo AS, et al. Approaches to eliminating sociocultural 

disparities in health. Min Heal Today 2001; 2:33–43. 

22.Nunez AE: Transforming cultural competence into cross-cultural efficacy in 

women’s health education. Acad Med 2000; 75:1071–80. 

23. Mesquita B: Emotions in collectivist and individualist contexts. J Pers Soc Psychol 

2001; 80:68–74. 

Wartime Civilian Injuries. An Epidemiological Shift in 

Terrorism and Complex Disasters 

Michel B. Aboutanos, MD, MPH 

Medical College of Virginia Hospitals, Virginia Commonwealth University. Richmond, 

Virginia, USA 


1. The audience should understand the recent trends in world violence in terms of 

terrorist activities and armed conflicts. 

2. The audience should understand the risk factors leading to increase morbidity 

and mortality in armed conflicts and terrorist events 

3. The audience should understand the implication of blast injuries in terms of prevention, 

response, and trauma and critical care management. 

Background. Two forms of world violence, international terrorism and major armed 

conflicts, have escalated exponentially in the post-world wars era. Since 1945, 160 wars and 

armed conflicts resulted in an estimated 22 millions deaths and over 60 million injuries. 

Between 1990 and 2000, 56 different major armed conflicts in 44 different locations were 

recorded, with 25 conflicts still active in 2000. 1,2 Similarly, since 1968 over 14,000 international 

terrorist attacks have taken place throughout the world. 3,4 

Purpose. To delineate the characteristics of the recent armed conflicts and the significant 

terrorist incidents in terms of demographics, method of wounding, causes of injury, risk 

factors, and the implications for the trauma and critical care communities. 

Methods. An extensive review of governmental documents and published experiences 

dealing with wartime injuries and prominent international terrorist incidents from 

1961 to 2001. Specific trends in demographics, etiologies, and methods of wounding were 

delineated along with the contributing risk factors. 

Results. A total of 392 terrorist incidents were reviewed, accounting for 27,312 casualties 

and 5,682 deaths. Seventy percent of all terrorist incidents were against civilian targets, 

which constituted 92% of all casualties. Bombings were the most frequent terrorist events 

(44%) and accounted for 74% (20,221) of all casualties and over 90% of all deaths. Similar 

results were observed in recent wars. Civilians were the major targets in recent armed conflicts 

and accounted for most of the killed and wounded (80%–90%). A shift toward more 

powerful explosive devices (artillery shells and mines) was also noted. Whereas noncivilian 

victims (army, paramilitary, government agents) were mainly male and restricted to the 21- to 

40-year-old age group in both armed conflicts and terrorist incidents, civilian victims were of 

all ages and both genders. The risk factors for lethal injuries identified in both wartime and 

terrorist incidents were similar and included 1) the intentional targeting of civilians, 2) the 

confinement of a large number of people in a single area (bomb shelters and hospitals in the 

armed conflicts, transportation vehicles such as buses and commercial airplanes in the terrorist 

incidents), 3) personal and environmental vulnerability of the targeted victims, and 4) 

the exponential increase in firepower and lethality of modern explosives. These factors also 

lead to higher mortality rates among critically injured survivors due to the enormous number 

of wounded from secondary blast injuries that can overwhelm triage, treatment, and 

resource/personnel allocation. 

Conclusion. In both wartime and terrorist incidents, civilians are now the primary targets. 

An epidemiological shift in the demographics of the victims and lethality of injuries corresponds 

to the shift in targeting of civilians and the methods of fatal wounding. The implications 

to international aid agencies and to the trauma and critical care communities in terms 

of prevention strategies, targeted preparation, and medical response are highly significant. 

References 

1. Seybolt TB. Major armed conflicts. SIPRI Yearbook 2001. Armaments, 

Disarmaments and International Security. Oxford: Oxford University Press, 2001. 

2. Wallensteen P, Sollenberg M. Armed Conflict, 1989–98. Journal of Peace Research 

36(5):593, 1999. 

3. Federal Bureau of Investigation. Terrorism in the United States. Washington, DC: 

FBI, 1999. 

4. U.S. Department of State. Patterns of Global Terrorism, 1999. 

Suicide Bombings in Israel: Injuries Never Seen Before 

Itamar Ashkenazi, MD, and Ricardo Alfici, MD 

Surgery B, Hillel Yaffe Medical Center PO Box 169, Hadera, Israel 38100 

In the past two years, victims from 38 terrorist incidents were treated in Hillel Yaffe 

Medical Center. Of these, 16 were bomb attacks that resulted in mass casualties. Our experience 

will be presented. Special emphasis will be given to injuries never reported before in the 

medical literature. The diagnostic and therapeutic challenge, together with the implications 

upon treatment, will be discussed. These new presentations of injury represent an introduction 

to a new phase in the ingenuity of perpetrating injury in suicide bombings. 

Rapid Evacuation and Transport of the Critically Injured Patient 

William Beninati, MD, Air Force Coalition for Sustainment of Trauma and Readiness 

Skills/R Adams Cowley Shock Trauma Center, Baltimore, Maryland, USA 

Todd Carter, MD, Office of the Air Force Surgeon General, Washington, DC, USA 

Gregory Rupert, RN, Wilford Hall Medical Center, San Antonio, Texas, USA 

James H. Henderson, MD, Wilford Hall Medical Center, San Antonio, Texas, USA 

Learning Objectives 

1. To describe the US Air Force Aeromedical Evacuation System for transporting 

casualties. 

2. To comprehend the clinical capabilities that can be reasonably be provided during 

long-range air transport. 

3. To explain the technological limitations to care during long-range air transport. 

4. To explain the USAF Critical Care Air Transport Team experience with evacuation 

of casualties across a spectrum of settings from peacetime healthcare to combat. 

The United States Air Force (USAF) maintains an Aeromedical Evacuation System 

(AES) designed to operate across a broad spectrum of activities from peacetime healthcare 

to combat support. This system is flexible and scalable, and can accommodate a range from 

single-patient to mass casualty evacuation. To provide for the care of casualties who have 

been stabilized by ground-based medical teams, but who remain critically ill or injured, the 

USAF developed Critical Care Air Transport Teams (CCATT). The CCATT capability permits 

the use of small, highly capable, ground-based resuscitative teams without imbedded postresuscitative 

care. Such teams can be rapidly inserted with minimal impact on limited airlift 

resources, relying on the AES to provide post-resuscitation/post-surgical care. 

Methods. The AES uses opportune cargo aircraft staffed by dedicated aeromedical 

evacuation (AE) crews consisting of flight nurses and technicians. Patients with imminent loss 

of life, limb, or vision are designated urgent or priority for rapid evacuation; a subset of these 

casualties are critically ill. For transport of critically ill patients, the AE crews oversee the conduct 

of the mission to include flight safety, loading and unloading, and access to oxygen and 

electricity. Direct care of critical patients is provided by CCATT. A CCATT consists of a critical 

care physician, critical care nurse, and respiratory therapist equipped with appropriate supplies 

and portable, battery-operated medical equipment. This equipment includes mechanical 

ventilators, physiologic monitors, a pacemaker/defibrillator, multi-channel infusion 

pumps, and a laboratory analyzer. This personnel and equipment package provides the 

majority of capability available in a hospital-based intensive care unit. A training pipeline has 

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been developed for team members, which includes clinical qualification, basic aeromedical 

training, evacuation exercises, as well as operational and clinical sustainment training. 

Results. The USAF CCATTs have safely transported critically ill and injured patients in 

settings that include peacetime health care, disaster response, terrorist attacks, peacekeeping 

operations, and combat. Transport times have been as long as 20 hours. Specific missions 

will be discussed to demonstrate the flexibility, clinical capabilities, and limitations of this system. 

In the early phase of Operation Enduring Freedom in Afghanistan, initial casualty care 

was provided by forward surgical teams with limited capacity for sustained critical care postdamage 

control. This care was provided in the air by the AES. In the first 17 months of this 

operation, CCATTs transported 172 critical casualties (see graph), representing 12% of total 

casualties moved. There was no peri-transport morbidity or mortality. 

for re-exploration. The patient is unpacked and residual bleeding dealt with. Careful inspection 

should be made for injuries missed at initial laparotomy. Gastrointestinal integrity can be 

reconstituted. 

Occasionally, it is possible to close the fascia primarily at this point. Temporary closure 

can be effected in a number of ways, such as mobilization of skin flaps or bridging the fascial 

defect with absorbable mesh. If mesh is used, this can be skin grafted in about 2 weeks. 

Delayed abdominal wall reconstruction can be accomplished at 6 months when all intraabdominal 

inflammation has subsided. 

Damage control can also be utilized elsewhere in the body, especially in polytrauma 

patients with long-bone fractures. While the advantages of early fracture fixation are clear, 

definitive fixation can be time consuming and risks considerable blood loss. Temporary 

external fixation provides the advantages of fracture stabilization without blood loss or time 

in the operating room. When the patient is stable, the intra-medullary techniques can be used 

to gain final fracture stabilization. 

Damage control involves utilizing standard trauma principles in a slightly different way 

when dealing with the most critically ill patients. It is a philosophy of care, not a technique, 

and is applicable to a large number of critically ill patients. 

— Session C— 

Trauma Education, Simulation, and Patient Safety 

Co-Chair: James G. Cain, MD Pittsburgh, Pennsylvania, and West Virginia University, 


Co-Chair: Michael J.A. Parr, MB BS MRCP FRCA FANZCA, FJFICM, University of New South 

Wales, Sydney, NSW 

Discussion. The CCATT model demonstrates a highly successful balance of small size, 

portability, and robust clinical capability. This model has proven flexible across a broad range 

of settings. This model for rapid evacuation of stabilized casualties can be adapted to civilian 

disaster response and to novel situations that may arise. 

Organization of Nurses Working with Terror Victims in the Emergency 

Department and on the Wards 

Gila Hyams, RN, MA 

Rambam Medical Center, Haifa, Israel 

Over the past two years, Israel has been hit by a wave of terror attacks, mostly bomb 

explosions, amidst the civilian population. The large number of events has brought about an 

improvement in the organization of every link in the chain of survival. 

Organizing a hospital to deal with a mass casualty situation (MCS) is a very complicated 

affair. It includes organizing the physical space, the equipment, and the manpower. In 

manpower, the largest group is the nurses. A variety of subjects must be dealt with: 1) knowledge/medical 

skills, 2) recruiting of nursing staff, 3) organization in the admitting sites, and 

4) preparation of wards. 

This means that every nurse in an MCS should know what to do, where to do it, and 

how to do it. To achieve this end, a complex process of preparedness must occur in a continuing 

fashion. The tools to achieve this goal are lectures, computer lessons, drills, and, 

above all, writing detailed standing orders for each and every situation. With our experience 

in recent terror attacks, we will describe the benefits and drawbacks of each tool in preparing 

the nursing staff to deal successfully with an MCS. 

In addition, we will discuss new protocols that we have adopted for a ‘limited’ MCS, 

with training of teams, nurses and physicians together, at a medical simulation center and 

debriefing of teams after every event. 

Damage Control Surgery: Principles of Care for Critical Injury 

Thomas Scalea, MD, FACS 

Physician in Chief, R Adams Cowley Shock Trauma Center, University of Maryland School 

of Medicine, Baltimore, Maryland, USA 

Learning Objectives: To understand the conditions that warrant damage control 

surgery and the procedures associated with this approach to the stabilization of severely 

injured patients. 

Damage control applies standard principles differently in critically injured patients. 

Damage control is divided into phases. Phase 1 occurs in the emergency department. Patients 

who present in extremis should undergo rapid evaluation with limited radiographs ascertaining 

the location of cavitary blood loss. This should take less than 15 minutes and the 

patient taken directly to the operating room. The damage control operation should be tailored 

to stop named bleeding and control gross contamination. Expendable organs (the 

spleen) should be resected. Major vascular injuries should be repaired, or temporarized by 

intraluminal shunting. Non-expendable organs (the liver) should have major bleeding controlled 

and non-surgical bleeding packed. Gastrointestinal injuries should be ligated or 

resected without anastamosis. Once major blood loss is controlled, the patient should be 

packed and temporarily closed. 

Exsanguinating hemorrhage often leads to hypothermia acidosis and coagulopathy. 

Further operation perpetuates this cycle. Thus, early selection is important. This may be 

based on either anatomic criteria (multiple visceral injuries, major vascular injury) or physiologic 

criteria (acidosis, blood product requirements). 

The patient should then be taken to the ICU. Cardiovascular function is optimized generally 

using invasively derived hemodynamic parameters. Respiratory function should be 

optimized, often using pressure limited ventilatory strategies. Most importantly, coagulopathy 

must be reversed and normal temperature restored. 

Adjunctive hemostasis can be obtained using angiographic embolization. This technique 

is most helpful with central liver injuries, bleeding deep in the pelvis or adjacent to the 

great vessels. Strong consideration for re-operation should be given for ongoing transfusion 

requirements or inability to normalize lactate. 

When homeostasis is restored, the patient should be returned to the operating room 

Human Crisis Simulation for Rural Medical Education 


Allegheny General Hospital, Pittsburgh, Pennsylvania, USA, and West Virginia University, 


Learning Objective: To provide an introduction to simulation as a means to 

extend resources in providing trauma education in a rural setting. 

Rural areas present unique challenges in providing trauma services and educating 

practitioners in acute care. Rural populations have experienced unique patterns of trauma 

since medieval times. Thirty percent of the United States’ population is rural, yet 70% of all 

trauma fatalities occur in that population. The reasons for increased risk are multifactorial. 

Poverty and unemployment are higher. Hazardous occupations are more common. More 

than half of all fatal motor vehicle collisions occur on rural roads and involve local residents. 

Rural patients are more frequently aged, chronically ill, or disabled (congenital or acquired), 

increasing the likelihood of death from less severe injuries. Trauma is the number one cause 

of childhood death. Mortality from rural pediatric trauma is approximately twice that of urban 

pediatric trauma. 

A major impediment for the rural trauma patient is access to adequate health care. It 

is difficult to attract and retain physicians of any description to rural areas. Economic pressures 

limit physician staffing of rural emergency departments. Rural settings benefit from 

innovations improving acute care management, such as medical simulation. 

Medical simulation’s roots are vested in aviation, a standard, accepted tool for pilot 

education, evaluation, and reproduction of critical events. Similar to flying, anesthesiology 

requires vigilance while multitasking in the face of distracters. In 1986, the VA Palo Alto 

HSC/Stanford University Center for Crisis Management Training in Health Care extrapolated 

technology from aviation to medicine and anesthesia. Medical simulation now includes critical 

care, trauma, and emergency medicine and may decrease morbidity related to critical 

events. Most major simulation centers worldwide have developed simulation programs focusing 

on the dynamics of Crisis Resource Management (CRM). CRM is resource intensive and 

requires expenditures for the simulator, physical plant, personnel, and support staff required 

to produce complete operating room, emergency department, or critical care simulations. 

Institutions unable to muster such resources may feel unable to participate. 

The West Virginia University Human Crisis Simulation Program developed a successful, 

heavily utilized center with a modicum of resources in a rural setting. Simulation allows 

stretching of educational resources. Simulation offers rural medical trainees and practitioners 

a safe and effective environment in which to learn appropriate actions and procedures in 

acute care situations. The West Virginia Human Crisis Simulation Program is located in a 

recently renovated 700-square-foot facility near clinical areas and includes a simulator room, 

control room, and physician office. The simulator is used extensively to introduce anesthesia 

residents to anesthesia and acute care medicine and for multidisciplinary education, medical 

student education, and continuing medical education. Videotaped simulations may be used 

to educate juries, judges, and attorneys in medical malpractice trials. Media coverage 

expounding the benefits of simulation in medicine and its potential to decrease the likelihood 

for serious errors provided welcome favorable publicity and enhanced public relations. 

Future uses for the simulator include multidisciplinary research, modeling work environment 

for new technologies, videoconferencing with statewide CME capability, and professional 

evaluations and certifications. The curriculum is unique in its application of tertiary care and 

Level 1 trauma skills to a rural population. 

The Role of Microsimulators in Training Trauma Professionals 

Ulrik Juul Christensen, MD 

Sophus Medical A/S, Copenhagen, Denmark 

Learning Objective: To provide an overview of the background for the use of 

microsimulators (PC-based simulators) in medical education in general and in trauma 

education in particular. 

Background. Medical microsimulators are PC-based simulators that can be used for 

training the cognitive aspects of handling patients in a low-risk, instructor-less, and easily accessible 

environment. The debriefing after simulation sessions is just as important for microsimulation 

as in full-scale (also known as macrosimulation) simulation with manikins and instructors 

involved. In order to use microsimulators for self-directed learning and optimally for distance 

learning, the simulators should have as advanced technology for debriefing as possible in order 

to provide qualified feedback on the performance in the virtual simulators. 

Most microsimulators are designed to supplement the existing education based on lec- 

51


tures, reading, classroom teaching, and optimally large numbers of hands-on practice in safe 

environments such as full-scale simulators, task trainers, and simulated patients (actors). The 

philosophy is that microsimulators in the same way as chess computers (i.e., microsimulators 

for chess playing) can provide the learning access to a vast amount of more or less seldom cases 

that can be dealt with dynamically. This aspect becomes particularly more important if the learners 

have limited access to “real” cases where they can be taught in an apprenticeship manner. 

The issue of access to only a very limited number of clinically challenging problems 

(and consequently the lack of cognitive and psychomotor practice) is evident in the case of 

the training of the US Army Combat Medics (the so-called 91W program). The 91W program 

is a condensed 16-week course, with the first part being a standard EMT-B education. Due to 

a variety of reasons, with some being quite obvious during peacetime, the equivalent of clinical 

encounters, bedside learning, and clinical sessions is very limited. Therefore, the US 

Army decided to train to up to 8000 each year with extensive use of full-scale human patient 

simulators, a variety of task trainers such as IV arms and CPR manikins, and finally days in a 

simulated battlefield with both portable simulators and humans with wound make up. 

The US Army is now introducing microsimulation as a integrated part of the training 

of the army combat medics in order to achieve a number of benefits: a) to strengthen the 

cognitive training by focusing more on deep learning (by doing!) rather than more superficial 

learning types that can be the result of classroom teaching only, b) to use less intensive 

time during practical exercises for more self-directed learning, and c) to free resources during 

the practical exercises in order to increase the instructor-to-student ratio during psychomotor 

and field training exercises. The military microsimulators are based on systems 

used in prehospital and inhospital care as well as by the Red Cross in many countries for training 

in First Aid (in the military environment the target for the latter technology is the equivalent 

of First Aid – called Self Aid and Buddy Aid). The immediate implementation of the military 

microsimulators will be at the combat medic level, but the technology has been developed 

to be scaled up and down to be used for all group of personnel from emergency physicians 

to EMT-Bs, combat medics, and nurses. The majority of the cases will focus on trauma 

care, but a large number of cases will also be aimed at the EMT-B education, including ALS 

and other aspects of acute medicine as well as several cases aimed at CBRNE (chemical, biological, 

radiation, nuclear, explosions) related patients. 

