Abstracts

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Abdominal compartment syndrome – still an underdiagnosed entity

R. IVATURY

Medical College of Virginia Hospital, Richmond, USA

It has been more than a century since Marey in 1863 and Braune in 1865 first studied the physiology of intra‐abdominal pressure [1]. In the last three decades elevated intra‐abdominal pressure (intra‐abdominal hypertension, IAH) and the relentless sequelae of untreated IAH (collectively called the abdominal compartment syndrome, ACS) have become clinical entities in critical care [2]. The last two decades witnessed a mushrooming of our knowledge of these conditions. From these observations, one might expect a general familiarity with IAH and ACS in the trauma and critical care community. Even among the surgeons in the Northern Hemisphere, IAP monitoring is not universally practiced, even in patients at high risk for IAH [3–5]. In the US fully a third of surgeons belonging to the American Association of Surgery for Trauma never or rarely monitored IAP [3]. In a survey of Canadian Trauma Surgeons published this year, Kirkpatrick and associates noted that physical examination (!) was reported as a diagnostic criterion for ACS by 66%, and was the method used for screening by 21% of respondents [4], despite ample evidence in the literature that physical examination to diagnose IAH is unequivocally misleading [6]. The neonatal problems of gastroschisis and omphalocele define the pediatric surgeons as pioneers in the problems of abdominal closure but only recently, however, has intra‐abdominal pressure received attention in the pediatric surgical ICUs.

Malbrain and associates [7], in a 1‐day prevalence study in 13 ICUs throughout Europe and Australia, confirmed that >50% of medical patients had a critical value of IAP (>12 mm Hg). The same authors, in a very recent multi‐center study [8], established the high frequency of IAH and ACS in mixed ICU patients from 14 different centers. In addition, the occurrence of IAH during the intensive care unit stay was noted to be an independent predictor of mortality (relative risk, 1.85; 95% confidence interval, 1.12–3.06).

Despite this increasing frequency in critically ill patients and an escalation of medical literature on the subject, there appears to be an underrecognition of the syndrome. In a survey of intensivists from 207 hospitals in the UK, Ravishanker and Hunter [9] noted that a large number, >95%, had prior knowledge of IAH and ACS but with wide gaps and inconsistencies in that knowledge. Kimball et al. [10] recently presented the results of two important surveys on abdominal compartment syndrome conducted back‐to‐back. The authors note observations that are very similar to those from prior surveys. Overall, 13% of the respondents were unaware of bladder pressure measurement. This was especially true with pediatric (28%) and medical intensivists (23.8%) working in their respective ICUs. Three percent never used it ‘because they did not believe it had clinical correlation’! As with prior surveys there was a lack of uniformity in defining these conditions, the need for treatment and the method of intervention. Perhaps predictably, 30% of pediatric intensivists and 20% of medical intensivists stated that they would ‘never’ use decompressive laparotomy to treat ACS. When Kimball et al. conducted a follow‐up survey 2 years later, 76% of intensivists agreed that ‘peer reviewed literature had convinced them that there is a correlation between high volume resuscitation in sepsis, IAH and multiple organ failure’. More impressively, 94% of respondents answered ‘yes’ when asked if they would begin monitoring more patients for intra‐abdominal pressure if research can convince them of the adverse outcome from IAH . These data confirm that ACS is still under‐diagnosed and underappreciated.

To accomplish worldwide consensus on definitions and interventions for IAH and ACS, and with a mission to foster education and research, a World Society on Abdominal Compartment Syndrome (WSACS) was founded in December 2004. This international congress has proposed a series of definitions for IAH and ACS to serve as an initial foundation. The WSACS website (www.wsacs.org) is a valuable resource for the study of IAH and ACS. In addition, a state‐of the art monograph on abdominal compartment syndrome [2] by members of the executive committee is in press and will be released shortly. It can also be accessed on line at: http://www.eurekah.com/categories.php?catid = 83&category = SURGERY

The endovascular management of haemorrhage in trauma

KRASSI IVANCEV

Endovascular Center, Department of Radiology, Malmö University Hospital, Malmö, Sweden

Author's email: [email protected]

Introduction

A variety of imaging modalities have contributed significantly to the success of endovascular treatment of bleeding in trauma [1]. The endovascular approach has become an accepted means of haemorrhage control, either as a first line of treatment replacing open surgery, or an important adjunct to open surgery. A large proportion of patients are now managed by one or a combination of transarterial embolization (TAE), stent or stent‐graft placement.

