Clinical experiences on perfluorochemical emulsion as an artificial blood has confirmed that perfluorochemical could transport oxygen indefinitely in circulating blood. We felt that an adequate cardiac output could be maintained no longer due to concomitant hypovolemia after the replacement with perfluorochemical emulsion for massive hemorrhage. Few studies have been reported on changes in the blood volume after replacement of circulating blood volume with fluorochemical.

Shock appears to complicate acute myocardial infarction (AMI) more often during the hot summer in Kuwait, than it does in winter. The aim of this study was to define the forms of shock, investigate its frequency, and evaluate the effects of fluid therapy.

Material and Methods

In a 3 month period during the hot summer of 1980, 21 shock patients (pts.) (18 male, 3 female) with AMI were studied. Their average age was 55 years (yrs.) (range 30–82), all had definite AMI (18 anterior, 3 inferior) and at least 3 known criteria of shock. Observations were made for 24 hours (hrs.) in the CCU, within one hour of admission. Initial hemodynamic pressures were obtained and hemoglobin (Hb), hematocrit (Hct) and serum glutamic oxaloacetic transaminase (SGOT) on blood samples were estimated.

The pathology of mixed injuries resulting from simultaneous action of several damaging factors on the organism is still insufficiently known. Peritonitis is the most frequent complication of injuries to the abdominal organs. Co-existence of peritonitis with radiation sickness impairs considerably the results of therapeutic management and prognosis. Surgical treatment is indicated in the latent period of radiation sickness or only in the period of recovery. In the case of diffuse peritonitis, the time of performing the operation is of essential importance for the prognosis. The purpose of the reported investigations was the study of the effect of ionizing radiation before exposure of the organism on the course of diffuse peritonitis and a trial of prolonging with an antibiotic the preliminary stage of the disease in which surgical treatment is effective. Investigations were carried out on 160 male Wistar rats weighing 250g on the average, divided into five groups. Group 1 served as control. In Group 2, the rats were only exposed to radiation.

Major trauma in disasters leading to open wounds is frequently followed by infection with a variety of microorganisms. Usually, antibiotics are administered systemically to prevent the onset of sepsis. In thermal burns, topical therapy with 1% silver sulfadiazine (AgSD) cream has proven effective and now supersedes systemic therapy. Experimentally standardized traumatic wounds in animals have been difficult to obtain. Standardized burn wounds in mice subsequently infected with pseudomonas facilitated demonstration of the efficacy of silver or zinc sulfadiazine (ZnSD) which has also shown an advantage in improved wound closure. (Fox CL, fr: Burns 1978;4:223). In a limited series of 18 patients with a variety of surgical trauma and infected wounds, topical silver sulfadiazine was utilized after prolonged systemic antibiotics had failed to eradicate the infection.

Previous work of our group and data from the literature show that in the polytraumatic patient the metabolic status is characterized by a severe and persistent catabolic situation involving carbohydrate, protein, lipid, mineral metabolism and hormonal and chemical mediators. This situation is clinically expressed by the so-called “post stress syndrome.”

Total parenteral nutrition has assumed a major role in the treatment of polytrauma patients and its application has produced a significant modification of the physiopathological evolution and improvement of the clinical outcome.

The main aim of the primary treatment of polytraumatized patients at the accident site is the stabilization and maintenance of vital functions, especially the cardiocirculatory and the respiratory systems. The next step in the rescue chain is rapid transport to the nearest hospital with the ability to manage critically injured patients. Because of the difficulty in carrying out measurements in such critical situations, very little reliable data concerning trauma induced changes in respiratory function and metabolism is available. Clinical experience has shown that even after successfully recovering from the acute stress phase, a trauma related progressive respiratory distress syndrome can nevertheless develop during the first few days following injury.

Recent studies led to the conclusion that the late development of respiratory distress syndrome is already induced during the early shock phase. Early discovery and adequate treatment of trauma related metabolic and respiratory dysfunctions have a decisive influence on current status and outcome.

Spinal injuries associated with aquatic sports account for about 30 admissions per year to spinal injury units in Australia. These injuries are considered not only for their significance to the victim, to his family and to the community, but to ensure that voluntary organizations are teaching first-aid measures which help to reduce morbidity and mortality—for on those first-aid measures depend the quality of the victim's life.

A good deal of controversy currently surrounds the role of collars and extrication devices in the on-site immobilization of suspected injuries to the cervical spine. The plethora of manufactured items readily available for this purpose reinforces the general impression that no one device is universally acceptable.