Rapid Preparation of Reserve Military Medical Teams 

Using Advanced Patient Simulators 

Guy Lin,1 Yahav Oron, 1 Ron Ben-Abraham,1 Dafna Barsuk, 2 Haim Berkenstadt, 2 Amitai 

Ziv, 2 Amir Blumenfeld1 

1 

IDF-Medical Corps Trauma Branch and the 2 National Medical Simulation Center 

(M.S.R.), Chaim Sheba Medical Center, Tel-Hashomer, Israel 

Learning Objectives: To discuss the advantages of the use of advanced patient simulators 

in the training of reserve medical personnal. 

Primary prehospital medical treatment for trauma casualties has unique features in the 

military setting. The environment is sometimes hostile, and tactical situations together with 

the feasibility of evacuation are major considerations. Most of our reserve medical teams are 

not working routinely in this environment. In many debriefings, we recognize gaps in 

patients’ evaluation, diagnosis of deterioration in the patient respiratory or hemodynamic 

condition after the initial treatment, and need for rapid evacuation. We believed that training 

with advanced patient simulators could improve these tasks. 

Many reserve medical teams were recruited for the medical support of the “Defensive 

Shield” operation (April 2002). The reserve teams were composed of physicians having all 

kinds of expertise and medics having various non-medical professions. A questionnaire 

revealed that 72% of reserve staff rarely treat trauma patients. Forty-seven percent define 

themselves as not good enough in trauma management. Moreover, reserve forces are usually 

trained for a high-intensity conflict, being prepared for prolonged evacuation time, and are 

not accustomed to the nearness of trauma centers to the battle zone. 

Every military physician has ATLS certification. Complementary training is usually done 

by traditional methods such as simple manikins and living animal models. These models fit for 

technical skills and familiarity with the equipment, and less for diagnosis and decision-making. 

Team training is usually done by “fake” patients with less attention to individual performance. 

Advanced patient simulators give the opportunity to integrate all these skills. 

Recruitment of reserve medical teams for medical support of battle zones adjacent to 

medical centers creates a need to assimilate rapid diagnosis and decision making (which 

interventions are more important than time?), together with refreshment of the critical skills 

of airway management and chest decompression. 

During a 3-week period, 75 teams (90 physicians and 352 medics) were trained by 

advanced patient simulators in the Israeli Center for Medical Simulation (a collaboration of 

military and civilian systems). 

We developed a scenario-based training adapted to specific missions. The basic program 

included an airway station (Airman manikin), head injury with difficulties in endotracheal 

inbtubation (Sim Man manikin), penetrating chest injury causing tension pneumothorax 

and hemorrhagic shock (Meti manikin), a multi-trauma pediatric patient (Pediasim Meti 

manikin), and a multi-casualty event. Video-screened debriefing was conducted by experienced 

ATLS instructors. 

Feedback of trainees revealed overwhelming satisfaction. Reality of scenarios was evaluated 

as high by 95% of trainees. Eighty-seven percent said they are more ready for decision 

making in the care of combat casualties. Seventy-three percent felt they increased their 

knowledge and improved their skills. 

Twelve trained medical teams have treated major trauma patients during the operation. 

They reported great contribution of advanced simulators training to the care of their 

patients: improved individual performance, self-confidence, and staff coordination. 

Conclusion. Scenario-based training using HPS should be a leading system in the 

qualification of military medical teams. Rapid preparation for combat casualties care is feasible. 

This method of treatment should be developed, and the next step will be constructing a 

study for objective validation. 

Selected References 

Ali J, Adam R, Josa D, et al. Effects of basic pre-hospital trauma life support program on 

cognitive and trauma management skills. World J Surg 1998; 1192–6. 

Ali J, Adam R, Pierre I, et al. Comparison of performance two years after the old and 

new (interactive) ATLS courses. J Surg Res 2001; 97:71–5. 

Ali J, Cohen RJ, Gana TJ, Al-Bedah KF. Effects of ATLS program on medical students’ 

performance in simulated trauma patient management. J Trauma 1998; 44:588–91. 

Ali J, Gana TJ, Howard N. Trauma mannequin assessment of management skills of surgical 

residents after ATLS training. J Surg Res 2000; 93:197–200. 

Bond FB, Kostenbader M, McCarthy JF. Pre-hospital and hospital-based health care 

providers experience with a human patient simulator. Prehospital Emerg Care 

2001; 5:284–7. 

Blumenfeld A, Abraham RB, Stein M, et al. Cognitive knowledge decline after ATLS 

courses. J Trauma 1998; 44:513–6. 

Devitt JH, Kurrek MM, Cohen MM, Cleave-Hogg D. The validity of performance assessment 

using simulation. Anesthesiology 2001; 95:36–42. 

Issenberg SB, Megaghic WC, Hart IR, et al. Simulation technology for health care professional 

skills training and assessment. JAMA 1999; 282:861–6. 

Ziv A, Small S, Wolpe P, Patient safety and simulation based medical education. Med 

Tech 2000; 22:489–95. 

Drills: Are They the Best Way to Prepare for a Mass Casualty Situation? 

Moshe Michaelson, MD 

Trauma Unit, Rambam Medical Center, Haifa, Israel 

Learning Objective: To compare the types of drills available for training participants 

to respond to a mass casualty situation. 

The key to success in a mass casualty situation (MCS) is to be prepared. The first step 

in preparedness is writing detailed standing orders. Standing orders should provide answers 

to all the problems that may arise during this difficult situation. However, writing standing 

orders is only part of the solution. A bigger task is to disseminate the information to all participants. 

There are a few tools to help us in this undertaking, and drills are one of the best. 

We discuss the types of drills available, with emphasis on the role each drill plays in achieving 

the goal of preparing the system to deal with an MCS. Attention is paid to cost-benefits and 

the ability of a single hospital to organize drills without outside help. At the end of the presentation, 

it will be clear whether drills are the best way to prepare for an MCS. 


Simultaneous Afternoon Sessions 


Update on New Drugs, Equipment, and Techniques in Trauma Care 

Chair: Charles E. Smith, MD, FRCPC, Cleveland, Ohio, USA 

What’s New in Pulse Oximetry 


Professor and Head, Department of Anesthesiology 


Learning Objectives: This lecture will promote a better understanding of 1) how 

pulse oximeters work, 2) what they can and cannot measure, 3) the application of pulse 

oximetry to care of the trauma patient, and 4) current and expected new developments in 

the technology. 

This lecture will review the theoretical background and recent developments in pulse 

oximetry, with emphasis on its use in trauma patients. The relationship of pulse oximetry to 

other monitors of patient oxygenation will be explored through a review of the physiology of 

oxygen transport. Clinical applications will be used to show both the value and the limitations 

of saturation monitoring. 

Recent developments in pulse oximetry have been aimed chiefly at improving accuracy 

and reliability in the presence of various signal artifacts. These sources of error include patient 

motion, hypovolemia, shock, dyshemoglobinemias, and venous pulsations. Each of these artifacts 

and their potential remedies will be discussed in the context of the trauma patient. 

Capnography in Trauma 


Professor and Head, Department of Anesthesiology 


Learning Objectives: This lecture will provide a better understanding of the mechanisms 

of CO 2 transport from the body, the relationship between arterial and end-tidal CO 2 

tensions, and the use of the capnogram as a diagnostic tool. The attendee will be able to identify 

various abnormal capnogram shapes and use these to initiate and monitor treatment. 

Capnography, the measurement of respiratory carbon dioxide, is effectively a minimum 

standard of care for general anesthesia. It is particularly important in the trauma 

patient, because the capnogram provides information not only about ventilation, but also 

about circulation and metabolism. This lecture will review the physiology of carbon dioxide 

transport, using this background as a guide to the interpretation of expired CO 2 . The reasons 

for the difference between end-tidal and arterial carbon dioxide tensions will be discussed in 

detail, to show how this difference can be used as an important diagnostic tool. 

We shall also review some basic capnogram waveforms and their clinical interpretation. 

This waveform can provide valuable diagnostic information, and it can also be used to monitor 

the progress of therapeutic interventions. We will see how the capnograph can even be 

used to measure the effectiveness of chest compressions during CPR. Unlike the pulse 

oximeter, which provides data on only one patient variable (arterial oxygenation), the capnograph 

provides an indication of metabolism, circulation, and ventilation simultaneously. 

Neuromuscular Relaxant Pharmacology: An Update 


Department of Anesthesia, MetroHealth Medical Center, Case Western Reserve University, 

Cleveland, Ohio, USA 

Learning Objective: To discuss the scientific basis for choosing a neuromuscular 

relaxant for trauma patients. 

Non-depolarizing relaxants bind to the acetylcholine (Ach) receptor at the post junctional nicotinic 

receptor and competitively prevent binding of Ach to the receptor. The ion channel is closed and no 

52


current can flow. Depolarizers such as succinylcholine mimic the action of Ach and result in excitation of 

muscle contraction followed by blockade of neuromuscular transmission. Nonclassical mechanisms 

include prejunctional block, ion channel block, desensitization of receptors, perijunctional block, and 

tonic block of extraocular muscles. 

Relaxants are used to facilitate tracheal intubation and provide skeletal muscle relaxation 

for surgery and mechanical ventilation. Other reasons are to reduce oxygen demand 

and intracranial pressure, abolish shivering, and as adjuncts to the treatment of tetanus, and 

status epilepticus. 

Non-depolarizers are polar molecules. Potency is described by dose-response relationships. 

The ED90 is the dose that produces 90% block (± SD). In practice, larger doses such 

as 3 x ED90 are given to produce profound block initially. Smaller “repeat” doses or continuous 

infusions are then used to maintain block. Some muscle groups are more resistant than 

others with the dose-response curve shifted to right: e.g., diaphragm, larynx, eye muscles. 

Other muscle groups are more sensitive with the dose-response curve shifted to left: e.g., 

pharyngeal musculature that maintains upper airway patency. Monitoring of neuromuscular 

function is crucial in order to avoid complications from giving too much or too little relaxant. 

Various factors influence the choice of relaxant such as onset, duration, side effects, 

histamine release, biliary or liver disease, renal function, hypothermia, age, and altered pharmacology 

due to drug–drug and drug–disease interactions (e.g., volatile agents, magnesium, 

muscular dystrophies, burns, motor neuron disease, myasthenia gravis, and sepsis). The table 

summarizes some important clinical information on neuromuscular relaxants for trauma. 

Selected Neuromuscular Relaxants for Trauma 

Agent Intubating Intubating Duration Comments 

dose, mg/kg time (min)^ (min)* 

Succinylcholine 0.6-1.1 1 4-6 Side effects may 

contraindicate its use, e.g., 

hyperkalemia 

Rocuronium 0.6-1.2 0.7-1.1 31-67 Nondepolarizer of choice 

for rapid sequence 

intubation. Mild vagolysis 

Mivacurium 0.15-0.25 1.5-2.5 16-23 Metabolized by plasma 

cholinesterase. Histamine 

release 

Vecuronium 0.08-0.10 2.5-3 25-40 Onset time delayed unless 

high doses (0.3-0.4 mg/kg) 

used. Cardiovascular 

effects unlikely 

Cisatracurium 0.15-0.2 1.5-2 55-65 Potent stereoisomer of 

atracurium with organ 

independent elimination. 

Cardiovascular 

effects unlikely 

Atracurium 0.4-0.5 2-2.5 35-45 Organ independent 

elimination. 

Histamine release 

Pancuronium 0.06-0.10 2-3 65-100 Long acting. Associated 

with tachycardia and 

activation of the sympathetic 

nervous system 

^ Average time to good-excellent intubating conditions ((80% block). 

* Average time to 25% first twitch recovery. 

References 

1. Bevan DR. Complications of muscle relaxants. Semin Anesth 1995; 14:663. 

2. Smith CE, Grande CM, Wayne MA, ITACCS Consensus Panel, and International 

Review Committee. Rapid Sequence Intubation in Trauma. ITACCS, Baltimore, 1998. 

3. Grande CM, Smith CE, Stene JK. Trauma anesthesia. In Longnecker DE, Tinker JH, 

Morgan GE, eds. Principles and Practice of Anesthesiology, 2nd edition. St. Louis, 

Mosby, chapter 81, 1997, pp 2138–64. 

Acid-Base Balance in Trauma Resuscitation 


Associate Professor of Surgery, Director Emergency General Surgery, Yale University 

School of Medicine, Department of Surgery, Section of Trauma, Surgical Critical Care, 

and Emergency General Surgery, New Haven, Connecticut, USA 

Learning Objectives: 1) To articulate the recent advances in trauma care over the 

past 3 years, 2) to enumerate the directly applicable changes in the trauma care paradigm, 

and 3) to construct an integrated plan to minimize iatrogenic acidosis and minimize 

transfusion needs in severely traumatized patients. 

Military realities as well as civilian trauma (e.g., terrorist attacks of 9/11/01) have 

prompted a reexamination of trauma resuscitation tools and strategies. Traditional resuscitation 

strategies focused on hemorrhage control in conjunction with intense fluid resuscitation, 

including massive transfusion of blood and blood products as needed to clear lactate as 

an arbiter of hypoperfusion. 1 Recognition of the potential deleterious effects of this strategy 

prior to definitive hemorrhage control, limitation of the US blood banking system to meet 

demands, and heightened public and medical desires to avoid allogeneic exposures also promoted 

reevaluating the traditional resuscitation paradigm. 

Several key factors have influenced the reshaped perspective in trauma resuscitation: 

1) equivalent survivorship with low pressure resuscitation, 2 2) laboratory evidence of reduced 

survivorship with high volume resuscitation, 3 3) acknowledgement of the presence and 

importance of hyperchloremic acidosis following massive resuscitation, 4 4)recognition of the 

interplay between metabolic acidosis and coagulopathy independent of hypothermia, 5,6 5) 

improved understanding of the relationship between starch-based resuscitation and coagulopathy, 

7,8 6) accelerated interest in prehospital and military evaluation of hemoglobin-based 

oxygen carrier driven resuscitation, 7) the development and looming implementation of procoagulants 

such as recombinant factor VIIa 9 and a durable hemostatic dressing, and 10 ) elucidation 

of the key role of maintaining microcirculatory flow as a means of ameliorating regional 

hypoperfusion. 

As a result, increases in starch-based resuscitation, including during the current war in 

Iraq, and reduced prehospital volume resuscitation are becoming more widely accepted. 

Multiple trials are being initiated to explore the benefits of procoagulant agents as well as the 

efficacy of HBOC resuscitation. However, the clear benefit from these changes is an altered 

acid-base profile from reduced chloride loading. Further data evaluation will allow us to 

understand the impact such a strategy will have on ICU length of stay, minute ventilation 

needs, and blood product transfusion. 10 

References 

1. Cinat ME, Wallace WC, Nastanski F, et al. Improved survivorship following massive 

transfusion in patients who have undergone trauma. Arch Surg 1999; 134(9):964–8. 

2. Dutton RP, Mackenzie CF, Scalea TM. Hypotensive resuscitation during active hemorrhage: 

impact on in-hospital mortality. J Trauma 2002; 52(6):1141–6. 

3. Solomonov E, Hirsh M, Yahiya A, et al. The effect of vigorous fluid resuscitation in 

uncontrolled hemorrhagic shock after massive splenic injury. Crit Care Med 2000; 

28(3):749–54. 

4. Kaplan LJ, Bailey H, Kellum J. The etiology and significance of metabolic acidosis in 

trauma patients. Curr Op Crit Care 1999; 5(6):458–63. 

5. Roche AM, James MF, Grocott MP, Mythen MG. Coagulation effects of in vitro serial 

haemodilution with a balanced electrolyte hetastarch solution compared with a 

saline-based hetastarch solution and lactated Ringer’s solution. Anaesthesia 2002; 

57(10):950–5. 

6. Patterson T, Bailey H, Kaplan LJ. Hyperchloremia induces acidosis, increases the 

strong ion gap, and impairs coagulation. Crit Care Med 2000; 28(12):A118. 

7. Martin G, Bennett-Guerrero E, Wakeling H, et al. A prospective, randomized comparison 

of thromboelastographic coagulation profile in patients receiving lactated 

Ringer’s solution, 6% hetastarch in a balanced-saline vehicle, or 6% hetastarch in 

saline during major surgery. J Cardiothorac Vasc Anesth 2002; 16(4):441–6. 

8. Kaplan LJ, Bailey H, Walters W. Large volume resuscitation with hydroxyethyl starch 

in lactated ringers solution restores perfusion and minimally induces hyperchloremia 

without impairing coagulation. Crit Care 2001; 5(Suppl 1):S53. 

9. Martinowitz U, Kenet G, Segal E, et al. Recombinant factor VII for adjunctive hemorrhage 

control in trauma. J Trauma 51(3):431–9. 

10. Claridge JA, Schulman AM, Young JS. Improved resuscitation minimizes respiratory 

dysfunction and blunts interleukin-6 and nuclear factor-kappa B activation after 

traumatic hemorrhage. Crit Care Med 2002; 30(8):1815–9. 

The Management of Massive Bleeds in Trauma by an Injury Site-Specific Agent 

(Recombinant Activated Factor VII) 

U. Martinowitz, 1 L. Aharonson-Daniel, 2 G. Kenet,1 B. Savitsky, 2 , A. Lubezki,1 G. 

Martonowits, 3 G. Lin, 3 A. Blumenfeld, 3 and K. Peleg 2 

1 

The National Hemophilia Center, 2 The National Center for Trauma and Emergency 

Medicine Research, The Gertner Institute, Sheba Medical Center, Tel Hashomer, Ministry of 

Health and Sackler School of Medicine, Tel Aviv University, and 3 Medical Corp, Israel 

Defense Forces (G.M. is the Surgeon General), Israel 

Learning Objective: To discuss the use of recombinant activated factor VII as a 

hemostatic agent in trauma patients with massive hemorrhage. 

Uncontrolled hemorrhage is a major cause of death in trauma patients, accounting for 

about 40-50% of the mortality in both military and civilian trauma. Most critically ill trauma 

patients develop profound multifactorial coagulopathy due to activation of coagulation with 

consumption of coagulation factors and platelets, activation of fibrinolysis (with fibrinogenolysis 

and hyperfibrinolysis in massive trauma), hemodilution, massive transfusions, 

hypothermia, and metabolic changes (acidosis, hypocalcemia, etc.). Introduction of a “sitespecific” 

agent enhancing hemostasis only at the site of injury may decrease hemorrhagic 

mortality and morbidity in trauma patients. Such an agent, rFVIIa, has been used successfully 

for almost a decade in patients with hemophilia developing inhibitors to factor VIII or IX. 

rFVIIa activates the coagulation system on the membrane of activated platelets, adhered to 

the site of injury, upon complex formation with tissue factor that is exposed at that site. 

Hence, its action is compartmentalized, limited to the site of injury, without a systemic effect. 

The use of rFVIIa in trauma patients was avoided due to the theoretical risk of thromboembolic 

complications. We performed a pig trauma study that supported the safety and efficacy 

of rFVIIa in this animal trauma model and, immediately after, a few exsanguinating trauma 

patients were treated successfully with rFVIIa, which led to ethical committee approval of this 

agent in patients suffering uncontrolled bleeding. 

Patients. Since mid-1999, more than 105 trauma, surgical, and medical patients suffering 

massive life-threatening bleeding have been treated with rFVIIa in Israel. We describe 

here the data of 36 trauma patients treated in 14 of the 22 hospitals in Israel. Patients were 

critically ill (ISS 25-75 in 86%), multi-transfused (see below), hypothermic, and acidotic and 

suffered profound coagulopathy (see below). Median age was 20 (range 14-65). Most were 

victims of terror (40%) and other violence (32%), which reflected the type of injury (46% penetrating, 

11% blast, and the rest, blunt). 