All patients admitted with trauma must be assessed clinically to make the diagnosis and determine the course of treatment. Clinical evaluation will broadly identify three groups of patients. First are those patients who are haemodynamically unstable despite resuscitation. These patients are transferred directly to the operating room for ‘focused assessment with sonography for trauma’ (FAST). FAST enables the surgeon to undertake immediate laparotomy or thoracotomy without requiring additional imaging. A second group of patients are those who respond transiently to fluid resuscitation. They benefit from computed tomography (CT), which directs definitive endovascular or open surgery. A final group of patients are those who are and remain haemodynamically stable. These patients may be evaluated with CT for further minimal non‐operative management (NOM).

The following are different types of traumatic injuries, which may be considered for endovascular treatment:

Pelvic fracture

Severe pelvic fractures, particularly with disruption of the sacroiliac joints, are associated with significant bleeding. Pelvic stabilization (external fixation) often results in spontaneous tamponade and control of the venous bleeding. Arterial bleeding often requires TAE, which has become the first line of treatment, including those who are in shock.

TAE should be considered where there is CT evidence of ongoing bleeding (contrast extravasation and pelvic haematoma with bladder compression). Haemodynamic instability without evidence of extrapelvic bleeding sources is another indication to consider TAE [2].

TAE requires abdominal aortography and selective catheterization of the internal iliac arteries. In patients with haemodynamic shock an occlusion balloon may be placed in the infrarenal aorta to achieve haemodynamic control. When contrast extravasation is demonstrated, the bleeding vessels are catheterized superselectively and embolized. Embolization may be performed with coils, or a combination of coils and gelfoam particles. If distal embolization is not possible due to spasm or uncontrolled haemorrhage, then central embolization of the internal iliac arteries is performed using coils. Gelfoam is not to be recommended as a sole embolizing agent because its effect is only temporary. Glue should also be avoided, especially distally because of the risk of tissue necrosis.

In patients where the pelvic fracture has been stabilized but there is recurrent hypotension or persistent metabolic acidosis, repeat angiography and TAE should be performed. In this subgroup of patients, there is a possibility of severe venous bleeding. Venous bleeding may be demonstrated by venography. A balloon is placed in the infrarenal inferior vena cava and contrast is injected in to the iliac veins. Upon visualization of disruption of the iliac veins, stents may be used for stabilization of the tears in the venous walls [3].

Blunt splenic injuries

Patients who are haemodynamically stable with blunt trauma to the spleen should be managed non‐operatively (NOM). The majority of patients make a good recovery. A non‐operative approach avoids the long‐term deleterious effects of splenectomy, notably overwhelming infections.

NOM has also become an accepted treatment in patients with severe splenic injuries where there is haemoperitoneum and moderate haemodynamic instability. Haemorrhage control is achieved using splenic artery embolization (SAE) [4].

The indications for SAE include a drop in haematocrit, tachycardia and haemoperitoneum, in addition to CT evidence of ongoing bleeding. The CT scan may demonstrate with contrast extravasation outside or within the spleen, formation of a pseudoaneurysm or subcapsular haematomas.

Selective catheterization of the splenic artery is performed, followed by superselective catheterization of the bleeding arteries or feeders to the pseudoanerysms. Embolization is then performed using microcoils in combination with gelfoam particles or microspheres. In this way splenic infarction is minimized.

Technical difficulties may be encountered if there are multiple bleeding arteries or if catheterization is impossible due to spasm. If this is the case, then central embolization of the splenic artery may be performed using coils. Central embolization usually decreases the perfusion pressure sufficiently to arrest haemorrhage but multiple collaterals are often sufficient to prevent major splenic necrosis.

Applying such selection criteria, NOM of blunt splenic injuries may be performed in 85–90% of all patients suffering this type of traumatic bleeding [4],[5]. Similar embolization techniques may be used for hepatic and renal haemorrhage.

Traumatic aortic and arterial rupture

Traumatic injuries to the aortic arch vessels are uncommon and are often the result of sudden deceleration. Physical findings are often non‐specific and diagnosis is usually made on CT.

