Emergencies in the home: what equipment is needed

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Doctor in a cave

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Clinical evaluation of a new device for the treatment of tension pneumothorax

The two accepted major methods for decompression of a pneumothorax are needle aspiration in the second intercostal space and large bore chest tube insertion in the midaxillary line, sixth, seventh or eight intercostal space. Both of these devices have drawbacks in the emergency management of a tension pneumothorax. Relating to size, case of insertion, volume of air aspirated and cumbersomeness of associated equipment. This evaluation of its effectiveness is both in the prehospital phase and in the Emergency Department by studying 40 patients, 55% of which were prehospital. Sixty per cent were placed by EMT-Paramedic personnel. All of those patients that survived their multiple trauma long enough to allow x-rays to be made, had partial to total re-expansion of the pneumothorax. Of those patients undergoing autopsy or surgical exploration no indication could be identified of pulmonary injury secondary to the insertion of the device. The only complications were: intercostal artery laceration and a minor laceration of the dome of the diaphram. In summary this study of 40 patients demonstrates the effectiveness of the use of a device for the management of tension pneumothorax, both prehospital and in-hospital by physician and EMT-Paramedic personnel.

[Initial experience in accident surgery performed in an operation theater equipped with ASID sterile filter partition screen (author's transl)]

The article reports on initial experience in accident surgery performed in an operation theater equipped with an ASID sterile filter partition screen. This filter screen is representative of, and corresponds to, the room-within-room solution with laminar airflow in horizontal direction. The advantages of this sterile filter partition in the performance of the broad spectrum of accident surgery operations are explained. During the first twelve months since we started using this screen, no postoperative infection was observed, whereas the infection rate in primarily aseptic surgery performed in the conventional operation theaters of the type normally used to date, amounted to 0.36% during the same period.

[The emergency transport of children (author's transl)]

We report upon the development of a special stretcher which allows the transportation of ventilated children without problem. It is a stretcher according to DIN 13025 with a guide-rail for a respirator, a suction pump, a heart rate monitor. There are two oxygen cylinders with accessories in a wooden box under the stretcher, which is detachable and portable.

Roadside care and rescue American style

The development of an emergency services system in the USA is described, including the training of paramedical personnel. The increase in the survival rate of the severely injured appears to be impressive and it is suggested that lessons can be learned from the American system.

[A new suction pump to be used in the field of emergency medicine (author's transl)]

In the field of emergency medicine there has been a need for an efficient suction pump that can be used under all types of conditions and included both in doctors' emergency kits as well as in the standard equipment of mobile units such as ambulance cars, helicopters etc. The devices available in the past had decided disadvantages in their construction and performance. A newly designed suction pump -- the AMBU Uni-Suction -- has been subjected to laboratory and practical tests concerning function, material and practical use, based on a specification of requirements for such a device. The results show that this universally applicable suction pump meets every requirement under the different test conditions. The effectiveness is good, irrespective of the mode of operation applied, i.e. by hand, by foot or by compressed gases. Maintenance and service are negligible and no susceptibility to malfunction was observed. In addition, the design, function and performance of an accessory unit, the Suction Booster, are presented. This device can be used effectively in combination with the new suction pump, or with any other type of suction unit to prevent dangerous aspiration in emergencies.

Role of an accident flying squad in medical emergencies

A retrospective study of medical cases attended by the Derbyshire Royal Infirmary Accident Flying Squad demonstrates that of 17 cases only two patients survived to leave hospital. Nine cases of cardiac arrest have been studied in further detail. In all of these cases it was found that diagnosis of arrest had been made before the Flying Squad was called and that the situation had become extreme before the arrival of the medical team. In every case the Flying Squad team took more than 3 min to arrive, irrespective of distance. Review of the literature appears to support the conclusion that medical teams have been of little value when called to cardiac arrest at any distance from the hospital because of the time lag. It is suggested that more sophisticated primary care should be available immediately, preferably by highly trained ambulance personnel. Medical teams would give appropriate support to such primary care.

Retrieval of the critically ill in South Australia: a coordinated approach

A system is described for the stabilization and evacuation of the critically ill in South Australia, with a discussion of experience in 278 patients. The integration of activities of peripheral medical practitioners, major teaching hospitals, and the ambulance transport authority (St John Ambulance Council) is paramount. Modes of communication are by "urgent line" telephone and radio. Advanced life-support equipment is portable, may be placed in any ambulance vehicle, and is used and maintained principally by the staff of intensive care units. The design characteristics of a suitable road vehicle and fixed-wing aircraft are considered, with emphasis on dimensions for the particular needs of advanced life-support. The cost of transporting such a patient is approximately two-thirds of an average bed day cost in a public hospital, plus the basic ambulance charge. The number of patients who need such measures is 0.2% of the total number of patients carried by ambulance per annum.