Results. The abnormal coagulation tests improved significantly within 15-20 minutes 

after administration of rFVIIa (PT shortened from 20.7±8.4 to 13.3±6.3 seconds [P


Damage Control Orthopedics 

James C. Duke, MD 

Associate Director, Department of Anesthesiology, Denver Health Medical Center; 

Associate Professor of Anesthesiology, University of Colorado Health Sciences Center, 

Denver, Colorado, USA 

Learning Objective: To gain some understanding of the evolution in management 

of long-bone fractures in the multiply injured patient. 

“Damage control” surgery began with packing of significant hepatic injuries when it 

was recognized that prolonged operative time resulted in exsanguinating, cold, acidotic, 

coagulopathic patients who often went on to die. 1 When hemorrhage was controlled, the 

patient was transferred to the ICU for further correction of these metabolic problems. The 

patient then received a planned reoperation once physiologic stabilization was achieved. 

Since that time, the techniques of damage control have evolved and been applied to other 

surgical disciplines, including orthopedic trauma. 

The timing of long-bone fracture fixation has long been a topic of controversy. In 

selected patients, early total fracture care has benefits, including less pain, earlier mobilization, 

ease in nursing care, less fat embolization, fewer decubitus ulcers, as well as reduced 

pulmonary sequelae. However, controversy exists as to whether early total care may place 

certain patients with associated pulmonary or head injuries at risk for clinical deterioration. 

No randomized clinical trials exist with which to make the best clinical recommendations or 

to support a “standard of care.” The best clinical data tend to be prospective and noncomparative, 

and recommendations are very general in nature. 

“Damage control orthopedic” care has been adopted by many trauma centers as the 

preferred method of managing long-bone fractures in the multiply injured patient. 2–4 

Generally speaking, these patients are hemodynamically unstable and have multisystem 

injuries, and, in particular, pulmonary injuries. Damage control is practiced by employing 

temporary external fixation as a bridge to definitive operative repair. The orthopedic complication 

rate for delayed definitive fixation compares favorably with that of patients receiving 

early definitive fixation. 

In conclusion, there is a clear benefit to early stabilization of long-bone fractures. Early 

intramedullary fracture fixation remains a desirable goal in the patient with only isolated 

femur fractures. However, certain multiply injured “borderline” patients with long-bone fractures 

should receive temporary external fixation. Many of the benefits of definitive 

intramedullary fixation, such as decrease in pain and requirement for analgesics, less fat 

embolization, and ease in nursing care will be conferred while limiting surgical trauma, fluid 

and blood resuscitation, and hypothermia in a vulnerable period. 

References 

1. Johnson JW, Gracias VH, Schwab CW, et al. Evolution in damage control for exsanguinating 

abdominal injury. J Trauma 2001; 51:261–71. 

2. Scalea TM, Boswell SA, Scott JD, et al. External fixation as a bridge to intramedullary 

nailing for patients with multiple injuries and with femur fractures: damage control 

orthopedics. J Trauma 2000; 48:613–23. 

3. Pape H-C, Giannoudis P, Krettek C. The timing of fracture treatment in polytrauma 

patients: relevance of damage control orthopedic surgery. Am J Surg 2002; 

183:622–9. 

4. Pape H-C, Hildebrand F, Pertschy S, et al. Changes in the management of femoral 

shaft fractures in polytrauma patients: from early total care to damage control 

orthopedic surgery. J Trauma 2002; 53:452–62. 


Ethics: Organ Donation, End of Life Issues 

Chair: Anne J. Sutcliffe, MB ChB, FRCA, Birmingham, UK 

Managing Death and Dying 

Anne Sutcliffe MB ChB, FRCA 

Consultant in Anaesthesia and Critical Care, Queen Elizabeth Hospital, Birmingham B15 

2TH, UK, and Honorary Senior Lecturer, University of Birmingham 


• To demonstrate that death is easier to accept if it is explained in terms that 

include not only medical but also religious and cultural concepts. 

• To illustrate that traditional and brain stem death are more similar that commonly 

believed. 

Death of a loved one is never easy to accept. This is particularly true following head 

injury, because the severity of external injury is often minimal in comparison to internal, invisible 

injury. The difficulty is even greater when the diagnosis of brain stem death is made in a 

warm, pink, “breathing” patient. 

Unlike other medical diagnoses, death is final and is not amenable to further treatment. 

Treatment occurring at the time of death is stopped rather than withdrawn. Decisions 

to withdraw or withhold treatment imply that although treatment may have short-term physiological 

benefit, this benefit will not alter the underlying disease process and death is 

inevitable in days or weeks. In the case of brain stem death, treatment is neither possible nor 

of benefit. 

Recommendations for end-of-life care in the intensive care unit deal mainly with 

patients in whom treatment is withdrawn. 1 Nevertheless, they contain useful guidance for 

management of the brain-dead patient. Communication with families is essential. It may help 

them to accept death if they are able to understand the similarities between traditional and 

brain stem death. This implies that the staff supporting them must also be clear about how 

its current medical concepts fit into religious, societal, and cultural concepts of death. 

Brain stem death has been an accepted diagnosis for approximately 20 years but is still 

challenged by some doctors 2 and religious groups. 3 Others see it as a means to the end of 

developing the organ transplantation programme. In Japan, it is possible to choose how the 

declaration of death is made. 4 

For the following reasons, I believe traditional death and brain stem death are more 

closely related than many people appreciate: 

• Traditional death depends on recognisable features such as absence of respiration and 

a pulse. Some religions, e.g., Judaism, require that breath has left the body, based on 

medicine as it was practiced in ancient times. In fact, unsuccessful cardiopulmonary 

resuscitation is always associated with brain stem death and this is the reason the 

patient does not breathe and the heart does not beat. 

• Life and death are a continuum marked by the acquisition of mandatory certificates at 

given points of time. Death in all its forms is a process, not an event, as suggested by 

the legal requirement to state a time of death. This time describes the time the diagnosis 

is made, not the time when the process reached a point where medical death can 

be diagnosed. 

• The diagnosis of death has always described the death of the organism as a whole, not 

the whole organism. 

• All diagnoses of death require that preconditions are met. Hypothermia is an exclusion 

criterion for both traditional and brain stem death. 

Further Reading 

1. Truog RD, Cist AFM, Brackett SE, et al. Recommendations for end-of life care in the 

intensive care unit: The Ethic Committee of the Society of Critical Care Medicine. 

Crit Care Med 2001; 29:2332–48. 

2. Taylor RM. Reexamining the definition and criteria of death. Semin Neurol 1997; 

17:265–70. 

3. Lazar NM, Shemia S, Webster GC, et al. Bioethics for clinicians: 24. Brain Death. 

CMJA 2001; 164:833–6. 

4. Morioka M. Reconsidering brain death. A lesson from Japan’s fifteen years of experience. 

Hastings Center Report 2001; 31:41–6 (www.lifestudies.org/reconsidering.html). 

Diagnosing Brain Stem Death: After 30 Years, Couldn’t We Do Better? 

Dr. Gerlinde Mandersloot 

Royal London Hospital, London, United Kingdom 

Learning Objectives: To assess the changes and progress in medical technology, philosophy, 

and ethics relating to brainstem death. 

The development of medical technology in intensive care medicine dramatically 

increased the complexity of cases over the past 30 to 40 years. The ability to maintain ventilation 

and circulation artificially, and the advances made in organ transplantation, showed 

that meaningful life could be maintained even though these organs had failed. Therefore, the 

concept of cessation of cardiorespiratory function as the defining criteria for death had to be 

revised. 

The (re)definition of death–‘irreversible loss of the capacity for consciousness, combined 

with the irreversible loss of the capacity to breathe’–has largely been accepted throughout 

the western world, since its inception in the 1960s. The debate surrounding brain (stem) 

death initially involved mainly clinicians, lawyers, philosophers, and religious leaders. This 

concept of death has been accepted in the United Kingdom and United Sates without much 

public debate, but in the last 20 years it has seen extensive public debate in Denmark, 

Germany, and also Japan. It remains interesting to note that worldwide the public voice was 

not heard as much in this debate as in the one on when ‘life’ begins. 

Although clinical diagnosis remains at the heart of the diagnosis of brain stem death, 

some countries specify additional special tests. These may be required by law as an essential 

component of the diagnosis, or left to the discretion of the clinicians to be used as an additional 

decision-making tool. The special investigations also vary from country to country and 

include EEG, vascular flow studies, CT scanning, and MRI. Little work has been done to objectively 

assess the contribution and validity of these investigations. 

Also, the point of death remains a varying one. For example, in the United Kingdom, 

the time of death is recorded as the time when the first set of clinical tests confirm brain stem 

death, in Denmark it is recorded as the time when the heart stops. 

Although brain stem death has gained increasing acceptance over the last 30 years, 

many questions surrounding the philosophical concept of what death is and when it occurs, 

the diagnostic criteria, and confirmatory tests required still remain. 

Bibliography 

Beecher HK. A definition of irreversible coma. Report of the ad hoc committee of the 

Harvard Medical School to examine the definition of brain death.” JAMA 1968; 

205:337–40. 

Working Group of Conference of Medical Royal Colleges and their Faculties in the 

United Kingdom. The criteria for diagnosing brainstem death. J R Coll Phys 

(Lond) 1995; 29:281–2. 

Pallis C, Harley DH. ABC of brainstem death, second edition. London, BMJ Publishing 

Group, 1996. 

Improving Organ Donation Rates 

Walter Mauritz 1 , MD, Paul Sporn 2 , MD, Emanuel Sporn, MD 3 

1 

Department of Anesthesia and CCM, Trauma Center „Lorenz Boehler”, 2 Department of 

Anesthesia and CCM, KA „Rudolfstiftung“, 3 Department of Surgery, University of Vienna, 

Vienna, Austria, EU 

Learning Objectives: To describe the current state of organ donation, as well as 

medical, organizational, financial, and legal approaches to improve donation rates. 

Methods. Medline searches for “organ donation rates”, “organ transplantation” (by 

organs), and “donation rate improvement” from 1994 – 2003. Internet search for “transplant 

statistics”. With a few exceptions, only data from the US and the EU were used. 

Results. There is a serious worldwide shortage of transplantable organs. The maximum 

donation rate is estimated to be 50/mill.pop./yr; 35/mill.pop/yr is considered optimal. 

Most centers achieve only a fraction of this value, and many patients die on the lists. Different 

strategies have been employed to improve donation rates: 

• Medical: “Expanded donor criteria”: kidneys from elderly donors, non-heart-beating 

donors, donors with renal disease; livers from hepatitis C-positive donors, from aged donors 

(>70 yr!!); lungs from older donors (>55 yr), from smokers with >20 “pack yrs” (!), hearts 

from poisoned donors, and various organs from donors with a history of cancer have been 

used with good results. “New techniques”: split liver transplantation, xenotransplantation (?). 

All these options increase the rate of available organs by a considerable margin. 

• Organizational: Increasing awareness of medical staff that organ donation is an 

option, improving the request process, and improving donation logistics have all resulted in 

increased donation rates. 

• Financial: In some countries (e.g. Turkey, India), organs may be bought, which gives 

acceptable long-term results but higher rates of HIV- and hepatitis B-infected recipients. This 

is illegal in the EU and US, yet some ethically acceptable financial incentives (e.g., reim- 

54


bursement for funeral expenses) are discussed. 

• Legal: The “Final Rule” was introduced in Hawaii in 1998; it states that “all hospitals 

are required to notify organ procurement organizations of all deaths and imminent deaths” 

in order to remain eligible for Medicare and Medicaid reimbursement. Donor referrals 

increased by 50%. Some EU countries use a “Presumed Consent” policy, thus avoiding the 

often difficult request process. This results in heart and lung transplantation rates that are at 

least twice as high as those from comparable EU countries. 

Conclusions. Many different strategies have been developed and tested. Each transplant 

center or organ procurement organization has to find the best way to deal with the local 

situation. With the right combination of techniques, an optimal donation rate should be 

possible to achieve. 

Managing the Donor 

Linda E. Pelinka, MD,1 and Emanuel Sporn, MD2 

1 

Department of Anesthesia and Critical Care Medicine, Lorenz Boehler Trauma Center, 

and 2 Clinical Department of Transplantation, Surgical University Clinic of Vienna, 

Vienna, Austria, European Union 

Learning Objectives: To review the pathophysiologic changes that occur after brain 

death and the clinical actions necessary to maintain the brain-dead, heart-beating donor. 

The most important limitation in organ transplantation is donor availability. For many 

patients with end-stage organ disease, the brain-dead, heart-beating donor is the only potential 

source from which to gain a healthy organ. Many available organs are lost to transplantation 

because of insufficient knowledge of the pathophysiology of brain death and because of 

inadequate management of the potential donor. 

Pathophysiologic Changes. A brief parasympathetic phase is followed by intense 

catecholamine release, associated with increased systemic vascular resistance, myocardial 

work, and oxygen consumption. Subsequently, cardiac output and blood pressure drop and 

ischemic tissue injury is enhanced because the inotropic and chronotropic condition of the 

heart is impaired. Loss of antidiuretic hormone secretion causes diabetes insipidus, which is 

associated with hypernatremia, hypokalemia, hypocalcemia, and hypomagnesemia. Damage 

to the hypothalamus causes hypothermia. Plasminogen activator release causes disseminated 

intravascular coagulopathy. 

Aims of Therapy 

Ventilatory management: Lower FiO 2 as much as possible while keeping pO 2 >100 

mmHg and keep peak end-expiratory pressure 30% in multiple organ donors and >24% in 

other donors. Replace clotting factors with fresh frozen plasma and platelets. INR should be 

50.000. 

Electrolytes: Replace 0.9% saline with 0.45% saline and 5% dextrose water when sodium 

>136 mEq/L. Treat diabetes insipidus with a 4 µg bolus of desmopressin acetate; repeat 

every 4 hours if necessary. Urinary output should be approximately 1 ml kg –1 hr –1 . 

Kidney function: Administer furosemide if urinary output


donation and recovery process, including the time frame/limit for death to occur. A 

written informed consent is obtained for organ and tissue donation, according to 

established TRC policies. The consent must be witnessed and signed by a hospital 

staff member. The TRC coordinator writes a detailed note in the patient’s hospital 

record regarding the consent process. 

9. All necessary laboratory and diagnostic testing is performed according to established 

TRC policies. 

10. The operating room staff is notified of the pending NHBD recovery. Space and OR 

nursing staff availability will be determined. Anesthesia services will not be required 

for the customary withdrawal of care. Arrangements for continuous palliative care 

should be made should donation be precluded. 

11. Once all necessary evaluation, organ placement arrangements, and recovery 

arrangements have been completed, and all members of the organ recovery team 

are in place, withdrawal of care will take place in accordance with individual hospital 

policies. The physician may order, as part of his/her usual and customary practice, 

ongoing pain relief, if in the physician’s belief it is medically and ethically necessary. 

No member of the TRC or the transplant team/center is present for or 

involved with this portion of the process. 

12. The patient’s vital signs are closely monitored and recorded every 5 minutes from 

the time the ventilator/pressor support is discontinued. The patient will be pronounced 

dead by the physician of record or intensivist designee after 5 minutes of 

asystole as measured by 1) the absence of electrical activity, and 2) the absence of 

an arterial pulse waveform, and 3) the absence of ventilatory efforts. Should death 

not occur within 60 minutes after discontinuing life support, the patient is returned 

to the intensive care unit or a private room for ongoing palliative care. After declaration 

of death, surgical recovery of organs occurs according to standard procedures 

as directed by the transplant recovery surgeons. 

Thank you to Charlie Alexander, RN, BSN, CPTC, Director, Development and Donor 

Services Center, TRC of Maryland, for the use of the above prepared information 

Living Donors 

Jane McNeill, MB ChB, FRCA 



Trauma Airway Management: Hands-On Skills Station 

Andreas Thierbach, MD Mainz, Germany 

Jeffrey Berman, MD, Chapel Hill, North Carolina, USA 

James M. Rich, MA, CRNA, Dallas, Texas, USA 

Freddy Lippert, MD, Copenhagen, Denmark 

Marvin A. Wayne, MD, FACEP, Bellingham, Washington, USA 

William C. Wilson, MD, San Diego, California, USA 

Saturday, May 17, 2003 

Simultaneous Morning Sessions 


Pediatrics 

Co-Chair: Gail E. Rasmussen, MD, Meridian, Mississippi, USA 

Co-Chair: Jeffrey M. Berman, MD, Chapel Hill, North Carolina, USA 

Emergency Airway Management in the Pediatric Trauma Patient 

Gail E. Rasmussen, MD 

Adjunct Clinical Faculty, Department of Anesthesiology, University of Mississippi Medical 

Center, Jackson, Mississippi, USA 

Learning Objectives: To review emergency airway management in the pediatric 

trauma patient. The lecture will include discussion of the difficult airway algorithm and 

alternative airway devices and cervical spine immobilization. 

The most immediate concern in the management of the pediatric trauma patient begins 

with the ABCs of resuscitation with airway assessment and assurance of adequate oxygenation. 

Without adequate oxygenation and effective ventilation, all other resuscitative efforts will be 

ineffective. Pediatric patients also force our hands more quickly than adults because the apneato-hypoxia 

interval is so much shorter and we are forced to intervene more quickly. Airway 

management in the trauma setting differs from other scenarios because of the need for cervical 

spine stabilization and immobilization, which may restrict options for intubation. The differences 

between adult and pediatric cervical spine injury will be delineated. One must recognize 

the need for airway intervention in the setting of respiratory distress and impending 

respiratory failure. This is often overlooked in the initial resuscitation, where there may be 

more concern for establishment of IV access than airway control. 

After initial assessment and relief of anatomic obstruction, patients who do not resume 

spontaneous ventilation and those with altered levels of consciousness (Glasgow Coma Scale 

score of 8 or less) will need more definitive airway protection and probably intubation. One 

must have the proper airway equipment available and checked before this is undertaken. 

Also, alternative airway adjuncts should be available should intubation prove difficult (including 

LMAs, jet ventilation equipment, and equipment for cricothyroidotomy). 

The trauma patient also poses an increased risk for aspiration of stomach contents 

because they are considered to be full stomachs. GI prophylaxis is optimal if time allows 

before undertaking a rapid sequence induction with cricoid pressure. The use of succinylcholine 

and its relative contraindications in the pediatric patient will be discussed. In the trauma 

setting, regardless of the age of the patient an anticholinergic agent is recommended (i.e., 

atropine, 5-10 mcg/kg, up to a maximum of 0.4 mg, or glycopyrrolate, 0.1 mg/kg) prior to 

induction. There has also been the recommendation, particularly in head trauma, to pretreat 

with 2 mg/kg of intravenous lidocaine prior to intubation. The sedative-hypnotic selected 

depends on the hemodynamic stability of the patient and the presence or absence of raised 

intracranial pressure (ICP). The top three choices include propofol, thiopentothal, and etomidate, 

depending on the particular circumstance of the patient. 

Once endotracheal intubation has been accomplished, confirmation of correct placement 

is essential, via auscultation. Tracheal rings can be visualized via bronchoscopy and the 

presence of carbon dioxide determined on capnogram or with an attachable CO2 detector. 