If patients do not exsanguinate immediately they are usually sufficiently stable to undergo CT. These patients are well suited to the use of stent‐grafts, not the least because these patients suffer from multiple associated injuries. A minimally invasive approach is likely to improve outcome [6]. Consequently, stent‐graft treatment of acute aortic transections is today considered to be the first line of treatment of these patients. However, caution has to be exerted when placing stent‐grafts in small aortas in young patients with acute angulation of the arch, which may lead to failure of the stent‐graft treatment in the long run [7].

The endovascular approach is also suitable for injuries of the common carotid arteries, brachiocephalic and subclavian arteries [8].

Conclusion

Contemporary CT examinations of patients suffering traumatic injuries have opened the way for evaluation of the extent of trauma and for the use of endovascular treatment.

Arterial embolization of pelvic haemorrhage caused by fractures plays an essential role in the damage control of patients with polytrauma. NOM of blunt splenic injuries is standard care, and can be extended to an even higher number of patients by performing splenic artery embolization. Stent‐graft treatment of acute aortic transections appears to have replaced open surgery.

In order to apply endovascular treatment in traumatic bleeding it is of utmost importance to combine knowledge from the surgical, intensive care and endovascular field, expressed in a close co‐operative teamwork.

Prehospital ultrasonography in trauma management

FIKRI ABU‐ZIDAN

Head, Trauma Group, Faculty of Medicine and Health Sciences, UAE University

Focused Assessment Sonography for Trauma (FAST) has been accepted worldwide to evaluate severely traumatized patients. The discovery of free fluid in the abdomen and around the heart or in the chest can lead to appropriate and timely definitive care when needed. New developments in ultrasound technology have a tremendous potential in prehospital and disaster trauma management, allowing accurate patient triage in the most austere of environments. The portability, small size, lightweight, improved quality and low price are advantages of the new hand‐held portable ultrasound machines. Different trials of FAST using portable hand‐held ultrasound machines have shown that they have comparable accuracy to hospital‐based ultrasound machines in detecting fluid. This proved useful to define patients who need to be swiftly evacuated to the hospital. A recent multicentric study from Germany has shown that prehospital FAST has very high sensitivity and specificity compared with clinical examination. Prehospital FAST has changed the management in 30% of patients and redirected patients to proper centres in about 20% of the patients. Satellite and mobile wireless transmission of FAST has been tested. One of the problems of this approach is the reduced clarity of the images. Despite that, interpretation of these images proved to be correct in the majority of cases. Recently, FAST images have been successfully transmitted from an international space station to earth. An expert sonographer remotely guided the non‐medical operator, who was using an instruction card to help him. The quality of the received ultrasound video could allow clinical decisions. FAST use can be maximized with adequate training, experience, and appreciation of its technical limitations. Its potential in prehospital setting is practically tremendous.

Systemic inflammatory response

ROLAND ANDERSSON

Department of Surgery, University Hospital, Lund, Sweden

Background

The magnitude of the net proinflammatory response following trauma, in critical illness, acute abdominal disease and also following major elective surgery, correlates with the concomitant clinical course and outcome. Up to now, interventions have been merely considered as directed ‘downstream’ and being organ supportive by nature. Treatment is thereby not primarily directed at underlying pathophysiological mechanisms, a knowledge which to a large extent still is lacking.

Ongoing research and results

Ongoing and future research and understanding on the complex underlying dynamics and interactions of the acute phase response, metabolic consequences and also, for example, effects on gut barrier function including both permeability and immune function, is needed in order to be able to improve and develop future treatment concepts. Not least this is necessary in order to ‘tailor’ management to be more based on the requirements needed by the individual.

Mechanisms of dysfunction in both gut barrier integrity and local immune function as well as the systemic acute phase response are complex, dynamic and have inter‐organ differences in both magnitude and time sequence. For example, many local ongoing inflammatory responses occur simultaneously with systemic immunodepression, especially during later phases of critical illness. Intervention directed at one specific underlying pathophysiological mechanism has not been successful and this illustrates the complexity of mechanisms and the need for individualized treatment in a more tailored fashion. Experimental studies using multimodal treatment concepts directed at several steps in the inflammatory response have pointed at potential success, but clinical implementation is still awaited.