Application of portable cardiopulmonary bypass to emergency instrumentation

Although most emergency conditions may be reversed with standard treatment protocols, mechanical cardiopulmonary bypass may be utilized to resuscitate highly selective patients who are in extremis. The addition of a battery mode to drive the pump oxygenator allows for portability from one area of the hospital to another. With the extensive availability of pump teams for elective heart surgery, cardiopulmonary bypass is applicable to patients with emergency conditions.

Mast pneumatic trousers: a mechanical device to support blood pressure

Maintaining the oxygenation of the heart-brain-lung circulation system is vitally important in reducing morbidity and mortality in emergency medicine. Mast pneumatic trousers were developed that compress the abdomen and legs, thus transfusing more than 20 percent of the whole blood volume into the heart-brain-lung circulation. This report consists of the results of treatment of approximately 70 patients whose blood pressures were significantly reduced before application of the trousers. These patients, for the most part, were delivered to the hospital in relatively good clinical condition. Complications with this device have been few. There is a question of pulmonary compromise because of the increased intra-abdominal pressure. Hard data on the number of lives saved are difficult to obtain because of the complexity of the human system in determining which lives would or would not have been saved without long-term studies. However, it can be shown that there is a significant increase in blood pressure with the utilization of such devices. This, then, infers that lives probably were saved in specific patients.

Esophageal obturator airway

The Esophageal Obturator Airway, a device designed for use in the management of cardiopulmonary arrest, obstructs the esophagus while simultaneously ventilating the lungs. The EOA was clinically tested in 29,000 patients with a low incidence of false entries and complications. Physiological studies indicated that vital capacity, blood gases, and pH were comparable to those obtained with the use of the endotracheal tube. Furthermore, the insertion of the EOA was more rapid (mean 6 sec vs 20 sec), more accurate (98 percent vs 48 percent), and easier to teach to paramedical personnel. It was concluded that whenever optimal conditions for endotracheal intubation are unavailable, the EOA should be first choice in the management of the airway in aneflexic, apneic patients. Specific contraindications are listed.

The clinical assessment of cardiovascular emergencies

Data are given for a 2-year study of fire department ambulance runs in Houston, Texas. Comparisons are made between those runs in which telemetry was used and those in which telemetry was not used. These data show an important relationship between the prognosis of patients who were recognized by emergency medical technicians as cardiac emergencies (and therefore received telemetry service) and those patients who were not identified as cardiac emergencies and did not receive telemetry service. Criteria used for clinical assessment and classification of emergencies are discussed. Emergency life-support systems with telemetry can have significant benefit for certain selected acute, recognizable cardiovascular emergencies, but the majority of ischemic heart disease fatalities do not appear to be deriving benefit from these systems.

Rationale and indications for microfiltration of blood in emergency medicine

Documentation in the literature shows that massive transfusions for severe, nonthoracic trauma contribute to development of progressive pulmonary failure in some patients. Further review shows embolic phenomena in cardiopulmonary bypass procedures contribute to a number of postoperative complitions. These complications are related to the numbers and physical characteristics of aggregates in banked whole blood and to the morphology of the pulmonary circulation. Many of these complications can be prevented or markedly attenuated by microfiltration of banked blood. It is concluded that all transfusions of banked whole blood and blood products should be administered through microfiltration units.

Improvement of defibrillators for EMS use: a problem in engineering and medicine

Recent improvement in defibrillators has been limited mostly to decreased size and weight of portable units. An overview of the scientific literature indicates that the main limitation to further improvement in defibrillators is the lack of medical and physiologic information. Technology probably exists to change defibrillators if the manufacturers know what changes would be desirable. Clinical studies are needed for determining (a) more accurate quantitation of electrical dose for human use, (b) the relative effectiveness of different waveforms, (c) the toxicity and damage of electrical shocks to the heart, (d) the effects of drugs upon defibrillation threshold, (e) improvement of defibrillation techniques, (f) optimal placement and size of electrodes, and (g) the effects of cardiac disease on defibrillation threshold. Most of the needed studies are not technically difficult to carry out but they will be moderately expensive. In some cases special equipment may be needed or special techniques may have to be developed. The experimental animal studies appropriate as background for these clinical studies have been completed. With limited resources available, it is important to ask the most important questions first in order to develop improved defibrillation techniques and defibrillators.

Emergency medical kits aboard aircraft

For a long time it has been considered necessary to place medical kits aboard aircraft. Nevertheless, since these kits were first made up, a reevaluation of this equipment has become necessary because of new circumstances, in particular the appearance of mass transportation. It is not possible to assure complete, perfect therapeutic action against all of the pathological manifestations that can occur during flights. Aside from the slightest incidents, and despite the frequent presence of a physician among the passengers, the problem usually is to try to gain time under the best possible conditions so that the plane can proceed to the next scheduled stop. The airlines of the ATLAS Group (Air France, Alitalia, Iberia, Lufthansa and Sabena) have moved in this direction and decided to equip their planes with such a kit.