The pediatric trauma patient has several unique aspects in clinical practice that must 

be taken into consideration in the successful management of the emergency airway and ultimately 

the resuscitation. 

References 

McAllister JD, Gnauck KA. Rapid sequence intubation of the pediatric patient: fundamentals 

of practice. Ped Clin North Am 1999; 46:1249–84. 

Gausche M, Lewis RJ, Stratton SJ, et al. A prospective randomized study of the effect of 

out-of-hospital pediatric endotracheal intubation on survival and neurological outcome. 

JAMA 2000; 283:783–90. 

O’Kelly SW, Reynolds PI, Collito M. The use of fiberoptic endoscopy and laryngeal mask 

airway in securing the traumatized airway in the pediatric patient. Am J Anesth 

1995; 22:152–3. 

Sedation/Analgesia/Anesthesia for Diagnostic Studies and Treatment 

Outside the Operating Room 

James E. Fletcher, MD 

Department of Anesthesia, University of North Carolina, Chapel Hill, North Carolina 

Learning Objectives: 1) To review pain management strategies for children with 

trauma-induced pain and 2) to consider various sedatives, analgesics, and anesthetic 

agents and the implications of their use on assessment procedures. 

In addition to experiencing the pain directly caused by trauma, children who have suffered 

injury may have to undergo procedures that provoke anxiety and pain as part of their 

diagnostic workup or treatment. The nature of the injury, ranging from an isolated fractured 

long bone to a semiconscious head injury with chest contusion, will affect the strategy chosen 

to manage the patient’s comfort and cooperation. Similarly, the proposed intervention 

will determine the use of anxiolytics, analgesics, sedatives, and anesthetics. 

Diagnostic studies may involve painful procedures such as tapping of the peritoneal 

cavity or invasive radiology such as angiography. Immobility is important for noninvasive radiology 

such as CT or MRI, particularly in the latter instance. Alternatively, a therapeutic intervention 

such as placement of a chest drain or fixation of a broken limb will require analgesia 

to facilitate cooperation. 

Central to any such intervention is an assessment of the patient’s cardiorespiratory system, 

including keen attention to either pre-existing or trauma-induced compromise of the 

airway or circulating blood volume. 

Pain should be assessed frequently in the pediatric population, as children are reluctant 

to report pain. The pain experience includes sensory qualities–where, when, how 

much–and motivational-affective qualities–emotional, aversive (‘hurt’), and pain-reducing 

behavior. Parental guidance is useful in understanding the child’s pain and distress behaviors. 

Children who have difficulty communicating, such as those with cognitive deficits or who do 

not speak English, are particularly difficult to assess. Age-specific methods of assessment are 

available. The pain language used by the child should be determined (e.g. ‘hurt’, ‘booboo’). 

Self-reporting is preferred in most children over 4 years of age; for those above age 7 years, 

a numerical pain scale may be used. Observation of body posture, activity, and facial expression 

may also help, although some apparently “normal” behavior may represent a coping 

mechanism for pain. 

Sedation, anesthesia, and systemic analgesia represent a spectrum of CNS depression, 

which has the potential to compromise the airway and cardiovascular system, while also providing 

humanitarian relief of suffering and facilitating successful diagnostic studies and treatment. 

“Conscious sedation” involves the use of CNS depressants to produce inattention, anxiolysis, 

and analgesia. The essential feature of this technique is that the patient remains conscious 

and able to respond to a mild stimulus–ideally, a voice. Once consciousness is lost, the 

child has lapsed into a state of light anesthesia, with its accompanying risks. As it is not possible 

to predict the effect of medication and the interaction of the medication with the 

patient’s medical state, full resuscitative equipment and expertise must be available at all 

times when sedation is administered. 

Often, sedative/analgesic drugs can be combined usefully with local anesthetic techniques. 

Options include IV (PCA) opioids, oral analgesics/sedatives, inhalation of nitrous oxide, 

ketamine, behavioral techniques, epidural local anesthetics and opioids, NSAIDs. Each drug has 

a specific profile of anxiolysis, analgesia, and sedation, as well as specific pharmacological features 

such as speed of onset and duration of action, which affect selection. Because of this, the 

non-analgesic, slow onset/offset sedative chloral hydrate is relatively unhelpful in comparison 

to morphine or fentanyl, combined with midazolam. Often, behavioral techniques can be combined 

with pharmacological methods. However, opioid analgesics and local anesthetics remain 

the cornerstone of procedural pain management. Sedative/anxiolytics should be reserved for 

non-painful procedures, as they will not relieve pain, while making assessment more difficult. 

All drugs should be given incrementally to effect. 

Pediatric Prehospital Care 

Dr. Charles D. Deakin 

Consultant Anaesthetist, Southampton University Hospital, Southampton, UK 


• To understand injury patterns in children. 

• To understand how differences in paediatric anatomy and physiology relate 

to injury patterns. 

• To understand the principles of prehospital trauma care in children. 

56


• To understand splinting, packaging, and transport of injured children. 

Injury Patterns in Children. The commonest cause of death and injury in infants 

and children is trauma. In urban settings, 35% of accidents are due to pedestrian injury from 

motor vehicles, and a similar percent from falls from heights. Drowning and choking also 

contribute significantly to pediatric mortality, although the incidence of both is gradually 

decreasing. In Europe, blunt trauma accounts for 98% of injuries, whereas the pattern is very 

different in the USA, with penetrating trauma approaching 50% of all serious injuries. Child 

abuse is an under-reported cause of pediatric injury. 

Paediatric Anatomy and Pathophysiology. Anatomical and physiological differences 

in children result in increased risk for specific injuries. The head is disproportionately 

large, which, combined with weak neck muscles and underdeveloped protective arm reflexes, 

predisposes children to head injury. Raised intracranial pressure is more common than in 

adults and occurs more rapidly following head injury. Respiratory muscles are also underdeveloped, 

making respiratory failure more common and worsening secondary brain injury from 

ischemia and hypercapnia. Bone requires more energy than adults to cause fractures, and in 

chest trauma, lung contusion without overlying rib fracture is common. Abdominal organs are 

disproportionately large, and the liver and spleen are particularly susceptible to rupture following 

abdominal trauma. The large surface area:volume ratio predisposes to hypothermia. 

Principles of Prehospital Trauma Care in Children. Unlike adults, primary cardiac 

arrest is rare, and cardiac arrest in children is usually due to hypoxia where bradycardia 

rapidly progresses to asystole. Ventricular fibrillation is rare and often due to hyperkalaemia, 

tricyclic overdose, solvents, or hypothermia. Treatable causes of pulseless electrical activity 

must be excluded rapidly (hypovolaemia, tension pneumothorax, cardiac tamponade). 

Airway management in the traumatised child is a priority. A short neck, large tongue, 

large tonsils, large epiglottis, and high anterior larynx make endotracheal intubation more difficult. 

Attempts at pediatric intubation in obtunded children are likely to fail without the use 

of appropriate sedative and neuromuscular blocking drugs. The laryngeal mask airway is now 

being introduced to prehospital care in Europe for the management of difficult paediatric airways. 

Prehospital surgical airways are particularly challenging. Gastric decompression with an 

orogastric tube may improve tidal volumes and lower airway pressures. Cardiovascular compensation 

to acute hypovolaemia is more marked in children than adults and a hypotensive 

child will be severely hypovolaemic. Bleeding into body cavities must be carefully excluded. 

Venous access is difficult because of small size, overlying adipose tissue, and venous collapse. 

Intraosseous access should be gained early. Effective analgesia is particularly important in 

children, and requires opioids and local or even general anaesthesia. 

Splinting, Packaging, and Transport of Injured Children. Careful splinting and 

packaging of children is vital for successful and safe transfer, particularly by air. Parents are 

generally a better alternative to sedation during transfer of the injured child. 

Reference 

Mazurek AJ, Meyer PG, Rasmussen GE. Prehospital trauma management of the pediatric 

patient. In Soreide E, Grande CM, eds. Prehospital Trauma Care. New York, 

Marcel Dekker, 2001, pp 421–40. 

Pediatric Head Injury: Where Have We Been; Where Are We Going? 


University of North Carolina, Chapel Hill, North Carolina 

Learning Objectives: 1) To appreciate changes in morbidity and mortality statistics, 

2) to appreciate the evolution of clinical management of pediatric head injury, 3) to 

appreciate evolving management strategies, and 4) to understand current guidelines. 

Mortality. The December 6, 2002, MMWR reported an 11.4% decline in mortality 

related to traumatic brain injury (TBI). These statistics, which cover the decade from January 

1989 to December 1998, also document the changes in the etiology of injury among patient 

groups, including children. The three leading causes of TBI death are motor vehicles, 

firearms, and falls. Motor vehicle crashes persist as the leading cause of TBI and subsequent 

deaths amongst children (1–19 years of age). 

Evolution of Clinical Management. In the past, clinical management of head injury 

focused on control of ICP. The modalities used to accomplish that goal were hyperventilation 

(to PaCO 2 into the mid 20s), barbiturates (including barbiturate coma), steroids, fluid restriction, 

osmolar and diuretic therapy (mannitol, furosimide), and nursing care delivered in the 

head-up position (~30˚). Simultaneous with a shift in focus to prevention of secondary brain 

injury, more sophisticated means to measure cerebral hemodynamics became available. 

These technologies made it apparent that in order to avoid secondary injury the therapeutic 

focus ought be on brain perfusion, especially in the penumbra of primary injury. To achieve 

this endpoint, a variety of modalities coupling brain monitoring with pharmacological and/or 

mechanical interventions are being employed (e.g., measurement of jugular venous saturation, 

drainage of CSF, osmotic therapy using hypertonic saline, induced mild hypothermia, 

and maintaining normocapnia). 

Current Guidelines. Current recommendations are based on the aforementioned 

principle of maintaining cerebral perfusion. At a minimum, ICP monitoring ought be 

employed in every child who has sustained a severe TBI (GCS score 40 mmHg in younger children and >50 in older children and 

adolescents. PaCO 2 ought range from 35-38 unless treating impending intracranial herniation. 

Osmolar therapy using mannitol or hypertonic saline may be of use but lacks definitive 

evidence, as does the use of barbiturates. 

Conclusion. Though much progress has been made in the identification of cellular 

mechanisms and likely triggers of pathophysiology, we have yet to produce unequivocal 

definitive therapies for TBI. Nevertheless, prevention efforts and aggressive neurointensive 

care focused on prevention of secondary brain injury have yielded very gratifying reductions 

in morbidity and mortality. As every year, we are hoping that discovery of the “silver bullet” 

is just days or months away. We are closer but have not yet achieved that goal. 

Fluid Management of the Injured Child 


Charles R. Drew University of Medicine, Martin Luther King Jr. Medical Center, Los 

Angeles, California, USA 

Learning Objective: To educate the participant about assessing volume status, 

recent advances in fluid management, and a rational therapeutic approach for fluid 

administration in the injured child. 

The leading cause of death in children age 1 to 14 years in the developed world is 

trauma. The major cause of disability in children is trauma. It has been reported that inadequate 

evaluation and inappropriate treatment contributes to 30% of early deaths in children 

with severe trauma. 1 

Prompt and accurate assessment and treatment are critical in the prevention of unnecessary 

pediatric morbidity and mortality from trauma. The most crucial first step in providing 

for the injured child is the establishment of adequate oxygenation and ventilation. Once oxygenation 

has been established, intravenous access and the administration of appropriate 

intravenous fluids are essential. 

Assessment of the pediatric circulatory system must take into account the following. 

Shock in children may exist with a normal blood pressure. In children, cardiac output 

decreases in a linear fashion as blood volume decreases; however, blood pressure may 

remain unchanged. In the pediatric patient, stroke volume is fixed; thus, cardiac output in 

the face of hypovolemia is maintained by increasing the heart rate and peripheral vascular 

resistance. When cardiac reserve is exhausted, bradycardia indicates significantly decreased 

blood volume. 

Intravenous access must be obtained while assessing the severity of injuries. With significant 

blood loss, the child’s compensatory vasoconstriction can make IV access difficult. 

Attempts at IV access should be limited to 60-90 seconds, and if unsuccessful, the clinician 

should proceed to insertion of an intra-osseous needle. Be sure to avoid the leg with a suspected 

tibial/femoral fracture or vascular injury. All IV fluids should be warmed to 37˚C. 

Children have small blood volumes and cannot afford to lose large amounts of blood. 

Occult blood losses from the head (especially scalp) and neck region can result in significant 

hemodynamic instability. Aggressive control of bleeding is indicated. Remember, a hemodynamically 

unstable child should never be sent to CT scan to determine the site of bleeding. 

That child must be taken to the OR for surgical exploration. The choice of colloid over crystalloid 

for the initial resuscitation has been reported to increase the mortality by 4%. 

Crystalloids 20 ml/kg times 2 doses should be given and if no improvement in hemodynamics 

occurs, then administer blood 10ml/kg. Colloids should be given only as a temporizing 

measure while you are waiting for blood products. 2 Dextrose-containing fluids should be 

given only when there is laboratory evidence of hypoglycemia. 

In the management of traumatic brain injury, the goal is maximizing cerebral perfusion 

pressure and reducing ICP. The early introduction of inotropes maintaining MAP of 70mmHg 

is recommended to avoid fluid overload. 

References 

1. Delayed diagnosis of injury in pediatric trauma. Pediatrics 1996; 98:56–62. 

2. Fluid resuscitation with colloid or crystalloid solutions in critically ill patients: a systematic 

review of randomized trials. BMJ 1998; 316:961–4. 

Early Care of the Pediatric Burn Patient 

Gary F. Purdue, MD 

Professor, Department of Surgery, UT Southwestern Medical Center, Dallas, Texas, USA 

Learning Objectives: 1) to learn to recognize the elements of burn severity and 

understand the components of a major pediatric burn, 2) to recognize the different types 

of inhalation injury, and 3) to appreciate the special aspects of burn treatment, including 

thermal maintenance, airway protection, and fluid resuscitation. 

Children are at special risk of burn injury, comprising one third of burn center admissions. 

A plan of initial burn assessment and therapy includes the care essential for all cases, 

specific treatments for minor burns, and the special requirements of major thermal trauma. 

Rapid estimation of body surface area burned permits planning of immediate management 

and fluid therapy and dictates the needs for definitive care. Only second- and thirddegree 

burns are tabulated with Lund-Browder or Berkow charts providing correction for 

age. The “Rule of Nine’s” is not appropriate for children. 

While depth of injury is important in determining the choice of care and ultimate outcome, 

initial evaluation is difficult. Characteristics will be discussed. 

Burns of the face, hands, feet, and perineum/genitalia present special problems, while 

burned children



Prehospital Care 

Co-Chair: Charles D. Deakin, MA MD MRCP FRCA, Southampton, UK 

Co-Chair: Marvin A. Wayne, MD, FACEP, Bellingham, Washington, USA 

Isolated ext injuries 

Mechanism 

GLF 

Moderate speed MVA 

High speed MVA 

Falls >20 feet 

GSW's 

Negative 

Uncertain 

Positive 

Use of Capnography in Pre-Hospital Trauma Care 

Dr. Charles D. Deakin 

Consultant Anaesthetist, Southampton University Hospital, Southampton, UK 


• To understand the physiology of CO2 production and excretion. 

• To understand the techniques of measuring end-tidal CO2. 

• To understand changes in end-tidal CO2 in relation to pathophysiology. 

• To understand predictive value of end-tidal CO2 in relation to outcome. 

What is End-Tidal Carbon Dioxide? Cellular metabolism results in carbon dioxide 

(CO2) formation as a by-product of adenosine triphosphate (ATP) production. CO2 is excreted 

by the cell, and ultimately by the body, to maintain normal homeostasis. CO2 diffuses out 

of the cell to enter the blood stream, where it is carried in the plasma or in erythrocytes. As 

blood flows through the lungs and the alveolar capillaries, a diffusion gradient causes CO2 to 

diffuse from the blood into alveolar air spaces. The CO2 is then excreted from the alveolar air 

spaces in expired air. The CO2 in expired air can be measured using capnography. The peak 

CO2 in expired air is maximal at end-expiration (end-tidal CO2; PetCO2) and equates approximately 

to arterial CO2 (PaCO2). 

How is end-tidal carbon dioxide measured? End-tidal CO2 is measured directly 

from respiratory gases. There are two methods by which it can be measured: 

• Colorimetric CO2 detectors change colour when exposed to CO2. 

• Electronic measurement. Uses spectrophotometry to give a real-time value of 

CO2. 

End-Tidal Carbon Dioxide and Cardiac Output. In low cardiac output states, 

blood flow to the lungs is low, so that relatively few alveoli are perfused. Since tidal volumes 

delivered with a resuscitation bag tend to be large, many alveoli are ventilated that are not 

perfused and consequently the PetCO2 is low. If the blood flow to the lungs improves, more 

alveoli are perfused and PetCO2 will increase. Providing the lungs are ventilated at a fixed 

minute volume (rate x tidal volume), changes in PetCO2 are proportional to changes in cardiac 

output. 

Use of Capnography in Pre-Hospital Care 

1. Confirmation of endotracheal intubation. In a patient with a spontaneous cardiac 

output, correct endotracheal intubation will immediately show the presence 

of CO 2 , whereas oesophageal intubation results in absence of PetCO 2 . In 

the absence of cardiac output, PetCO 2 is minimal and correct endotracheal 

placement should be confirmed by other means. 

2. Operator fatigue. Because PetCO 2 is proportional to cardiac output, PetCO 2 is 

an indicator of the effectiveness of cardiac massage. Decreased PetCO 2 during 

cardiac massage may indicate operator fatigue. 1 

3. Indication of the return of spontaneous cardiac activity. An increase in PetCO 2 is 

often the first indicator of the return of spontaneous circulation. 1,2 

4. Indication of adequate ventilation. PetCO 2 is a marker of adequate ventilation 

because it approximates to arterial CO 2 . Ventilation of trauma patients using 

capnography results in more optimal PaCO 2 values. 3 

5. Prediction of outcome. Patients suffering primary cardiac arrest in whom 

PetCO 2 has failed to rise above 1. 4 kPa after 20 minutes of advanced life support 

are extremely unlikely to survive. 4 Only 5% trauma patients with PetCO 2


IVF resuscitation in certain uncontrolled hemorrhage models and one major clinical study 

has even shown the efficacy of withholding IVF infusions preoperatively in those patients 

with penetrating torso injuries (versus the standard rapid infusions of IVF in both the prehospital 

and emergency department settings). It is therefore speculated that BP elevation, 

prior to achievement of hemostasis, may actually increase mortality in certain subgroups of 

injury patients. The rationale, experimental evidence, scientific design, and limitations of 

these studies will be examined and qualified in this discussion. In addition, the concept of 

using hypertonic solutions and new hemoglobin-based oxygen carriers in such circumstances 

will be analyzed as well. 

Bibliography 

Bickell W, Wall M, Pepe P, et al. Immediate versus delayed fluid resuscitation for 

hypotensive patients with penetrating torso injuries. Resuscitation 1995; 

29(2):183–4. 

Dutton R, Mackenzie C, Scalea T. Hypotensive resuscitation during active hemorrhage: 

impact on in-hospital mortality. J Trauma 2002; 52:1141–6. 

Fowler RL, Pepe PE. Prehospital care of the patient with major trauma. Emerg Med Clin 

North Am 2002; 20:953–74. 