Conclusion

Mechanisms involved in the systemic inflammatory response are profoundly complex. Overall, consideration has to be given to the interaction between gut barrier failure (including both permeability and immune alterations), metabolic response and the systemic acute phase (inflammatory) response. With different magnitudes, this takes place in critical illness, following trauma, acute abdominal diseases like acute pancreatitis and also following major elective surgery. Novel ways of potential intervention may include immunomodulation, immunonutrition, and nutritional pharmacology, not least using the enteral route for administration and provided as multimodal treatment and better tailored according to the need of the individual.

Recombinant factor VIIa – a potential new tool in trauma management

ULLA HEDNER BERGENTZ

Lund University, Sweden and Research & Development Novo Nordisk A/S, Måløv, Denmark

Background

Recombinant factor VIIa (rFVIIa) has been developed for treatment of bleeding in hemophilia patients complicated by the development of inhibitors against the protein they are lacking, FVIII in hemophilia A and FIX in hemophilia B. An efficacy rate of around 90% has been demonstrated in major surgery including major orthopedic surgery in severe hemophilia (Shapiro et al., 1998) and rFVIIa (NovoSeven) is approved for use in patients with inhibitors against FVIII/FIX in the EU, Japan and the USA. Furthermore, it is approved for use in patients with Glanzmanńs thrombasthenia who have developed inhibitors against platelets as well as in patients with FVII‐deficiency in the EU.

Mechanism of action of rFVIIa

The availability of rFVIIa has made it possible to further explore the hemostatic process and especially the role of the FVII‐TF (tissue factor) pathway. According to the current concept, hemostasis occurs on cell surfaces, essentially the TF‐bearing cells and thrombin activated platelets. As a result of vessel wall injury TF is being exposed to the circulating blood at the site of injury and forms complexes with already activated FVII (FVIIa) normally present in the circulation. These complexes provide the first limited thrombin activation leading to the activation of platelets. On the thrombin‐activated platelet surfaces the further full thrombin burst occurs, which leads to the formation of a tight fibrin hemostatic plug. The administration of pharmacological doses of rFVIIa enhances the thrombin formation on pre‐activated platelets at the site of injury, thereby mediating the formation of a tight fibrin plug resistant to premature lysis. A full thrombin burst also ensures full activation of the thrombin activatable fibrinolytic inhibitor (TAFI).

Clinical experience of the use of rFVIIa

Administration of high doses of rFVIIa has been found to, at least partially, compensate for lack of FVIII/FIX in hemophilia A and B by enhancing the thrombin generation on pre‐activated platelets (Monroe et al., 1997) thereby ensuring the formation of a tight fibrin hemostatic plug (He et al., 2003) and full activation of TAFI. Since the fibrin structure is dependent on the amount of thrombin generated as well as on the rate of thrombin generation it was assumed that extra, exogeneous rFVIIa may help to generate stronger fibrin hemostatic plugs in environments characterized by an impaired thrombin generation due to defects other than hemophilia. In situations complicated by thrombocytopenia as well as lowered levels of other coagulation proteins such as dilution coagulopathy therefore rFVIIa was assumed to be beneficial. Furthermore, an increased local fibrinolytic activity resulting in a diffuse oozing often occurs in patients with extensive tissue damage. In these situations the formation of a tight fibrin hemostatic plug should be beneficial to break the vicious circle of severe oozing on defective fibrin plugs. Several case reports have been published showing rFVIIa to be efficient in stopping bleeding in severe trauma situations (Kenet et al., 1999; Martinowitz et al., 2001; Dutton et al., 2004; ÓNeill et al., 2002). Recently, the results from randomized, placebo‐controlled, double‐blind clinical trials were published (Boffard et al., 2005). This study concluded that a significant reduction in red blood cell (RBC) transfusion was found in patients with blunt trauma in the group treated with rFVIIa after the transfusion of eight units of RBCs. Furthermore, the number of patients requiring >20 units of RBCs significantly decreased in the treated groups in both blunt and penetrating trauma patients. No safety concerns were found in the trial (158 patients randomized into the blunt trauma and 143 into the penetrating trauma groups). The conclusion from the study was that the ‘… administration of rFVIIa appears to be a promising adjunct to existing therapy within trauma …’.