In his book, Spinal Cord Injuries – Comprehensive Management and Research, Sir Ludwig Guttman stressed the importance of keeping all cervical movements to a minimum. Flexion, hyperextension and rotatory movements are particularly dangerous. The most difficult circumstances are those in which an unconscious front-seat occupant requires extrication from a damaged motor vehicle. Here the strict first-aid drill of gentle lifting by a six man team maintaining rigid traction in the line of the spine becomes impracticable and the rescuers have to resort to the use of aids.

Evaluation of the traumatized patient frequently involves consideration of possible cervical spine injury. When neurological deficits, unconsciousness, alcoholic intoxication, severe maxillofacial or head trauma, or local neck pain are present, it is an easy decision to obtain cervical spine x-rays. The dilemma arises in the patient without neck pain who has mild to moderate scalp or facial injuries. Such a patient usually arrives in the emergency department with a cervical collar placed by pre-hospital personnel because of the mechanism of injury and the associated head or facial soft tissue trauma. Due to the association of cervical spine fractures with “significant” facial trauma, neck x-rays have been recommended. What, however, constitutes “significant” facial trauma To delineate such facial injuries, a retrospective analysis of 30 patients with cervicalspine fractures hospitalizedin a five year period at the University of Nebraska Medical Center was performed. Seventeen patients had head, scalp or facial injuries ranging from skull fractures and scalp hematomas to minor abrasions and lacerations. To determine if cervical spine films are being over utilized, a current prospective study of patients undergoing this evaluation will be presented, detailing the facial and head injuries, location, degree of severity, and detection of cervical spine injuries.

In early 1975, H.J. Heimlich demonstrated external compression of the diaphragm as a first-aid measure in the event of threatening death by suffocation.

A controversial debate developed in the ensuing years. What speaks in favor of the so-called “Heimlich Maneuver,” which should be applied only when:

• the foreign substance sits too deep or too tight to be removed by other means; and

• the trachea is completely closed by the foreign substance and breathing has ceased entirely,

is the dramatic situation which leaves a helper only a few minutes to save life in view of imminent unconsciousness and threatening hypoxic cardiac arrest.

What speaks against applying the maneuver are possible lesions of the intrathoracic organs (including fractures of the osseous thorax) and ruptures of internal organs, also the application without an existing indication or inadequate mastery of the manipulation.

The Vitalograph bag resuscitator with the old and new reservoirs, the PMR 1, the PMR 2, and the Laerdal bag resuscitator were studied at various oxygen flowrates and ventilation patterns, with and without oxygen reservoirs, to determine fractional delivered oxygen (FDO2) and function of patient valves. The Vitalograph with the new or the old reservoir and the PMR 1 cannot deliver high oxygen concentrations (FDO2 > 0.90) and should not be used when high FDO2 is important. The PMR 2 and the Laerdal cannot deliver high oxygen concentrations without a reservoir attached; but with a reservoir and oxygen flowrates of 101/min the Laerdal does achieve FDO2 > 0.98, and at 15 1/min the PMR 2 does achieve > 0.90.

Airway Intubators are obtainable from Williams Airway Intubator Limited, 405–206 7th Avenue S.W., Calgary T2P0W7 Canada

The Airway Intubator serves two purposes: as an oropharyngeal airway and, should the need arise, an endotracheal tube can be passed through the center of the airway intubator into the trachea without the need for further instrumentation.

Sykes, in 1937, described a divided airway made of aluminum; following the introduction of the endotracheal tube, both halves of the airway were removed leaving the endotracheal tube in place. A plastic airway, as designed in the 1970's by Berman, consisted of a tunnel along its whole length so that an endotracheal tube was compelled to follow this pathway.

With the advent of plastic endotracheal tubes with a relatively fixed radius of curvature, the airway intubator has been more successful than its predecessors, both as an oropharyngeal airway and as a means of intubating the trachea.

Coughing is a vital reflex consisting of two steps: firstly, the simultaneous closure of the glottis and the rise of the intrathoracic pressure to 150–180 torr by maximum contraction of the abdominal muscles; and secondly, the quick opening of the glottis valve within 0.03 seconds. Consequently a small amount of air is pushed out of the lungs with a velocity as high as 5–8 liters/sec, carrying with it secretions or foreign materials. Under pathological conditions or in special medical situations such as general anesthesia with muscle relaxation—this physiological reflex mechanism is blocked or interrupted, possibly resulting in more or less severe pulmonary complications or even deadly asphyxia.

Since early recorded use of the endotracheal catheter for controlled ventilation of the lung and protection of the airway from aspiration, the protection of airway integrity has been inconsistently obtained and not without significant morbidity.

Trauma is the leading cause of death between the ages of 1 and 40. The three most common causes of trauma related death are inadequate ventilation, inadequate circulation and massive hemorrhage. Thus high priority must be given to airway management, breathing and circulation. The efficiency of the former is essential to optimal circulatory adjustment. No presently available instrument fulfills these needs within a single system.