Manning JE, Katz LM, Brownstein MR, et al Bovine hemoglobin-based oxygen carrier 

(HVOC-291) for resuscitation of uncontrolled, exsanguinating liver injury in swine. 

Shock 2000; 13:152–9. 

Pepe PE, Lurie K, Raedler C. Emergency ventilatory management in hemorrhagic 

states: elemental or detrimental? J Trauma June 2003; 54(6), in press. 

Pepe PE, Mosseso V, Falk JL. Prehospital fluid resuscitation of the patient with major 

trauma. Prehosp Emerg Care 2002; 6(1):81–91. 

Stern SA. Low-volume fluid resuscitation for presumed hemorrhagic shock: helpful or 

harmful. Curr Opin Crit Care 2001; 7:422–30. 

Stern SA, Wang X, Mertz M, et al. Effect of initially limited resuscitation in a combined 

model of fluid percussion brain injury and severe uncontrolled hemorrhagic shock. 

J Neurosurg 2000; 93:305–14. 

Stern SA, Zink BJ, Mertz M, et al. Under resuscitation of near-lethal uncontrolled hemorrhage: 

effects on mortality and end-organ function at 72 hours. Shock 2001; 

15:16–23. 

Prehospital Use of Hypertonic Saline Derivatives 

Professor Pierre Carli, MD, PhD 

Department of Anesthesiology, Hôpital Necker–Enfants Malades, Paris, France 

Learning Objectives: 1) To understand the importance of correct assessment of the 

status of trauma cases in the prehospital setting and 2) to learn the use of small-volume 

hypertonic solutions in penetrating trauma for rapid fluid replacement, providing a modified 

systemic arterial pressure capable of maintaining vital functions while limiting the 

possibility of further hemorrhage. 

Hypertonic saline solutions associated with colloids are particularly suitable for prehospital 

use in major trauma. 

In European EMS systems, where physicians are involved in prehospital care, three 

steps of management are closely linked. First, the on-site evaluation of the patient is essential 

to assess the mechanism of the injuries and the respiratory and ventilatory status. Special 

care must be taken with penetrating trauma with hypotension or multiple blunt trauma with 

severe brain injury because the management of these patients is different. 

Second, on-site respiratory management in order to provide efficient airway ventilation 

and oxygenation is the first priority of treatment. Stabilisation of respiratory status improves 

patient survival. Prehospital intubation is indicated in severe trauma patients who are unconscious 

(GCS


ble range of chemical and biological agents regarded as hazards is wide, the number that pose 

real threats is limited, particularly when being deployed by terrorists. A study of agents that 

have been used such as sarin and anthrax, together with experience gained from civil accidental 

releases, provides a basis for anesthesiological training to provide an effective response. 

Terror-Induced, Multiple Casualty Events: Injury Patterns and Emergency 

Department Response 

Amir Blumenfeld, Yahav Oron, Oleg Zaslavsky, Eitan Melamed, Ron Ben-Avraham, Guy Lin 

IDF Medical Corps Trauma Branch 

Learning Objectives: To review and discuss the types of injuries caused by suicidal 

terrorist attacks and to consider the implications of these injury patterns on emergency 

medical systems. 

By September 2000, the Israeli-Palestinian conflict escalated by what was later known 

as the “Al-Aksa Intifada.” It was a combination of civilian population riots and low-intensity 

military conflict between the Israeli army (IDF) and the Palestinian armed forces. Soon after 

these riots, which started in the west bank and Gaza strip, got into the hearts of the Israeli 

cities and towns and, by changing its nature to suicidal terrorist attacks, caused severe 

injuries and death among children, women, and men. 

Up to December 2002, more than 5,000 civilians and security force personnel had been 

injured. About 700 people were killed, 370 of them in multiple casualty events (MCE) caused 

by explosives carried on suiciders’ bodies or hidden in cars. 

In order to define injury patterns and estimate the needs of the injured, we conducted 

a retrospective survey. Data were collected from EMS (operational and medical) records, 

police reports, ED records, trauma registry files, and specially designed questionnaires run 

among ED personnel. 

MCE victims were divided into three groups by location of occurrence: open spaces 

(N=316), closed spaces (N=280), and buses (N=260). Injury severity as well as EMS and hospital 

resource utilization and patients’ immediate outcomes were analyzed according to this 

division. 

As a rule, an indoor blast magnifies both casualty generation and injury severity. 

Mortality rate, which ranged between 8% and 22%, was the highest among bus explosion victims. 

Severe injuries (ISS>16) rate ranges between 7% and 11.4%, while acute stress reaction 

is a common consequence (37% to 52%), especially among people injured in open spaces. 

Emergency interventions such as endotracheal intubation, chest drain insertion, and ED thoracotomy 

as well as operative procedures and ICU admission were needed much more frequently 

by victims injured in confined-space explosions. Though gathered experience 

improved hospitals’ performance, there was still an “over-recruitment” phenomena of medical 

resources on both the prehospital and ED level. 

The results and conclusions drawn from this study may serve as a basis for future planning 

of national emergency medical systems. 


CRNA Session 

Chair: James M. Rich, MA, CRNA, Dallas, Texas, USA 

Vascular Access for Trauma Anesthesia: 

Options, Risks, Benefits, and Complications 


Department of Nurse Anesthesia, Baylor University Medical Center, Dallas, Texas 

Learning Objectives: 1) To compare and contrast the classifications of shock, 2) to 

discuss the number, size, and location necessary for vascular access in trauma, 3) to 

understand the acute and chronic complications associated with vascular access, and 4) 

to discuss the options for vascular access for children younger than 5. 

Multiple trauma patients with hemorrhagic shock require rapid intravenous access 

after airway patency and ventilation are established. Timely restoration of intravascular volume 

improves systemic perfusion, alleviates tissue hypoxia and acidosis, and arrests cell 

death and progression to irreversible shock. Therapeutic goals include restoring volume 

deficits and preventing further loss. 1 The type and location of injury, duration and rate of 

blood loss, and classification of hemorrhagic shock (Table 1) will mandate the size, number, 

and location of intravenous catheters. 

Table 1. Classes of Shock 2 

Class Blood Heart Rate Blood Pulse Respirations/min 

loss (mL)/% Pressure Pressure 

Total Blood 

Volume 

Class 1 2000 

>40% >140 Decreased Decreased >35 

ATLS protocol recommends insertion of two large-bore (16g or larger) IV catheters 

before insertion of a central venous catheter or venous cutdown in patients with severe 

injuries and hemorrhagic shock. 3 Classes 2, 3, and 4 shock warrant central venous access for 

fluid replacement and monitoring. 

When considering a location for IV access, several factors are considered. Injuries 

below the diaphragm require one IV placed in a tributary of the superior vena cava because 

of possible disruption of the inferior vena cava. Patients with upper chest and neck injuries 

require access in lower extremities because superior vena cava disruption may be present. In 

multisystem trauma, large-bore IV access above and below the diaphragm is necessary. 

Patients in hypovolemic shock need rapid administration of IV fluids through short 

large-bore catheters. Doubling internal diameter of the catheter increases flow 16-fold. Eight 

and nine French large-bore catheter introducers deliver flow rates nearly twice as fast as short 

14g catheters and can be used in subclavian, internal and external jugular, femoral, and antecubital 

sites. 4 

Catheterization of large central veins provides access for rapid infusion and measurement 

of central venous pressure. Table 2 summarizes acute and chronic complications of subclavian 

and internal jugular catheters. Anesthesia providers must be aware of these complications, 

especially if the patient’s condition does not improve or deteriorates during anesthesia. 

Table 2. Acute and Chronic Complications of 

Subclavian and Internal Jugular Catheters 

Acute Complications 5,6 Late Complications 5,6 

Cardiac arrhythmias 

Infection 

Arterial puncture 

Sepsis 

Pneumothorax 

Intravascular thrombosis 

Hydrothorax 

Pseudoaneurysm 

Air embolism 

Arteriovenous fisula formation 

Horner’s Syndrome 

Thoracic duct injury 

Guidewire or catheter fragment embolization 

Cardiac tamponade 

Vessel perforation with hemorrhage 

Cerebral infarction 

Phrenic nerve injury 

Brachial plexopathy 

Intraosseous catheters can be used in children younger than 5 years of age because the 

cortical bone is softer. Specifically designed intraosseous needles are available and flow rates 

of 40 mL/min with crystalloids using pressure bags have been achieved. 7 Complications 

include disruption of the growth plate, cellulitis, osteomyelitis, fat embolism, and extravasation 

of fluids into the surrounding tissue. 

Anesthesia providers must be skilled in each catheterization technique and utilize the 

technique with which they are most experienced. However, they should have the expertise 

to perform as many techniques as warranted by the situation. Diligent observation for possible 

complications should be an ongoing process during anesthesia. Successful vascular access 

is of prime importance in preventing morbidity and mortality in trauma. 

References 

1. Sweeney MN. Vascular access in trauma: options, risks, benefits, and complications. 

Anesthesiol Clin North Am 1999; 17(1):97–106. 

2. Abraham E, Shapiro M, Podolsky S. Central venous catheterization in the emergency 

setting. Crit Care Med 1983; 11:515–7. 

3. Millikan JS, Cain TL, Hansbrough J, et al. Rapid volume replacement for hypovolemic 

shock: a comparison of techniques and equipment. J Trauma 1984; 

24:428–31. 

4. Bickell V, Pepe PE, Mattox KL. Complications of resuscitation. In Mattox KL, ed. 

Complications of Trauma. New York, Churchill Livingstone, 1994. 

5. Eckhard WF, Iaconetti J, Kwon JS, et al. Inadvertent carotid artery cannulations during 

pulmonary artery catheter insertion. J Cardiothorac Vasc Anesth 1996; 

10:283–90. 

6. Shoor PM, Berryhill RE, Benumof JL. Intraosseous infusion: pressure-flow relationship 

and pharmacokinetics. J Trauma 1979; 19:722–4. 

7. Alexander HA, Proctor HJ. Advanced Trauma Life Support, 5th edition. Chicago, 

American College of Surgeons, 1993. 

Massive Volume Replacement in the Trauma Patient 

Charles R. Barton, CRNA, MSN, M.Ed. 

Director, Graduate Anesthesia Program, The University of Akron 

College of Nursing, Akron, Ohio, USA 

Learning Objective: To discuss the means of evaluating hemorrhagic blood loss 

and the appropriate replacement fluids in the trauma patient sustaining severe injuries. 

Hemorrhagic blood loss in the trauma patient leads to shock and increased mortality 

unless treated promptly and appropriately at the earliest possible time following initial injury. 

With an adequate understanding of the mechanism of injury, the anesthetist develops a high 

index of suspicion for potential high volume of blood loss in patients with significant thoracic, 

abdominal, and pelvic injuries. Additionally, conditions such as bilateral femoral fractures and 

major vascular injuries are also associated with substantial hemorrhage. 

Initial Assessment and Management. In an ideal trauma system, intravenous fluids are 

initiated at the scene. Volume resuscitation is administered vigorously until the patient 

appears to normalize physiological parameters. Desirable endpoints include an adequate 

blood pressure, reasonable pulse rate, appropriate capillary refill, and 1-2 ml/kg urinary output 

per hour. 

In the trauma center resuscitation area, several large-bore intravenous catheters are 

placed and blood is drawn for determination of a CBC, SMAC, coagulation panel, and toxicology 

screen. The establishment of venous access facilitates volume restoration and provides a 

route for intravenous drug administration. During CPR, peripheral lines are placed. Following 

restoration of spontaneous circulation, central venous lines are placed as indicated. 

In life-threatening situations, type O-negative (or alternatively O-positive) blood is 

transfused without type and cross-matching. If time permits, generous volumes of crystalloid 

and colloid fluids are given with continuous evaluation of the patient’s clinical presentation. 

Concurrently, hemogloblin and hematocrit values are determined to guide progress of resuscitation 

and the need for additional blood. 

Management of major blood loss will include the placement of several large-bore intravenous 

catheters and placement of appropriate invasive physiological monitors. Liberal 

administration of balanced salt solution is used. Colloids are used to rapidly increase intravascular 

volume to aid in restoration of adequate blood pressure and appropriate pulse rate. 

During surgery, red blood cell salvaging is helpful in reducing the need for additional bank 

blood. Efficient fluid warming and adequate capacity to pump fluids at high flow rates are 

used to prevent hypothermia and to provide rapid fluid replacement. Initial comprehensive 

assessment and aggressive fluid resuscitation will often allow the anesthetist to avoid the 

need for ACLS drug interventions. 

Conclusions. Fluid resuscitation of the trauma patient is a critical element in the over- 

60


all anesthetic management. Early establishment of adequate venous access and administration 

of warmed crystalloid and colloid fluids and blood products are essential to initial resuscitation. 

Fluid management is based on careful assessment and monitoring of physiological and 

laboratory values. The principles of successful management of the trauma patient are based on 

organization and preparation, assessment of the patient’s injuries, proper priority for therapeutic 

interventions, achievement and maintenance of a patent airway, fluid resuscitation, 

application of appropriate continuous invasive and noninvasive monitoring, correction of acidbase 

and electrolyte disturbances, and careful titration of anesthetic and adjunctive agents. 

The degree of functional outcome of trauma patients is largely dependent on the early involvement 

of sound principles of anesthesia care in the resuscitation and overall anesthetic management 

during the perioperative period. In a well-managed team approach, assessment and 

treatment are carried out in rapid succession or even simultaneously. 

Suggested Readings 

Barton CR. Trauma anesthesia. In Nagelhout J, Zaglaniczny K, eds. Nurse Anesthesia, 

2nd edition. Philadelphia, WB Saunders, 2001, pp 824–47. 

Barton CR, Beeson M, Campbell J. Anesthesia for the trauma patient. Curr Rev Nurse 

Anesth 1998; 20:241–52. 

Barton CR. Anesthesia for the trauma patient. In McIntosh LW, ed. Essentials of Nurse 

Anesthesia. New York, McGraw-Hill, 1997, pp 477–97. 

Grande CM. Mechanisms and patterns of injury: the key to anticipation in trauma management. 

Crit Care Clin 1990; 6:25–35. 

to percussion of one hemithorax, distended neck veins, or tracheal shift. An upright expirational 

chest radiograph provides definite information if the problem is significant. However, 

if the trauma patient is unstable, a large-bore intravenous catheter is inserted into the superior 

portion of the second intercostal space along the midclavicular line. 

Many thoracic injuries can be life threatening. Massive hemothorax, which can be 

caused by bleeding from the heart and great vessels, must be treated immediately. Adequate 

fluid resuscitation is accomplished before placement of chest tubes. Chest tubes allow 

drainage of blood from the pleural cavity but can lead to more extensive bleeding and 

hypotension. Pericardial tamponade that restricts filling of the cardiac chambers during diastole 

and produces a fixed low cardiac output is also a life-threatening emergency that requires 

immediate correction with pericardiocentesis. Patients with cardiac rupture without pericardial 

tamponade seldom survive because exsanguination is extremely rapid in this situation. 

Traumatic aortic rupture, if complete, is usually fatal, but with an intimal tear with a dissecting 

aneurysm, the patient can be saved if the diagnosis and repair are performed promptly 

during well-managed fluid resuscitation and anesthesia care. Management of these cases 

requires rapid and accurate assessment and appropriate surgical and anesthesia intervention. 

Partial disruption of the trachea or major bronchi can be handled in many cases through 

securing of the airway (by intubation or tracheostomy) and surgical correction. Total disruption 

of the trachea is commonly fatal unless rapid surgical retrieval of the distal disrupted airway 

segment is accomplished; this measure allows life-saving mechanical ventilation. 

Diagnosis of stable chest injuries is frequently enhanced by computed tomography 

(CT), angiography, and other radiologic studies. 

Applying ATLS Guidelines to Trauma Care 

Wendell Spencer, CRNA, MHS 

President of North Central Anesthesia Services, LLC 

O’Neill, Nebraska, USA 

Learning Objective: To apply ATLS guidelines to management of the trauma 

patient in the critical care setting by CRNAs. 

Assessment of the patient should begin with the airway. 1 Decisions should be made in 

the opening minutes of assessment to recognize pitfalls in establishing the airway, recognition 

of the incorrectly established airway, displacement of an ongoing airway, and the possibility 

of aspiration. 

Problems that can occur early in assessment include several types of trauma: head 

trauma, neck trauma, and maxillofacial trauma that may influence the type of airway control 

used. The goal should be to provide airway support and deliver oxygen without causing further 

harm to patients (i.e., aspiration, further trauma). 

Maxillofacial trauma patients should be assessed for their ability to breath in supine 

position and for fractures to the trachea or oropharynx. Neck trauma patients may have penetrating 

injuries that cause displacement of the trachea and require tracheostomies. 

Associated laryngeal trauma may include a triad in the fracture of the larynx, including hoarseness, 

subcutaneous emphysema, and a palpable fracture. 

In the initial assessment of the airway, look, listen, and feel for any abnormalities. 

Looking at the airway should include observation of obstruction, decreased air movement, 

retraction, deformity, and debris. Listening to the airway may reveal noisy speech, gurgle or 

stridor, or hoarseness requiring further intervention. Feeling the airway may reveal the location 

of the trachea, hematoma formation, or fracture locations. 

Ventilation capabilities must be assessed for factors of the central nervous system that 

may impede the airway. These factors may include CNS depression, blunt chest trauma, spinal 

cord injury, and other problems. 

Management of patients must always include immobilization of the neck at all times 

with traction on the head in a neutral position and care to avoid complicated fractures of the 

face and nasal area. Needs for definitive airways include the following types of patients: 

unconscious, severe maxillofacial trauma, and those at risk for obstruction or aspiration. 

Nasal tracheal intubation should be used only when clearly indicated. Airway algorithms 

should be followed to minimize poor decision making in choosing the next step in assisting 

the patient to ventilate. Jet ventilators or surgical cricothyrotomies may be used as a last 

resort in rescuing the airway. 2,3 

References 

1. Wheeler M, Ovassapian A. Prediction and evaluation of the difficult airway. In 

Hagberg CA, ed. Handbook of Difficult Airway Management. Philadelphia: 


2. Bowman-Howard M. Management of the traumatized airway. In Hagberg CA, ed. 

Handbook of Difficult Airway Management. Philadelphia: Churchill Livingstone, 

2000, pp 319–45. 

3. Melker RJ, Florete OG. Cricothyrotomy: review and debate. In Doyle DJ, Sandler 

AN, eds. The Difficult Airway II. Anesthesiol Clin North Am 1995; 13: 565–83. 

Anesthetic Management of the Patient Sustaining Thoracic Trauma 

Charles R. Barton, CRNA, MSN, M.Ed. 

Director, Graduate Anesthesia Program, The University of Akron 

College of Nursing, Akron, Ohio, USA 

Learning Objectives: To understand manifestations and management of the lifethreatening 

conditions that can result from blunt thoracic trauma. 

Blunt thoracic trauma often results from the impact of drivers who are not wearing 

safety belts into the steering wheel during a motor vehicle crash. Penetrating and blunt trauma 

to the chest may injure several structures and thus compromise optimal resuscitation. 

These structures include the chest wall, the lungs and airways, the heart and pericardium, 

and the great vessels of the thorax. Injuries to these structures also compromise anesthesia 

care by affecting gas exchange and cardiac output. 