Neurological trauma

CARL‐HENRIK NORDSTRÖM

Department of Neurosurgery, Lund University Hospital, Lund, Sweden

Author's email: [email protected]

Traumatic brain injuries (TBIs) constitute a worldwide problem. In developing countries the rapid social changes and the enormous increase in the number of motor vehicles have led to the tragic consequence that TBI is one of the leading causes of lifelong morbidity and mortality among the young population. Also in highly developed countries TBIs constitute a major problem. Apart from a remaining high mortality, advances in medical technology and improvements in regional trauma services have in these countries increased the number of survivors, producing the social consequences and medical challenges of a growing pool of people with disabilities.

In the USA injury is the leading cause of mortality under 45 years of age and TBI is responsible for the majority of these deaths [1]. Between 50 000 and 70 000 lives are lost in the U.S. each year to TBI [1],[2]. Motor vehicle accidents, followed by gunshot injuries and falls, are the leading causes and males are 3.4 times as likely as females to die of TBI. The epidemiology of TBIs in Sweden was recently presented in a population‐based study, which included lesions of all degrees of severity [3]. The total incidence of head injuries was 546 per 100 000 including deaths (0.7%), hospital admissions (67%), and attendance at the emergency department in patients not admitted (32%). Males (644 per 100 000) had a 1.46 higher overall rate than females (442 per 100 000). About 50% of people who sustain TBI are intoxicated at the time of injury in Sweden [4], as well as in the USA [1].

TBI is conventionally divided into four categories according to HISS (Head Injury Severity Scale) [5], as follows. Minimal (no unconsciousness, no amnesia), mild (unconsciousness <5 min and/or amnesia), moderate (unconsciousness ⩾5min or focal neurological deficits), and severe. In most studies severe TBI is defined as the patient being unconscious for >6 hours. The loss of consciousness may be due to primary brain damage or secondary intracranial complications.

The definite clinical outcome is dependent on a well‐functioning chain of assessments and treatments from the scene of the accident to the final rehabilitation. This presentation will focus on a few of these important steps: the initial assessment and management after hospital admission and the non‐surgical treatment of increased intracranial pressure (ICP). The initial clinical assessment is performed in a standardized way by estimation of the level of consciousness and a simple neurological evaluation according to the Glasgow Coma Scale [6] or the Reaction Level Scale – RLS [7]. The results of the clinical assessments in combination with the findings on CT scanning determine the primary management and may be illustrated in a simplified diagram (Figure 1).

Figure 1 Clinical assessments and CT results determining the primary management.

The neuro‐intensive care is focused on treatment of increased ICP. All non‐surgical treatments are based on continuous monitoring of ICP and cerebral perfusion pressure (CPP). Opinions regarding the optimal way of treating increased ICP are, however, conflicting. According to the conventional US protocol a decrease in ICP is obtained by increasing arterial blood pressure (MAP) and CPP [8]. The ‘Lund concept’, on the other hand, argues that based on physiological principles a decrease in ICP is obtained by a pharmacologically induced reduction in MAP and CPP [9]. The physiological aspects of these two contradictory treatment policies will be presented. Further, the information obtained from intracerebral microdialysis with bedside biochemical analysis of metabolites reflecting cerebral energy metabolism and cell membrane degradation will be presented and discussed [10].

Mild brain injury (MBI)

S. OREDSSON

Emergency Department, Helsingborgs Hospital, Helsingborg, Sweden

There is currently no generally accepted definition of mild brain injury (MBI). A frequently used definition includes loss of consciousness and/or post‐traumatic amnesia, normal level of consciousness (GCS 15) upon presenting in the emergency department, and no neurological findings. Some definitions include GCS 13–14; however, the prognosis of this subgroup of patients is much worse.

The incidence of hospital‐treated patients with MBI ranges from 100 to 300 per 100 000. The true number is probably in excess of 600 per 100 000.

Intracranial CT abnormalities are found in approximately 5% of patients with MBI (GCS 15). About 1% require neurosurgical intervention and the mortality is <0.1%. An unknown, but substantial, number of patients suffer from post‐concussion syndrome following MBI.