The physiological range of respiratory rates and heart rates in neonates is approximately 40 per min and 120 per min, respectively, which yields a theoretical ventilation-compression ratio of 1:3ratherthan 1:5.

Thirty-six anesthetized pigs with an average body weight of 4–5 kg were used in the study. After establishing a steady state by artificial ventilation with 100% oxygen, a cardiac arrest was induced by an intravenous injection of potassium chloride. Following the cardiac arrest, the animals were resuscitated with ventilation rates of 30 and 40 per min, respectively, while external cardiac compression was performed at rates between 60 and 160 per min. Randomly selected animals were resuscitated with ventilation-compression ratios of 1:2, 1:3 and 1:4 for 10 min each, 6 animals each were ventilated using a ventilation rate of 30 per min, 40 per min, or positive end-expiratory pressure.

Investigation of High Frequency Jet Ventilation (HFJV) for cardiopulmonary resuscitation (CPR) was initiated to determine whether HFJV may be used as an alternative to conventional intermittent positive pressure ventilation (IPPV) and also to determine whether HFJV may be employed in CPR if cardiac arrest should occur during use of HFJV.

The novel method of HFJV has several advantages over conventional ventilation, namely low airway pressure, no hemodynamic impairment and no need for muscle paralysis. Transtracheal HFJV offers in addition cricothyroid membrane puncture as a fast alternative to tracheal intubation in cases of difficult airway control. It is able to prevent aspiration, and allows direct intrapulmonary drug administration.

Ventilation is an integral part of cardiopulmonary resuscitation (CPR). Early intubation is recommended not only for the sake of better ventilation but also to prevent aspiration since aspiration is a common occurrence during CPR. It probably not infrequently contributes to an unfavorable outcome. Endotracheal intubation is sometimes very difficult especially under field conditions. Cricothyroid membrane puncture or transtracheal puncture with a 14g or 16g catheter needle enables high frequency jet ventilation (HFJV) and can often be performed more easily than intubation.

It has previously been demonstrated that high frequency jet ventilation, via transtracheal cricothyroid membrane puncture, can maintain good gas exchange even during cardiopulmonary resuscitation. When the upper airways were filled with fluid, aspiration could be prevented without a cuffed endotracheal tube when respiratory rates of 100/min or higher and an inspiratory time of at least 50% were used. We have also shown that cricothyroid membrane puncture is relatively easy to perform and produces less tracheal damage than a cuffed endotracheal tube.

In one of our studies, cardio-green dye was mixed into the jet using a Y-connector on the proximal end of the angiocath cannula (Figure 1). In two dogs, the distribution of the dye in the lungs was investigated. It was found that nebulized dye was transported by the jet stream to the most distant bronchi which could be observed. On subsequent autopsy, the dye was found in the most peripheral airways.

Standard CPR, consisting of 60 chest compressions per min with a ventilation interposed after every fifth compression, often allows restoration of spontaneous circulation but cannot be relied upon to preserve the brain during resuscitation attempts. In experimental models, it produces only one-third to one-half of normal cerebral blood flow and cannot sustain EEG activity. Many attempts have been made to augment overall cardiac output during CPR and presumably thereby increase cerebral blood flow. Crile used a pneumatic pressure suit to bind the abdomen and legs, but subsequent investigations found a high risk of hepatic trauma with abdominal binding. Both Wilder and Harris showed in dogs that simultaneous ventilation and compression augment carotid flow. Birch showed in an animal model that prolonged compression increased mean arterial pressure during CPR. Weisfeldt and colleagues of Baltimore have recently extended these findings to man, and combined them into a so-called “New” CPR, which consists of:

a) high pressure ventilation simultaneous with sternal compression;

b) 40 compressions per min;

c) 60% compression duration; and

d) abdominal binding.

Sudden cardiac death is the number one killer in the western world. In the USA alone, CPR attempts are justified in 200,000 cases per year. Recovery of brain function requires immediate initiation and uninterrupted maintenance of artificial ventilation and circulation by basic life support (BLS) until restoration of spontaneous circulation (ROSC) is possible with advanced life support (ALS). Presently recommended standard CPR (SCPR) produces only 6–30% of normal common carotid blood flow. For this reason, a more effective method of prolonged CPR-BLS is necessary in the absence of ALS ambulance services, which is common in rural areas.

Augmentation of blood flow during CPR can be accomplished by intravenous fluid load and epinephrine, which are unavailable to BLS personnel. Sustained abdominal compression in dogs during CPR increases blood flow but produces a high incidence of hepatic trauma. The use of military anti-shock trousers (MAST) during short-term SCPR has been shown to increase common carotid blood flow (CCABF); this, however, has not been evaluated with a long-term model.