Several life-threatening conditions require immediate interventions in patients with 

chest injuries. A tension pneumothorax develops when the pleural cavity is punctured, creating 

a one-way valve that controls the flow of air into this cavity. With each breath, more air 

becomes trapped in this space, increasing intrapleural pressure to the point that it eventually 

exceeds all other intrathoracic pressures. The enlarging pleural cavity then collapses the 

ipsilateral lung and shifts structures of the mediastinum (e.g., trachea, great vessels, heart) 

into the opposite hemithorax, thereby compressing the contralateral lung. The size of a 

pneumothorax rapidly increases during positive-pressure ventilation, especially if nitrous 

oxide is used in the field for analgesia or during anesthesia in the trauma facility. Patients with 

a pneumothorax often present with hypotension, subcutaneous emphysema of the neck or 

chest, unilateral decrease in breath sounds, diminished chest wall motion, hyper-resonance 

Anesthetic Management of the Trauma Patient in the Rural Health Care Setting 

Wendell Spencer, CRNA, MHS 

President of North Central Anesthesia Services, LLC 

O’Neill, Nebraska, USA 

Learning Objective: To discuss the anesthetic considerations unique to the rural 

health care trauma patient as they relate to the area of shock. 

The rural health patient presents many challenges to the anesthetic care provider in 

resources and in the management and treatment of shock. Recognition of the signs and 

symptoms of shock is the key to successful intervention and treatment of trauma patients. 

Shock is defined as both inadequate tissue/organ perfusion and a lack of tissue oxygenation. 

Knowledge of cardiac output and stroke volume is necessary to evaluate the patient 

who presents in shock. Cardiac output is the volume of blood pumped per minute as a result 

of heart rate and stroke volume. Stroke volume is the amount of blood pumped by the heart 

as determined by preload, myocardial contractility, and afterload. 1 

Early changes of blood loss include tachycardia, progressive vasoconstriction, release 

of histamine, and bradykinin. Initial goals include restoring cardiac output via volume repletion 

with isotonic solutions. 1 Vasopressors may be contraindicated at this time due to the 

need for volume replacement and the additional stress placed on the heart muscle. 

Recognition of shock includes tachycardia, vasoconstriction, decreased cardiac output, 

a narrowing pulse pressure, decreasing mean arterial pressures, and decreased blood flow. 

Tachycardia varies by patient age group, and normal values should be taken into consideration 

while assessing the patient. 1 

Pitfalls in assessment of the shock patient include extremes of age, athletes, pregnant 

patients, medications ingested by the patient prior to arrival, and misleading hemoglobin and 

hematocrit values resulting from fluid resuscitation. 

Types of shock include hemorrhagic, cardiogenic, neurogenic, and some types of septic 

shock. Class I, II, III, and IV types of hemorrhagic shock can start as “minor” emergencies 

and quickly turn into the loss of patient life. Initial assessment of the patient and rapid allocation 

of equipment and personnel may yield the difference in outcome to the patient in the 

rural health setting. 1 

Equipment such as a large-volume rapid infusion system, forced-air warmer, intravenous 

fluid warmer may be utilized to reverse hypothermia and offset blood loss quickly. 2 

Lab personnel and nursing staff are essential to respond rapidly to the patient’s changing condition. 

ATLS( guidelines and practice trauma drills are helpful in training the trauma team to 

respond successfully to trauma patients and assist practitioners in the “rules of engagement” 

for highly successful outcomes. 

References 

1. Dutton RP. Shock and trauma anesthesia. In Grande CM, Smith CE, eds. Trauma. 

Anesthesiol Clin North Am 1999; 17:83–96. 

2. McCunn M, Karlin A. Nonblood fluid resuscitation. In Grande CM, Smith, eds. 

Trauma. Anesthesiol Clin North Am 1999; 17:107–24. 

Airway Management in Trauma Patients 



Learning Objective: Upon completion of this lecture, the participant will be able to 

list the four anatomic variants associated with a potential difficult airway. 

Airway management and fluid resuscitation are the two most important priorities of 

the trauma patient, if there is to be any chance of viable survival without significant disability. 

This lecture will cover important aspects of airway management for the trauma patient. 

Airway anatomy, evaluation, and assessment of the airway with recognition of airway 

distortion caused by either blunt or penetrating trauma are crucial to develop an appropriate 

plan of care. Remembering the “four Ds” will aid in airway assessment, i.e., disproportion, distortion, 

decreased range of motion, and dental overbite. 1 

In order to provide rapid correction of the “Crash Airway” patient, a quick method for 

recognizing this situation is crucial. Application of Mason’s PU-92 concept accomplishes 

this. 2,3 Rational selection of an appropriate airway technique to include aspiration prophylaxis 

and protection of suspected or evident cervical spine injuries is paramount. Populations 

that require special consideration in trauma include obstetrical patients, pediatric patients, 

patients with a traumatized airway, and patients with suspected or evident cervical spine 

injuries. Methods to secure the airway in these populations will be discussed. 4 

When airway difficulty is suspected, the practitioner must decide to either to temporarily 

avoid tracheal intubation through use of a non-intubation airway technique with or 

without application of a minimally invasive airway option. It is also crucial in the face of 

potential intubation difficulty that consideration be given to a technique that allows spontaneous 

ventilation versus apnea secondary to use of neuromuscular blocks. 

The choice of rapid-sequence intubation (RSI) should be reserved for patients with no 

61


signs of predicted difficulty. RSI should be avoided if rescue ventilation options are not available 

to treat a failed airway. 5 

A failed intubation strategy should include use of bag-valve-mask ventilation (BVMV) 

with cricoid pressure as well as the use of a Combitube, LMA, or LMA-Fastrach (ILMA) to provide 

life-saving ventilation and oxygenation as well as the potential for tracheal intubation 

(i.e., LMA-Fastrach [ILMA]). The Combitube offers aspiration prophylaxis similar to that of an 

endotracheal tube. The LMA protects from aspiration much better than BVMV. 2 , 6–8 

If rescue ventilation does not attain or maintain an acceptable SpO 2 (≥ 92%), then a 

cricothyrotomy option should be immediately applied; however, the use of rescue ventilation 

will greatly decrease the need for transtracheal jet ventilation, percutaneous dilational 

cricothyrtomy, or surgical cricothyrotomy. 9 

Confirmation of tracheal intubation is a central aspect of airway management. The best 

method to confirm endotracheal intubation is to use capnography in a patient with a beating 

heart and good pulmonary vascular blood flow and to use an esophageal detector device in 

patients with cardiac arrest or severe low flow states. 10 In addition to the use of a near-fail-safe 

device, the patient’s chest should also be auscultated along the mid-axillary lines and over the 

abdomen. 

References 

1. Wheeler M, Ovassapian A. Prediction and evaluation of the difficult airway. In 

Hagberg CA, ed. Handbook of Difficult Airway Management. Philadelphia: 





3. Mackay CA et al. Association between the assessment of conscious level using the 

AVPU system and the Glasgow coma scale. Pre-hospital Immediate Care 2000; 

4:17–9. 

4. Smith C, DeJoy S. New equipment and techniques for airway management in trauma. 

Current Opinion in Anaesthesiology 2001; 14:197–209. 

5. Smith C. Rapid-sequence intubation in adults: indications and concerns. Clinical 

Pulmonary Medicine 2001; 8; 47–65. 

6. Agro F, Frass M, Benumof JL, Krafft P. Current status of the CombitubeTM: a review 

of the literature. J Clin Anesth 2002; 14:307–17. 




8. Baskett PJF (coordinator). The use of the laryngeal mask airway by nurses during 

cardiopulmonary resuscitation: multicentre trial. Anaesthesia 1994; 49:3–7. 

9. Melker RJ, Florete OG. Cricothyrotomy: review and debate. In Doyle DJ, Sandler 

AN, eds. The Difficult Airway II. Anesthesiol Clin North Am 1995; 13:565–83. 

10. Salem MR, Baraka A. Confirmation of tracheal intubation. In Benumof JL, ed. Airway 

Management: Principles and Practice. St. Louis: Mosby, 1996, pp 531–60. 

Anesthetic Management of Patients with Abdominal Trauma 


Department of Nurse Anesthesia, Baylor University Medical Center, Dallas, Texas 

Learning Objectives: 1) To state the indications for emergency exploratory laparotomy, 

2) to determine appropriate intraoperative monitoring, 3) to determine “safe” drugs, 

4) to recognize transfusion complications, and 5) to determine when abbreviated damage 

control surgery is appropriate. 

Exsanguinating hemorrhage is the major acute cause of death following abdominal 

trauma. 1–3 Initial focus is on controlling hemorrhage, limiting contamination, rapid assessment, 

and treatment of blunt and penetrating abdominal trauma. 

First priority is securing the airway, then IV access, resuscitation, and identification and 

stabilization of life-threatening injuries. A decision is then made to proceed with surgical 

intervention or perform more diagnostic evaluation. 

Initial laboratory and diagnostic studies are based on the patient’s stability. Indications 

for emergency exploratory laparotomy 4 are listed below: 

1. Penetrating or blunt trauma with hypotension 

2. Uncontrolled hemorrhage 

3. Signs of peritonitis 

4. GSW to abdomen 

5. Positive objective study (CT, Sonogram, DPL) 

6. Ruptured diaphragm 

7. Pneumoperitoneum on admission chest film 

8. Evisceration of bowel or omentum 

9. Herniation of abdominal contents 

10. Significant bleeding from NG tube, rectum 

11. Ongoing bleeding from unknown source 

12. Stab wounds with known vascular, biliary, or colonic injury 

Minimum noninvasive monitors include EKG, automated B/P, pulse oximetry, core 

temperature probe with stethoscope, and capnography. A Foley catheter with urometer, radial 

or brachial arterial catheter for monitoring and frequent lab analysis during trauma laparotomy. 

Two large-bore peripheral catheters must be established with central venous access in 

cases involving large blood loss or transfusion. Blood must be available, often infusing prior 

to opening the abdomen in severely hypotensive patients. 

Early goals include re-establishment and maintenance of normal hemodynamics. 

Correct size and number of IV lines is accomplished before incision. Hypotension from drug 

effect, suppression of endogenous catecholamines, and initiation of positive-pressure ventilation 

will dictate the need for immediate surgical incision upon induction. Following incision, 

tamponade of abdominal bleeding is lost, and copious blood loss may precipitate. 

Etomidate (0.2 mg/kg), normally cardiac neutral, is well tolerated in awake traumatized 

patients. Ketamine can promote greater hypotension in a patient with poor sympathetic 

tone. In unstable hypotension, oxygen with a muscle relaxant is required until return of 

hemodynamics allow additional anesthetic drugs. When anesthesia needs to be withheld, 

scopolamine may be given for amnesia. 

Periodic measurement of laboratory values is essential. Central venous pressure, urine 

output and hemodynamics aid in calculation of fluid volumes. Cell saver blood should be 

given for noncontaminated intra-abdominal blood loss. 

The following complications can arise from massive transfusions 5,6 : coagulopathy, 

hypothermia, hypocalcemia, hyperkalemia, and hemolysis. 

With a pH

* 

*For infections due to susceptible strains 

of indicated organisms. 

Careful inquiry should be made 

concerning previous hypersensitivity 

reaction, as serious and occasionally 

fatal anaphylactic reactions have been 

reported in patients receiving therapy 

with penicillins. ZOSYN is contraindicated 

in patients with a history of these 

reactions to any of the penicillins, 

cephalosporins, or ß-lactamase inhibitors. 

While ZOSYN possesses the characteristic 

low toxicity of the penicillin group of 

antibiotics, periodic assessment of organ 

system functions, including renal, hepatic, 

and hematopoietic, during prolonged 

therapy is advisable. 

During clinical trials, pseudomembranous 

colitis has been rarely reported (

ZOSYN ® (Piperacillin and Tazobactam for Injection) Brief Summary 

See package insert for full prescribing information. 

INDICATIONS AND USAGE For the treatment of patients with moderate to severe infections caused by 

piperacillin-resistant, piperacillin/tazobactam-susceptible, β-lactamase producing strains of the designated 

microorganisms in the specified conditions listed below: 

Appendicitis (complicated by rupture or abscess) and peritonitis caused by Escherichia coli or the following 

members of the Bacteroides fragilis group: B. fragilis, B. ovatus, B. thetaiotaomicron, or B. vulgatus. 

The individual members of this group were studied in less than 10 cases. 

Uncomplicated and complicated skin and skin structure infections, including cellulitis, cutaneous 

abscesses, and ischemic/diabetic foot infections caused by Staphylococcus aureus. 

Postpartum endometritis or pelvic inflammatory disease caused by Escherichia coli. 

Community-acquired pneumonia (moderate severity only) caused by Haemophilus influenzae. 

Nosocomial pneumonia (moderate to severe) caused by Staphylococcus aureus. (See Full Prescribing 

Information—DOSAGE AND ADMINISTRATION.) 

Infections caused by piperacillin-susceptible organisms, for which piperacillin has been shown to be 

effective, are also amenable to ZOSYN treatment due to its piperacillin content. Treatment of mixed 

infections caused by piperacillin-susceptible organisms and piperacillin-resistant, β-lactamase producing 

organisms susceptible to ZOSYN should not require the addition of another antibiotic. 

ZOSYN is useful as presumptive therapy in the indicated conditions prior to the identification of causative 

organisms because of its broad spectrum of bactericidal activity against gram-positive and gram-negative 

aerobic and anaerobic organisms. Appropriate cultures should usually be performed before initiating 

antimicrobial treatment in order to isolate and identify the organisms causing infection and to determine 

their susceptibility to ZOSYN. 

CONTRAINDICATIONS ZOSYN is contraindicated in patients with a history of allergic reactions to any of the 

penicillins, cephalosporins, or β-lactamase inhibitors. 

WARNINGS SERIOUS AND OCCASIONALLY FATAL HYPERSENSITIVITY (ANAPHYLACTIC/ANAPHYLACTOID) 

REACTIONS (INCLUDING SHOCK) HAVE BEEN REPORTED IN PATIENTS RECEIVING THERAPY WITH 

PENICILLINS INCLUDING ZOSYN. THESE REACTIONS ARE MORE LIKELY TO OCCUR IN INDIVIDUALS 

WITH A HISTORY OF PENICILLIN HYPERSENSITIVITY OR A HISTORY OF SENSITIVITY TO MULTIPLE 

ALLERGENS. THERE HAVE BEEN REPORTS OF INDIVIDUALS WITH A HISTORY OF PENICILLIN 

HYPERSENSITIVITY WHO HAVE EXPERIENCED SEVERE REACTIONS WHEN TREATED WITH 

CEPHALOSPORINS. BEFORE INITIATING THERAPY WITH ZOSYN, CAREFUL INQUIRY SHOULD BE MADE 

CONCERNING PREVIOUS HYPERSENSITIVITY REACTIONS TO PENICILLINS, CEPHALOSPORINS, OR 

OTHER ALLERGENS. IF AN ALLERGIC REACTION OCCURS, ZOSYN SHOULD BE DISCONTINUED AND 

APPROPRIATE THERAPY INSTITUTED. SERIOUS ANAPHYLACTIC/ANAPHYLACTOID REACTIONS 

(INCLUDING SHOCK) REQUIRE IMMEDIATE EMERGENCY TREATMENT WITH EPINEPHRINE. OXYGEN, 

INTRAVENOUS STEROIDS, AND AIRWAY MANAGEMENT, INCLUDING INTUBATION, SHOULD ALSO BE 

ADMINISTERED AS INDICATED. 

Pseudomembranous colitis has been reported with nearly all antibacterial agents, including ZOSYN, 

and may range in severity from mild to life-threatening. Consider this diagnosis in patients who 

present with diarrhea after antibacterial agent administration. Treatment with antibacterial agents alters 

the normal flora of the colon and may permit overgrowth of clostridia. Studies indicate that a toxin 

produced by Clostridium difficile is one primary cause of “antibiotic-associated colitis.” 

After the diagnosis of pseudomembranous colitis has been established, initiate therapeutic measures. Mild 

cases usually respond to drug discontinuation alone. In moderate to severe cases, fluids and electrolytes, 

protein supplementation, and treatment with an antibacterial drug clinically effective against Clostridium 

difficile colitis may be necessary. 

PRECAUTIONS General: Bleeding manifestations have occurred in some patients receiving β-lactam 

antibiotics, including piperacillin. These reactions have sometimes been associated with coagulation test 

abnormalities such as clotting time, platelet aggregation, and prothrombin time and are more likely to 

occur in renal failure patients. If bleeding manifestations occur, discontinue ZOSYN and institute 

appropriate therapy. 

The possibility of the emergence of resistant organisms that might cause superinfections should be kept in 

mind. If this occurs, appropriate measures should be taken. 

As with other penicillins, patients may experience neuromuscular excitability or convulsions if higher than 

recommended doses are given intravenously (particularly in the presence of renal failure). 

ZOSYN is a monosodium salt of piperacillin and a monosodium salt of tazobactam, containing 2.35 mEq 

(54 mg) of Na+ per gram of piperacillin; consider this when treating patients requiring restricted salt intake. 

Perform periodic electrolyte determinations in patients with low potassium reserves; the possibility of 

hypokalemia should be kept in mind with patients who have potentially low potassium reserves and who 

are receiving cytotoxic therapy or diuretics. 

As with other semisynthetic penicillins, piperacillin has been associated with an increased incidence of 

fever and rash in cystic fibrosis patients. 

In patients with renal insufficiency or in hemodialysis patients, the intravenous dose should be adjusted to 

the degree of renal function impairment. 

Laboratory Tests: Perform periodic assessment of hematopoietic function, especially with prolonged 

therapy, ie, ≥21 days. (See ADVERSE REACTIONS—Adverse Laboratory Events.) 

Drug Interactions: Aminoglycosides —The mixing of ZOSYN with an aminoglycoside in vitro can result in 

substantial inactivation of the aminoglycoside. (See Full Prescribing Information—DOSAGE AND 

ADMINISTRATION—Compatible Intravenous Diluent Solutions.) 

When ZOSYN was co-administered with tobramycin, the area under the curve, renal clearance, and urinary 

recovery of tobramycin were decreased by 11%, 32%, and 38%, respectively. Pharmacokinetic alterations 

of tobramycin when administered with ZOSYN may be due to in vivo and in vitro inactivation of tobramycin 

in the presence of piperacillin/tazobactam. The inactivation of aminoglycosides in the presence of penicillinclass 

drugs has been recognized. It has been postulated that microbiologically inactive penicillinaminoglycoside 

complexes of unknown toxicity form. In patients with severe renal dysfunction (ie, chronic 

hemodialysis patients), tobramycin pharmacokinetics are significantly altered when administered with 

piperacillin. The alteration of tobramycin pharmacokinetics and the potential toxicity of the penicillinaminoglycoside 

complexes in patients with mild to moderate renal dysfunction who are administered an 

aminoglycoside with ZOSYN are unknown. 

Probenecid—Probenecid administered with ZOSYN prolongs the half-life of piperacillin by 21% and of 

tazobactam by 71%. 

Vancomycin—No pharmacokinetic interactions with ZOSYN have been noted. 

Heparin—Coagulation parameters should be tested more frequently and monitored regularly during 

simultaneous administration of high doses of heparin, oral anticoagulants, or other drugs that may affect 

the blood coagulation system or the thrombocyte function. 