There is no standard practice for managing patients with MBI. In Europe, in‐hospital observation dominates, whereas there is a trend towards increased use of CT and less in‐hospital care in the USA. Despite a paucity of scientific evidence, there are numerous guidelines in the literature as well as in local hospitals.

In‐hospital admission is by no means a guarantee that life‐threatening intracranial injury will be detected promptly and poor outcome prevented. On the contrary, there are indications that observation without CT could delay diagnosis and necessary treatment.

With an increase in CT availability and lowered costs, use of CT in MBI management is growing. However, the safety, risks and costs of such a strategy are under debate. The first randomized study comparing in‐hospital admission with early CT and discharge (OCTOPUS) will be discussed and guidelines based on the results presented.

Trauma in pregnancy

SVEN MONTAN

Department of Obstetrics and Gynecology, Malmö University Hospital, Malmö, Sweden

When a fertile woman is hurt in an accident, it is important to consider the possibility that she might be pregnant. If in doubt, an immediate pregnancy test should be performed, either as a urine HCG‐analysis or as beta‐HCG in a blood test.

Accidents are reported to occur in 6–7% of pregnancies and serious injuries contribute to an important part of maternal mortality. Fetal mortality is reported to be high following serious accidents, 15–45 % with major trauma and 1–4% with less severe trauma.

General principles for trauma care should also be practised in pregnancy. Special consideration must be given to the pregnant state and the increased risks involving mother and fetus. Fetal heart rate monitoring by Doptone or cardiotocography and ultrasound biometry are important instruments to evaluate fetal well‐being and should have a place in the emergency room.

It is important to know the physiological changes in relation to pregnancy to correctly evaluate how the injury might affect the pregnant woman and her offspring. Management of injured pregnant women should be carried out as teamwork between doctors experienced in trauma management, obstetricians and anaesthesiologists.

Trauma in children

P. DROTT

Department of Surgery, University Hospital, Linköping, Sweden

Participation of children in major accidents and disasters is a challenge for everyone involved at the trauma scene.

Children as participants at the trauma scene

Children are investigative by nature, they cannot be relied on to stay in place and wait for their turn. The ideal situation is when the parents can watch their own children and the families can be kept together, this is unfortunately not always the case. Uninjured children have to be kept away from the dangerous parts of the trauma scene and occupied, otherwise they are likely to start drifting to find their relatives or friends or just to see what is going on. This could of course be dangerous and cause more victims than necessary. Children have to be looked after, otherwise you might end up with a lot more injured than you started with.

Children as trauma victims

There are a few major differences between children and adults that have to be stressed when children are victims of major trauma.

1. Inability to regulate body temperature. Especially small children and neonates have limited resources to regulate temperature. This is true both for heat and cold. This has to be kept in mind when designing the areas for collection or care of children. A child of 5 years must increase its movements to keep body temperature under environmental temperature of 33.4°C. The corresponding temperature for an adult is 28–30°C. This need for movement is slowly decreasing during the first year and is around 32.5°C at 1 year of age.

2. Metabolism. Energy turnover is enhanced already in the newborn with requirements of 32 kcal/kg/day; this is increased during the first 2 weeks to reach a peak at approximately 2 weeks of age of 48 kcal/kg/day, where it stays until early teenage years, as it slowly declines to the level of the grown up around 24 kcal/kg/day. To this should be added the needs for growth and development, which is at its peak in the neonatal period, with an additional need for 33 kcal/kg/day, this declines and is at 3 months 18 kcal/kg/day and declines further to 4 kcal/kg/day at 6 months, where it stays until the age of 12–13 years in girls and 15–16 years in boys.

   Energy reserves are small in children. In the newborn the liver contains glycogen for about 3 hours. Fat reserves are smaller especially in the newborn. Reserves last, in the prematurely newborn, for about 4 days. In newborns of normal weight they last for about 10 days. Supplementation with 10% glucose in recommended volumes lengthens life by 7 days in the premature infant and 18 days in normal infants.

3. Haemodynamics. Neonates can be very sensitive to loss of volume (bleeding, dehydration), while older children often compensate for a loss of volume. They keep their blood pressure up by an increase in heart rate, a centralization of blood volume. After a loss of > 15–20% the blood pressure suddenly drops.

   A neonate has a blood volume of approximately 80 ml/kg/day (100 ml/kg/day for a premature neonate), which will give a blood volume of about 275 ml. At 3 months of age it has decreased to 75 ml/kg/day where it stays and gives a blood volume of 450 ml and at 1 year of age 750 ml, at 5 it is 1500 ml and around 10 years of age it will be approximately 2400 ml.

4. Vulnerability of the visceral organs. In a child the liver occupies a larger amount of the abdominal cavity. Only this relative size makes it easier to damage the organ. In addition to this the resistance of the abdominal wall is lower in a child, making all the abdominal organs more susceptible to trauma. Children have a great ability to diminish blood flow to injured organs by closing the arteries to the organ. Conservative treatment of injuries to the abdominal organs is mandatory.

5. The growing bone. The bones of a newborn are soft and allow bending without breaking. With growing age the bones become harder and break, with sharp edges. Damage to the vessels is usually caused by the displacement of the fracture or by soft tissue damage or swelling.

6. Head injuries. The head is a much larger and heavier part of the body in a small child. Accidents where the child is thrown a longer or shorter distance make injuries to the head more likely. The heavy part of the body takes the lead. The soft bones and the open sutures of the head act as a good shock absorber. Damage to the intracranial tissues must be considered without any noticeable skull damage. In children with open fontanelles, the tension of the fontanelle gives good guidance in estimating elevated intracranial pressure.

Trauma in the elderly

CHRISTER CARLSSON

Department of Anaesthesiology, University Hospital, Malmö, Sweden

The population above 65 years of age is the fastest growing section of age groups in the western world. In Sweden there is also a gender difference, with more women than men in that age group.

The people born after World War II have both the economic power and demand for advanced medical care. At the same time they have physiologic changes related to age and can withstand trauma less readily than younger people.

Trauma is not uncommon in this age group. In the USA trauma is the seventh most common cause of death in this age group. The most common causes of trauma are falls, motor vehicle accidents and burns. Falls are often coupled to the aging process (mental changes, coordination problems, visual and hearing impairment, stiffer joints, etc.) and to environmental hazards. Many trauma situations can be considered minor (fall at home, in the bathroom, etc.) but delayed care will cause a high incidence of both morbidity and mortality. For instance, fractured hips ought to be surgically stabilized within 24 hours to have low risk for thrombosis/pulmonary embolism, pneumonia, etc.

In our institution we have not been bale to organize our emergency services to meet the target quality of 24 hours, despite major efforts towards such a goal, the reason being that many different emergencies are competing for available resources during call hours.

Motor vehicle accidents with trauma to both the skeleton and the soft tissue cause stress to physiology and metabolism in the elderly, but sometimes even a much smaller trauma (purse snatching, knocked down on the sidewalk) can give rise to the same level of problem. Therefore all trauma victims should be treated the same way and ATLS principles are sound.

A brief list of specific problems in the ATLS concept could be:

• A: poor dentition, problems with stabile airway, nasopharyngeal fragility.

• B: loss of respiratory reserve, chronic pulmonary problems, rib fractures, pneumothorax,

• stiffer chest wall.

• C: coronary artery stenosis, low cardiac index, lower maximal heart rate, reduced blood

• volume, increased myocardial stiffness, dysrythmias.

• D and E: skin and tissue damage, less thermal control, less active immune system.

Liberal use of supplemental oxygen and early intubation are recommended in such patients.

Careful monitoring is used early to see early changes from the desired ‘normal’ state, and things like skin damage, thermal control, bacterial infections, osteoporosis, muscle weakness and caloric needs will need much higher attention than in a younger patient population.

Another area of focus today is the changes in cognitive functions that elderly patients may experience after trauma, surgery and hospitalization. There is evidence that about one‐third of patients with hip fractures have decreased cognitive scores related to the surgical intervention. Such patients might need prolonged medical attention and cannot recover on their own at home.

Trauma in the elderly is an entity which should be of concern and given appropriate attention in every emergency room.

Endovascular techniques in aortic aneurysms

MARTIN MALINA

Department of Surgery, University Hospital, Malmö, Sweden

Open aneurysm repair is a very successful treatment that has been routinely available in major centres for four decades. However, open repair is associated with considerable surgical trauma and consequently with significant morbidity and mortality. This is particularly true in patients with ruptured aneurysms or traumatic pseudoaneurysms of the aorta. The surgical mortality rate in this setting is often reported to be in the range of 40%!