Vecuronium—Piperacillin used with vecuronium has been implicated in the prolongation of the neuromuscular 

blockade of vecuronium. ZOSYN could produce the same phenomenon if given with vecuronium. Due to their 

similar mechanism of action, the neuromuscular blockade produced by any of the non-depolarizing muscle 

relaxants could be prolonged in the presence of piperacillin. (See package insert for vecuronium bromide.) 

Methotrexate—Piperacillin may reduce the excretion of methotrexate; therefore, serum levels of methotrexate 

should be monitored in patients to avoid drug toxicity. 

Drug/Laboratory Test Interactions: As with other penicillins, ZOSYN may result in a false-positive reaction 

for glucose in the urine using a copper-reduction method (CLINITEST ®§ ). Glucose tests based on enzymatic 

glucose oxidase reactions (such as DIASTIX ®§ or TES-TAPE ®§ ) are recommended. 

Carcinogenesis, Mutagenesis, Impairment of Fertility: Long term carcinogenicity studies in animals have 

not been conducted with piperacillin/tazobactam, piperacillin, or tazobactam. Piperacillin/tazobactam was 

negative in the following mutagenicity tests/assays up to the concentrations noted: microbial mutagenicity 

assay (14.84/1.86 µg/plate), unscheduled DNA synthesis (UDS) test (5689/711 µg/mL), mammalian point 

mutation (Chinese hamster ovary cell HPRT) assay (8000/1000 µg/mL), and a mammalian cell 

(BALB/c-3T3) transformation assay (8/1 µg/mL). In vivo, piperacillin/tazobactam did not induce 

chromosomal aberrations in rats dosed I.V. with 1500/187.5 mg/kg; this dose is similar to the maximum 

recommended human daily (MRHD) dose on a body-surface-area basis (BSA) (mg/m 2 ). 

Piperacillin was negative in the following mutagenicity tests/assays up to the concentrations noted: 

microbial mutagenicity assays (50 µg/plate), UDS test (10,000 µg/mL), and a cell (BALB/c-3T3) 

transformation assay (3000 µg/mL). There was no DNA damage in bacteria (Rec assay) exposed to 

piperacillin at concentrations up to 200 µg/disk. In a mammalian point mutation (mouse lymphoma cells) 

assay, piperacillin was positive at concentrations ≥2500 µg/mL. In vivo, piperacillin did not induce 

chromosomal aberrations in mice at I.V. doses up to 2000 mg/kg/day or rats at I.V. doses up to 

1500 mg/kg/day. These doses are half (mice) or similar to (rats) the MRHD dose based on BSA (mg/m 2 ). 

In another in vivo test, there was no dominant lethal effect when piperacillin was administered to rats at I.V. 

doses up to 2000 mg/kg/day, which is similar to the MRHD dose based on BSA (mg/m 2 ). When mice were 

administered piperacillin at I.V. doses up to 2000 mg/kg/day, which is half the MRHD dose based on BSA 

(mg/m 2 ), urine from these animals was not mutagenic when tested in a microbial mutagenicity assay. 

Bacteria injected into the peritoneal cavity of mice administered piperacillin at I.V. doses up to 

2000 mg/kg/day did not show increased mutation frequencies. 

Tazobactam was negative in the following mutagenicity assays up to the concentrations noted: microbial 

mutagenicity assays (333 µg/plate), UDS test (2000 µg/mL), mammalian point mutation (Chinese hamster 

ovary cell HPRT) (5000 µg/mL), a cell (BALB/c-3T3) transformation assay (900 µg/mL). In another 

mammalian point mutation (mouse lymphoma cells) assay, tazobactam was positive at concentrations 

≥3000 µg/mL. In an in vitro cytogenetics (Chinese hamster lung cells) assay, tazobactam was negative at 

concentrations up to 3000 µg/mL. In vivo, tazobactam did not induce chromosomal aberrations in rats at 

I.V. doses up to 5000 mg/kg, which is 23 times the MRHD dose based on BSA (mg/m 2 ). 

Pregnancy: Teratogenic effects—Pregnancy Category B: Piperacillin/tazobactam: Reproduction studies in 

rats have revealed no evidence of impaired fertility due to piperacillin/tazobactam administered up to a dose 

which is similar to the MRHD dose based on BSA (mg/m 2 ). 

Teratology studies in mice and rats have revealed no evidence of harm to the fetus due to 

piperacillin/tazobactam administered up to a dose which is 1 to 2 times and 2 to 3 times the human dose 

of piperacillin and tazobactam, respectively, based on BSA (mg/m 2 ). Piperacillin and tazobactam 

cross the placenta. 

Piperacillin: Reproduction and teratology studies in mice and rats have revealed no evidence of impaired 

fertility or fetal harm due to piperacillin administered up to a dose which is half (mice) or similar to (rats) 

the MRHD dose based on BSA (mg/m 2 ). 

Tazobactam: Reproduction studies in rats have revealed no evidence of impaired fertility due to tazobactam 

administered at doses up to 3 times the MRHD dose based on BSA (mg/m 2 ). 

Teratology studies in mice and rats have revealed no evidence of fetal harm due to tazobactam administered at 

doses up to 6 and 14 times, respectively, the human dose based on BSA (mg/m 2 ). In rats, tazobactam crosses 

the placenta. Concentrations in the fetus are less than or equal to 10% of those found in maternal plasma. 

There are no adequate and well-controlled studies with the piperacillin/tazobactam combination or with 

piperacillin or tazobactam alone in pregnant women. Use this drug during pregnancy only if clearly needed. 

Nursing Mothers: Piperacillin is excreted in low concentrations in human milk; tazobactam concentrations 

in human milk have not been studied. Exercise caution when ZOSYN is administered to a nursing woman. 

Pediatric Use: Safety and efficacy in pediatric patients have not been established. 

Geriatric Use: Patients over 65 years are not at an increased risk of developing adverse effects solely 

because of age. However, dosage should be adjusted in the presence of renal insufficiency. 

ADVERSE REACTIONS During the initial clinical investigations, 2621 patients worldwide were treated with 

ZOSYN in phase 3 trials. In the key North American clinical trials (n=830 patients), 90% of the adverse 

events reported were mild to moderate in severity and transient in nature. However, in 3.2% of the patients 

treated worldwide, ZOSYN was discontinued because of adverse events primarily involving the skin (1.3%), 

including rash and pruritus; the gastrointestinal system (0.9%), including diarrhea, nausea, and vomiting; 

and allergic reactions (0.5%). 

Adverse local reactions that were reported, irrespective of relationship to ZOSYN therapy, were phlebitis (1.3%), 

injection site reaction (0.5%), pain (0.2%), inflammation (0.2%), thrombophlebitis (0.2%), and edema (0.1%). 

In the completed study of nosocomial lower respiratory tract infections, 155 patients received ZOSYN 

3.375 g every 4 hours in combination with an aminoglycoside. In this trial, 88.5% of the adverse experiences 

reported were mild to moderate in severity and transient in nature. In this trial, ZOSYN was discontinued in 

four patients (2.6%) due to adverse experiences: thrombocytopenia and pancreatitis in one patient; fever in one 

patient; fever and eosinophilia in another patient; and diarrhea and elevated liver enzymes in the fourth patient. 

Adverse Clinical Events: Based on patients from the North American trials (n=1063), the events with the 

highest incidence in patients, irrespective of relationship to ZOSYN therapy, were diarrhea (11.3%); headache 

(7.7%); constipation (7.7%); nausea (6.9%); insomnia (6.6%); rash (4.2%), including maculopapular, bullous, 

urticarial, and eczematoid; vomiting (3.3%); dyspepsia (3.3%); pruritus (3.1%); stool changes (2.4%); fever 

(2.4%); agitation (2.1%); pain (1.7%); moniliasis (1.6%); hypertension (1.6%); dizziness (1.4%); abdominal 

pain (1.3%); chest pain (1.3%); edema (1.2%); anxiety (1.2%); rhinitis (1.2%); and dyspnea (1.1%). 

Based on patients in the completed study of nosocomial lower respiratory tract infections (n=155), using 

every-4-hour dosing and aminoglycoside therapy, the events with the highest incidence in patients, 

irrespective of relationship to ZOSYN and aminoglycoside therapy, were diarrhea (20%); constipation 

(8.4%); agitation (7.1%); nausea (5.8%); headache (4.5%); insomnia (4.5%); oral thrush (3.9%); 

erythematous rash (3.9%); anxiety (3.2%); fever (3.2%); pain (3.2%); pruritus (3.2%); hiccough (2.6%); 

vomiting (2.6%); dyspepsia (1.9%); edema (1.9%); fluid overload (1.9%); stool changes (1.9%); anorexia 

(1.3%); cardiac arrest (1.3%); confusion (1.3%); diaphoresis (1.3%); duodenal ulcer (1.3%); flatulence 

(1.3%); hypertension (1.3%); hypotension (1.3%); inflammation at injection site (1.3%); pleural effusion 

(1.3%); pneumothorax (1.3%); rash, not otherwise specified (1.3%); supraventricular tachycardia (1.3%); 

thrombophlebitis (1.3%); and urinary incontinence (1.3%). 

Additional adverse systemic clinical events reported in 1.0% or less of the patients in the initial North 

American trials and/or in the patients administered ZOSYN 3.375 g every 4 hours plus an aminoglycoside 

in the nosocomial lower respiratory tract study are listed below within each body system (bracketed events 

occurred only in the nosocomial pneumonia trial): Autonomic nervous system: hypotension, ileus, 

syncope. Body as a whole: rigors, back pain, malaise, [asthenia, chest pain]. Cardiovascular: tachycardia, 

including supraventricular and ventricular; bradycardia; arrhythmia, including atrial fibrillation, ventricular 

fibrillation, cardiac arrest, cardiac failure, circulatory failure, myocardial infarction, [angina]. Central 

nervous system: tremor, convulsions, vertigo, [aggressive reaction (combative)]. Gastrointestinal: melena, 

flatulence, hemorrhage, gastritis, hiccough, ulcerative stomatitis, [fecal incontinence, gastric ulcer, 

pancreatitis]. Pseudomembranous colitis was reported in one patient during the clinical trials. The onset of 

pseudomembranous colitis symptoms may occur during or after antibacterial treatment. (See WARNINGS.) 

Hearing and vestibular system: tinnitus, [deafness, earache]. Hypersensitivity: anaphylaxis. Metabolic and 

Nutritional: symptomatic hypoglycemia, thirst, [gout, vitamin B12 deficiency anemia]. Musculoskeletal: 

myalgia, arthralgia. Platelets, Bleeding, Clotting: mesenteric embolism, purpura, epistaxis, pulmonary 

embolism, [ecchymosis, hemoptysis]. (See PRECAUTIONS—General.) Psychiatric: confusion, 

hallucination, depression. Reproductive, Female: leukorrhea, vaginitis, [perineal irritation/pain]. 

Reproductive, Male: [balanoposthitis]. Respiratory: pharyngitis, pulmonary edema, bronchospasm, 

coughing, [atelectasis, dyspnea, hypoxia]. Skin and Appendages: genital pruritus, diaphoresis, 

[conjunctivitis, xerosis]. Special senses: taste perversion. Urinary: retention, dysuria, oliguria, hematuria, 

incontinence, [urinary tract infection with trichomonas, yeast in urine]. Vision: photophobia. Vascular 

(extracardiac): flushing, [cerebrovascular accident]. 

Additional adverse events reported from worldwide marketing experience with ZOSYN, where causal 

relationship to ZOSYN is uncertain: Gastrointestinal: hepatitis, cholestatic jaundice. Hematologic: hemolytic 

anemia, anemia, thrombocytosis, agranulocytosis, pancytopenia. Immune: hypersensitivity reactions, 

anaphylactic/anaphylactoid reactions (including shock). Infections and Infestations: candidal superinfections. 

Renal: rarely, interstitial nephritis, renal failure. Skin and Appendages: erythema multiforme and Stevens- 

Johnson syndrome, rarely reported; toxic epidermal necrolysis. 

Adverse Laboratory Events (Seen During Clinical Trials): Of the studies reported, including that of 

nosocomial lower respiratory tract infections in which a higher dose of ZOSYN was used in combination 

with an aminoglycoside, changes in laboratory parameters, without regard to drug relationship, include: 

Hematologic: decreases in hemoglobin and hematocrit, thrombocytopenia, increases in platelet count, 

eosinophilia, leukopenia, neutropenia. The leukopenia/neutropenia appears to be reversible and most 

frequently associated with prolonged administration, ie, ≥21 days of therapy. These patients were 

withdrawn from therapy; some had accompanying systemic symptoms (eg, fever, rigors, chills). 

Coagulation: positive direct Coombs’ test, prolonged prothrombin time, prolonged partial thromboplastin 

time. Hepatic: transient elevations of AST (SGOT), ALT (SGPT), alkaline phosphatase, bilirubin. Renal: 

increases in serum creatinine, blood urea nitrogen. Urinalysis: proteinuria, hematuria, pyuria. 

Additional laboratory events include abnormalities in electrolytes (ie, increases and decreases in sodium, 

potassium, and calcium), hyperglycemia, decreases in total protein or albumin, blood glucose decreased, 

gamma-glutamyltransferase increased, hypokalemia, and bleeding time prolonged. 

The following adverse reaction has also been reported for PIPRACIL ® (sterile piperacillin sodium): Skeletal: 

prolonged muscle relaxation. (See PRECAUTIONS—Drug Interactions.) 

Piperacillin therapy has been associated with an increased incidence of fever and rash in cystic fibrosis patients. 

OVERDOSAGE There have been post-marketing reports of overdose with piperacillin/tazobactam. The 

majority of those events experienced including nausea, vomiting, and diarrhea have also been reported with 

the usual recommended dosages. Patients may experience neuromuscular excitability or convulsions if 

higher than recommended doses are given intravenously (particularly in the presence of renal failure). 

Treatment should be supportive and symptomatic according to the patient's clinical presentation. Excessive 

serum concentrations of either piperacillin or tazobactam may be reduced by hemodialysis. (See Full 

Prescribing Information—CLINICAL PHARMACOLOGY.) 

§ 

CLINITEST ® and DIASTIX ® are registered trademarks of Ames Division, Miles Laboratories, Inc. 

§ 

TES-TAPE ® is a registered trademark of Eli Lilly and Company. 

This Brief Summary is based on ZOSYN direction circulars CI 4630-5 and CI 4813-4 (Revised November 2002). 

© 2003, Wyeth Pharmaceuticals, Philadelphia, PA 19101 102682-01


SPONSORS & EXHIBITORS 

We wish to recognize and thank the following sponsors 

and exhibitors for their gracious support: 

— Platinum Sponsor — 

Abbott Pharmaceuticals 

— Gold Sponsor — 

Novo Nordisk Pharmaceuticals 

— Grand Sponsors — 

Organon Pharmaceuticals 

Smiths/Level 1 

Wyeth Pharmaceuticals 

— Elite Sponsor — 

Laerdal Medical Corporation 

— Special Sponsor — 

Lodox Systems 

— Exhibitors — 

Belmont Instrument Corporation 

Elsevier: W.B. Saunders/Mosby/Churchill Medical Publishers 

Financial Planners of the South 

First Care Products/Z Medica 

Great Plains Ballistics 

Pneu-Pac 

King Systems Corporation 

The Exhibit Hall will be open on Friday, May 16, at 0700; 

during the morning break at 0915; during lunch (1200–1315); 

during the afternoon break at 1445; and during the 

evening reception (1715–1830). 

••• 

Editorial Board for TraumaCare 

Editors-in-Chief 

Adolph H. Giesecke, MD (USA) • John K. Stene, MD, PhD (USA) 

Prehospital Care 

Dario Gonzalez, MD, FACEP (USA) • Herbert Kuhnigk, MD (Germany) 

David Lacombe, NREMT-P (USA) • Hans Morten Lossius, MD (Norway) 

Eldar Søreide, MD, PhD (Norway) 

Emergency Department Care 

Bruce Adams, MD (USA) • Dale M. Carrison, DO, FACEP (USA) 

Ludi Jagminas, MD (USA) • Marvin Wayne, MD, FACEP (USA) 

OR and Intensive Care 

James G. Cain, MD (USA) • Richard P. Dutton, MD (USA) 

William F. Fallon, Jr., MD, FACS (USA) • Maureen McCunn, MD (USA) 

Pediatric Trauma 

Gail E. Rasmussen, MD (USA) • James E. Fletcher, MD, MBBS (USA) 

Calvin Johnson, MD (USA) 

Thomas J. Long, MD (USA) 

CRNA Section 

Charles R. Barton, MEd, CRNA (USA) • James M. Rich, MA, CRNA (USA) 

International Advisory Board 

Wolfgang F. Dick, MD, PhD (Germany) • Christopher M. Grande, MD, MPH (USA) 

Louis M. Guzzi, MD (USA) • Yves Lambert, MD (France) 

Walter Mauritz, MD, PhD (Austria) • Jerry Nolan, MB, ChB, FFARCS (England) 

Michael J.A. Parr, MB, BS, MRCP(UK), FRCA (Australia) 

Anne J. Sutcliffe, FRCA (England) • Keiichi Tanaka, MD (Japan) 

ITACCS thanks the following for their 

support of and contributions to the Trauma Airway 

Management workshop: 

Airway Education & Research Foundation 

AMBU, Inc. - Ambu Intubation Trainers 

Clarus Medical - Shikani Optical Stylet 

Cook Critical Care - Melker Kits, ENK TTJV Kits, Retrograde 

Intubation Kits 

Glide Scope - glide scope video scope system 

Karl Storz - Bon Fils Scope 

King Systems Corporation - The KING LT 

Laerdal/MPL - 7 AirMan Simulators, 1 SimMan Simulator, 4 

Difficult Airway Trainers 

LMA North America - LMA Classics and LMA-Fastrachs 

Nonin Medical - Electronic Carbon Dioxide Detector 

Olympus - Flexible fiberoptic intubation stations with manikins 

Sunmed - Laryngoscope sets 

Tyco Kendall - Combitubes 

Educational Objectives 

This publication/activity is designed to provide trauma 

care professionals interested in the treatment of critically ill 

trauma patients with a regular overview and critical analysis of 

the most current, clinically useful information available, covering 

strategies and advances in the diagnosis of traumatic 

injuries and the treatment of trauma patients. Controversies, 

advantages, and disadvantages of diagnosis and treatment plans 

are emphasized. There are no prerequisites for participation in 

this activity. 

After reading each issue, participants should have a working 

familiarity with the most significant information and perspectives 

presented and apply what they have learned promptly 

in clinical practice. Specific learning objectives are printed at 

the opening of each abstract. 

65

After high blood loss surgeries, 

patient outcomes can hang 

in the balance. 

The carrier in your plasma volume expander can 

affect outcomes such as: 

• Coagulation difficulties. 

• Pain, including chest pain. 

• Use of anti-emetics. 

• Reduced renal output. 

Find out more with a call to your Abbott representative 

or to 1-866-464-4261, extension HEXTEND (439-8363). 

® 

6% HETASTARCH IN LACTATED ELECTROLYTE INJECTION 

3-013-Mar., 03

• HEXTEND (6% Hetastarch in Lactated Electrolyte injection) is indicated in the treatment of hypovolemia 

when plasma volume expansion is desired. It is not a substitute for blood or plasma. 

• Solutions containing hetastarch are contraindicated in patients with known sensitivity to hydroxyethyl 

starch, bleeding disorders or with congestive heart failure where volume overload is a potential problem. 

• Solutions containing hetastarch should not be used in renal disease with oliguria or anuria not related 

to hypovolemia. 

Please see brief summary of Prescribing Information on following page.

BRIEF SUMMARY 

a HEXTEND ® 

6% Hetastarch in Lactated Electrolyte Injection 

Flexible Plastic Container 

INDICATIONS AND USAGE 

HEXTEND (6% Hetastarch in Lactated Electrolyte Injection) is indicated in the treatment of hypovolemia 

when plasma volume expansion is desired. It is not a substitute for blood or plasma. 

CONTRAINDICATIONS 

Solutions containing hetastarch are contraindicated in patients with known hypersensitivity to 

hydroxyethyl starch or with bleeding disorders or with congestive heart failure where volume overload 

is a potential problem. Solutions containing hetastarch should not be used in renal disease with oliguria 

or anuria not related to hypovolemia. 

Solutions containing lactate are NOT FOR USE IN THE TREATMENT OF LACTIC ACIDOSIS. 

WARNINGS 

Solutions containing calcium should not be administered simultaneously with blood through the same 

administration set because of the likelihood of coagulation. 

Life threatening anaphylactic/anaphylactoid reactions have been rarely reported with solutions 

containing hetastarch; death has occurred, but a causal relationship has not been established. 

Patients who develop severe anaphylactic/anaphylactoid reactions may need continued supportive 

care until symptoms have resolved. 

Hypersensitivity reactions can occur even after solutions containing hetastarch have been 

discontinued. 

Solutions which contain potassium should be used with great care, if at all, in patients with 

hyperkalemia and severe renal failure and in situations in which potassium retention is present. 

Solutions containing sodium ions should be used with great care, if at all, in patients with congestive 

heart failure and severe renal insufficiency and in clinical states in which edema with sodium retention 

occurs. 

In patients with diminished renal function, 

administration of solutions containing sodium or 

potassium ions may result in sodium or potassium 

retention. 

Solutions containing lactate ions should be used with 

great care in patients with metabolic or respiratory 

alkalosis. The administration of lactate ions should be 

performed with great care when dealing with conditions in 

which an increased level or an impaired utilization of 

these ions occurs, such as severe hepatic insufficiency. 

DO NOT USE IN LEUKAPHERESIS. 

Usage in Plasma Volume Expansion 

Large volumes of isotonic solutions containing 6% 

hetastarch (HEXTEND or Hetastarch Injection) may 

transiently alter the coagulation mechanism due to 

hemodilution and a mild direct inhibitory action on Factor 

VIII. Hemodilution by isotonic solutions containing 6% 

hetastarch may also result in a 24 hour decline of total 

protein, albumin, and fibrinogen levels and in transient 

prolongation of prothrombin, activated partial 

thromboplastin, clotting, and bleeding times. 

Hematocrit may be decreased and plasma proteins 

diluted excessively by administration of large volumes of 

isotonic solutions containing 6% hetastarch. 

Administration of packed red cells, platelets, and fresh 

frozen plasma should be considered if excessive dilution 

occurs. 

In randomized, controlled, comparative studies of Hetastarch Injection (n = 92) and Albumin (n = 85) 

in surgical patients, no patient in either treatment group had a bleeding complication and no significant 

difference was found in the amount of blood loss between the treatment groups. 

HEXTEND has not been adequately evaluated to establish its safety in situations other than treatment 

of hypovolemia in elective surgery. In some cases, the use of isotonic solutions containing 6% 

hetastarch has been associated with coagulation abnormalities in conjunction with an acquired, 

reversible von Willebrand’s-like syndrome and/or Factor VIII deficiency when used over a period of 

days. Replacement therapy should be considered if a severe Factor VIII or von Willebrand deficiency is 

identified. If a coagulopathy develops, it may take several days to resolve. Certain conditions may affect 

the safe use of isotonic solutions containing 6% hetastarch on a chronic basis. For example, in patients 

with subarachnoid hemorrhage where an isotonic solution containing 6% hetastarch is used repeatedly 

over a period of days for the prevention of cerebral vasospasm, significant clinical bleeding may occur. 

Intracranial bleeding resulting in death has been reported with the use of Hetastarch Injection. 

PRECAUTIONS 

General 

The possibility of circulatory overload should be kept in mind. Caution should be used when the risk of 

pulmonary edema and/or congestive heart failure is increased. Special care should be exercised in 

patients who have impaired renal clearance since this is the principal way in which hetastarch is 

eliminated and in clinical states in which edema with sodium retention occurs. 

Indirect bilirubin levels of 8.3 mg/L (normal 0.0-7.0 mg/L) have been reported in 2 out of 20 normal 

subjects who received multiple infusions of Hetastarch Injection. Total bilirubin was within normal 

limits at all times; indirect bilirubin returned to normal by 96 hours following the final infusion. The 

significance, if any, of these elevations is not known; however, caution should be observed before 

administering isotonic solutions containing 6% hetastarch to patients with a history of liver disease. 

If a hypersensitivity effect occurs, administration of the drug should be discontinued and appropriate 

treatment and supportive measures should be undertaken (see WARNINGS). 

Caution should be used when administering solutions containing hetastarch to patients allergic to 

corn because such patients can also be allergic to hetastarch. 

Clinical evaluation and periodic laboratory determinations are necessary to monitor changes in fluid 

balance, electrolyte concentrations, acid-base balance, and coagulation parameters during prolonged 

parenteral therapy or whenever the condition of the patient warrants such evaluation. 

Solutions containing dextrose should be used with caution in patients with known subclinical or 

overt diabetes mellitus. 

Caution must be exercised in the administration of parenteral fluids, especially those containing 

6% HETASTARCH IN LACTATED ELECTROLYTE INJECTION 

sodium ions, to patients receiving corticosteroids or corticotropin. 

Potassium containing solutions should be used with caution in the presence of cardiac disease, 

particularly in digitalized patients or in the presence of renal disease. 

Solutions containing lactate ions should be used with caution as excess administration may result in 

metabolic alkalosis. 

Elevated serum amylase levels may be observed temporarily following administration of 

solutions containing hetastarch although no association with pancreatitis has been 

demonstrated. Serum amylase levels cannot be used to assess or to evaluate for pancreatitis 

for 3-5 days after administration of solutions containing hetastarch. Elevated serum amylase 

levels persist for longer periods of time in patients with renal impairment. Solutions containing 

hetastarch have not been shown to increase serum lipase. 

One report suggests that in the presence of renal glomerular damage, larger molecules of hetastarch 

can leak into the urine and elevate the specific gravity. The elevation of specific gravity can obscure 

the diagnosis of renal failure. 

Hetastarch is not eliminated by hemodialysis. The utility of other extracorporeal elimination 

techniques has not been evaluated. 

If administration is by pressure infusion, all air should be withdrawn or expelled from the bag through 

the medication port prior to infusion. 

Carcinogenesis, Mutagenesis, Impairment of Fertility 

Long-term studies of animals have not been performed to evaluate the carcinogenic potential of 

hetastarch. 

Teratogenic Effects: Pregnancy Category C. 

Hetastarch Injection has been shown to have an embryocidal effect on New Zealand rabbits when 

given intravenously over the entire organogenesis period in a daily dose 1/2 times the maximum 

recommended therapeutic human dose (1500 mL) and on BD rats when given intraperitoneally, from the 

16th to the 21st day of pregnancy, in a daily dose 2.3 times the maximum recommended therapeutic 

human dose. When Hetastarch Injection was administered to New Zealand rabbits, BD rats, and Swiss 

mice with intravenous daily doses of 2 times, 1/3 times, and 1 times the maximum recommended 

therapeutic human dose, respectively, over several days during the period of gestation, no evidence of 

teratogenicity was evident. There are no adequate and well controlled studies in pregnant women. 

HEXTEND should be used during pregnancy only if the potential benefit justifies the potential risk to the 

fetus. 

Nursing Mothers 

It is not known whether hetastarch is excreted in human milk. Because many drugs are excreted in 

human milk, caution should be exercised when HEXTEND is administered to a nursing woman. 

Pediatric Use 

The safety and effectiveness of HEXTEND in pediatric 

patients have not been established. Adequate, wellcontrolled 

clinical trials to establish the safety and 

effectiveness of HEXTEND in pediatric patients have not 

been conducted. However, in one small double-blind 

study, 47 infants, children, and adolescents (ages 1 year 

to 15.5 years) scheduled for repair of congenital heart 

disease with moderate hypothermia were randomized to 

receive either Hetastarch Injection or Albumin as a 

postoperative volume expander during the first 24 hours 

after surgery. Thirty-eight children required colloid 

replacement therapy, of which 20 children received 

Hetastarch Injection. No differences were found in the 

coagulation parameters or in the amount of replacement 

fluids required in the children receiving 20 mL/kg or less 

of either colloid replacement therapy. In children who 

received greater than 20 mL/kg of Hetastarch Injection, 

® 

an increase in prothrombin time was demonstrated (p = 

0.006). There were no neonates included in this study. 

Geriatric Use 

Of the total number of patients in clinical trials of 

HEXTEND (n=119), 30% were 65 or older while 12% were 

70 or older. Other reported experience with Hetastarch 

Injection has not identified differences in responses 

between elderly and younger patients, but greater 

sensitivity of some older individuals cannot be ruled out. 

This drug is known to be substantially excreted by the 

kidney, and the risk of toxic reactions to this drug may be greater in patients with impaired renal 

function. Because elderly patients are more likely to have decreased renal function, care should be 

taken in dose selection, and it may be useful to monitor renal function. 

ADVERSE REACTIONS 

In clinical trials comparing the plasma volume expanding properties of HEXTEND (n=60) with those of 

Hetastarch Injection (n=59), there were no significant differences in the number of adverse or serious 

adverse events between the two groups. 

Reported adverse reactions with isotonic solutions containing 6% hetastarch include: 

General 

Hypersensitivity (see WARNINGS). 

Death, life-threatening anaphylactic/anaphylactoid reactions, cardiac arrest, ventricular fibrillation, 

severe hypotension, non-cardiac pulmonary edema, laryngeal edema, bronchospasm, angioedema, 

wheezing, restlessness, tachypnea, stridor, fever, chest pain, bradycardia, tachycardia, shortness of 

breath, chills, urticaria, pruritus, facial and periorbital edema, coughing, sneezing, flushing, erythema 

multiforme, and rash. 

Cardiovascular 

Circulatory overload, congestive heart failure, and pulmonary edema (see PRECAUTIONS). 

Hematologic 

Intracranial bleeding, bleeding and/or anemia due to hemodilution (see WARNINGS) and/or Factor VIII 

deficiency, acquired von Willebrand’s-like syndrome, and coagulopathy including rare cases of 

disseminated intravascular coagulopathy and hemolysis. With extensive clinical use of Hetastarch 

Injection, rare cases of disseminated intravascular coagulopathy and hemolysis have been observed. 

Metabolic 

Metabolic acidosis. 

Other 

Vomiting, peripheral edema of the lower extremities, submaxillary and parotid glandular enlargement, 

mild influenza-like symptoms, headaches, and muscle pains. Hydroxyethyl starch-associated pruritus 

has been reported in some patients with deposits of hydroxyethyl starch in peripheral nerves. 

Caution: Federal (USA) law prohibits dispensing without prescription. 

©Abbott 1999 Reference 58-0851-R2-Rev. September, 1999 Printed in USA 

Manufactured and Distributed by: Abbott Laboratories, North Chicago, IL 60064, USA 

Under license from BioTime, Inc., Berkeley, CA 94710, USA 

68


CME QUESTIONS 

This issue of TraumaCare can be used to earn 20 CME credit hours. 

Accreditation Statement 

This activity has been planned and produced in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education (ACCME) through the sponsorship 

of the International Trauma Anesthesia and Critical Care Society (ITACCS). ITACCS is accredited by the ACCME to sponsor continuing medical education (CME) for physicians and 

takes responsibility for the content, quality, and scientific integrity of this CME activity. 

Credit Designation Statement: ITACCS designates this educational activity for a maximum of 20 hours per issue in category 1 credit toward the 

AMA Physician’s Recognition Award. 

Nurse Anesthetists/CRNAs: Please apply to AANA for post-activity continuing education credits. Certificates of completion will be provided. 

Faculty Disclosure Statement 

It is the policy of ITACCS that faculty members disclose real or apparent conflict of interest relating to the topics of this educational activity and also disclose discussions of unlabeled/unapproved 

uses of drugs or devices in their presentations. The authors’ completed disclosure forms are on file in the managing editor’s office. 

INSTRUCTIONS 

• On the answer form at the bottom of page 71, circle only one response next to each number. 

• Complete the evaluation form. 

• Cut out or copy your completed answer form and evaluation form. 

• Write a check for $200 (or $100 accompanied by verification of current ITACCS membership), payable to the International Trauma Anesthesia and Critical Care Society. 

• Mail the forms and your check (and membership verification, if applicable) to ITACCS, Department of CME Credit, PO Box 4826, Baltimore, MD 21211. 

• The completed test will be accepted for grading if received by May 31, 2004. 

• Please allow 4 to 6 weeks for processing. 

CME QUESTIONS 

1. Which of the following therapies is appropriate for early resuscitation of the patient with active hemorrhagic shock? 

a. Pressor therapy with norepinephrine 

b. Rapid crystalloid administration to maintain SBP > 120 

c. Bicarbonate infusion to maintain pH > 7.30 

d. Administration of O-positive PRBC 

2. Dexmedetomidine is a potent respiratory depressant. 

a. True b. False 

3. Concerning traumatic thoracic aortic tears, which of the following statements is true? 

a. Paraplegia and death are less common after surgical repair in the presence of preoperative hemodynamic instability. 

b. Medical control of blood pressure with beta blockers (e.g., esmolol, metoprolol, labetalol) is of doubtful clinical importance. 

c. One-lung ventilation is contraindicated for descending thoracic aorta surgery because of the risk of hypoxemia. 

d. Delayed repair is often indicated in the presence of major co-morbidity (e.g, head injury, pulmonary contusion, coagulopathy). 

e. None of the above. 

4. The main goal of triage in a mass casualty setting in which health care resources are exceeded is to rapidly treat the most critically ill patients. 


5. Chemical warfare agents can act upon 

a. the central nervous system 

b. the alveoli 

c. the gastrointestinal system 

d. the bone marrow 

e. all of the above 

6. Trauma simulation is possible only in major centers with extensive resources. 


7. What is the unique contribution of the advanced patient simulators for trauma management training? 

a. Team training 

b. Acquiring technical skills 

c. Learning algorithms and protocols 

d. Diagnosis-making capability 

8. The difference between end-tidal and arterial carbon dioxide tension can be increased by: 

a. Pulmonary embolism. 

b. Isoflurane. 

c. Hypovolemia. 

d. Atropine. 

e. All of the above 

69


9. Most pulse oximeters that are commercially available today will provide erroneous SpO2 values in the presence of all the following EXCEPT: 

a. Venous blood pulsations. c. Carboxyhemoglobin. 

b. Mal-positioned sensor on the finger. d. Anemia. 

10. Concerning monitoring of neuromuscular block, which of the following statements is true? 

a. There is a narrow margin of safety of neuromuscular transmission. 

b. Loss of all 4 twitches in response to supramaximal train-of-four indicates mild block. 

c. The diaphragm, larynx, and eye muscles are more sensitive to non-depolarizing agents compared with muscles of the thumb. 

d. Compared with muscles of the eye (orbicularis oculi, superciliary), muscles that maintain patency of the upper airway are more 

sensitive to non-depolarizing agents. 

e. None of the above. 

11. Which of the following resuscitation solutions is not associated with the development of hyperchloremic metabolic acidosis? 

a. 0.9% NSS d. Albumin 

b. Lactated Ringers e. Hydroxyethyl starch in balanced salt solution 

c. Hypertonic saline 

12. Low-pressure, high-volume resuscitation strategies are associated with hypoperfusion and reduced survival. 


13. Mortality and morbidity after head injury are significantly reduced by 

a. Maintaining a PaO2 at greater than normal c. Steroids 

b. Preventing hypotension (true) d. Hypothermia within 6 hours of injury 

14. Strict pre-conditions have to be met before the diagnosis of brain stem death can be considered. 


15. CO2 is excreted from the body only via the lungs? 


16. Differences in trauma care around the world are associated with 

a. economic disparities c. lack of education 

b. cultural variances d. all of above 

17. The large number of civilian deaths caused by explosive wounds can be attributed to 

a. The aggregation of large numbers of people in a single confined area. 

b. The exponential increase in firepower of modern explosives. 

c. Deliberate targeting. 

d. Personal and environmental/structural vulnerability. 

e. All of the above. 

18. The USAF has adopted physician-based crews to conduct critical care air transport of stabilized casualties. 


19. Brain death 

a. is diagnosed only if the patient is a potential organ donor. 

b. is a process, not an event. 

c. is an acceptable diagnosis to all races and religions. 

d. is always present if brain stem reflexes and respiration are absent. 

20. The inotrope of choice for the management of the brain-dead, heart-beating donor is 

a. Dopamine b. Norepinephrine c. Vasopressin 

21. End-tidal CO2 is the peak value of exhaled CO2 at end-expiration. 


22. The absence of end-tidal CO2 following attempted intubation confirms oesophageal placement of the tube. 

a. True b. False. 

23. Decreasing end-tidal CO2 during cardiac massage may indicate operator fatigue. 


24. Low end-tidal CO2 values in trauma patients are positively associated with survival. 

a. True b. False. 

25. A patient suffering primary cardiac arrest with an end-tidal CO2 of 1.0 kPa after 20 minutes of resuscitation is unlikely to survive. 

a. True. b. False 

26. The use of hypertonic saline combined with a dextran instead of crystalloid in the prehospital care of patients with severe head injury with hypotension 

improves survival by a factor of two. 


70


27. In physician-operated EMS care in France, all of the techniques listed below have a place in the provision of prehospital analgesia EXCEPT: 

a. use of opioids 

b. use of paracetamol 

c. rewarming 

d. spinal block 

e. peripheral nerve blocks 

28. Anesthesiologists have no immediate role to play in the management casualties from terrorist chemical and biological attacks. 


29. Road traffic incidents and falls from height are the commonest causes of paediatric trauma. 


30. The most common paediatric arrhythmia at cardiac arrest is pulseless electrical activity. 


31. A cause of ventricular fibrillation that should be excluded is hypothermia. 


32. A low larynx in children makes visualisation of the vocal cords more difficult. 


33. Intraosseous access is contraindicated distal to a limb fracture. 


34. The recommended fluid for initial resuscitation of the pediatric trauma patient is: 

a. Crystalloid solutions b. Colloid solutions c. Dextrose solutions 

35. The two most important determinants of burn severity are burn size and location. 


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TraumaCare Spring 2003 issue 

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1. a b c d 

2. a b 

3. a b c d e 

4. a b 

5. a b c d e 

6. a b 

7. a b c d 

8. a b c d e 

9. a b c d 

10. a b c d e 

11. a b c d e 

12. a b 

13. a b c d 

14. a b 

15. a b 

16. a b c d 

17. a b c d e 

18. a b 

19. a b c d 

20. a b c 

21. a b 

22. a b 

23. a b 

24. a b 

25. a b 

26. a b 

27. a b c d e 

28. a b 

29. a b 

30. a b 

31. a b 

32. a b 

33. a b 

34. a b c 

35. a b

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