Endovascular aneurysm repair (EVAR) offers a minimally invasive option to prevent hemorrhage and aneurysm expansion with subsequent rupture. EVAR avoids not only laparatomy (or thoracotomy) and surgical blood loss but also cross‐clamping of the aorta. The stent graft can be inserted percutaneously, often under local anaesthesia. So‐called ‘permissive hypotension’ is encouraged in the urgent setting. It has been shown in prospective randomized trials that perioperative mortality is reduced by EVAR in planned aneurysm repair and preliminary data suggest strongly that this also applies to urgent cases, both in the thoracic and abdominal aorta. EVAR is currently the treatment of choice for urgent aortic repair in several leading vascular centres.

Logistics, equipment and training remain limiting factors for EVAR in many centres and need to be adjusted accordingly. The endovascular technology is currently undergoing rapid development and an increasing proportion of aortic aneurysms can be treated with stent graft. This will influence future referral patterns and urgent care of these critically ill patients. Today, the technology is already being decentralized to many Scandinavian county hospitals.

Mesenteric thromboembolism

S ACOSTA

Department of Surgery, Lund, Sweden

The incidence and relationship between the four aetiologies of intestinal ischaemia have been estimated in Malmö, Sweden, between 1970 and 1982, when the autopsy rate was 87%. Among 402 patients, two‐thirds had acute thromboembolic occlusion of the superior mesenteric artery (SMA) (Figure 1). The overall incidence of acute SMA occlusion was 8.6/100 000/year, which is higher than for ruptured abdominal aortic aneurysm in Malmö during the same time period. The incidence increased exponentially with age in both men and women, and reached 217/100 000 persons/year in the age category 85 and above.

Autopsy studies have shown that thrombotic occlusions are generally located more proximally within the SMA and are associated with a more extensive intestinal infarction, whereas embolic occlusion are associated with a higher frequency of acute myocardial infarction. Synchronous embolism, often multiple, and remaining cardiac thrombi occurs in two‐thirds and one‐half, respectively, of patients with embolic SMA occlusion.

In modern series, one‐third of the patients are initially managed in non‐surgical wards. The diagnosis must be considered when there is severe abdominal pain with initially minimal abdominal signs (pain out of proportion) in an elderly patient. Pain out of proportion (I), accompanied by rapid and often forceful bowel evacuation (II), and a source of embolus (III) due to atrial fibrillation or recent myocardial infarction, or previous history of embolism, is labelled the ‘clinical triad’ of early embolic SMA occlusion. Sometimes three phases of pain intensity can be recognized: an initial phase with severe pain, that sometimes fades, followed by a third phase characterized by full wall bowel necrosis, peritonitis and increased pain.

Laboratory tests such as elevated D‐dimer and leucocytosis have high sensitivity, but low specificity for the disease, in the early phase. A normal D‐dimer at presentation most likely excludes the diagnosis. CRP will be normal or slightly elevated initially. Plasma lactate and metabolic acidosis have high sensitivity in the late phase of the disease, but are unspecific. Experimental data have not shown any difference in plasma lactate levels between pigs with extensive intestinal ischaemia and controls. The evolution of multiple detector row computed tomography (CT) angiography, with the possibility of three‐dimensional reconstructions, in terms of resolution, availability and investigation time, have had a great impact on the evaluation of patients with acute abdomen. The high resolution of CT nowadays makes it possible to definitively detect SMA occlusion in the main branch. Hence, in questions of acute abdomen in elderly, it is no exaggeration to say that the radiologists ought to have a routine to visualize and describe the great mesenteric vessels.

Prompt recognition and timely intestinal revascularization are crucial to avoid extensive bowel resections, to reduce mortality and to avoid short bowel syndrome. The degree of intestinal ischaemia caused by the occluding thrombus/embolus cannot be predicted. In case of rapidly developing extensive intestinal ischaemia, only vigorous action can rescue the patient from death. However, in a few patients revascularization can be successful late in the course, even after symptom duration beyond 3 days. Besides, only laparotomy can estimate the extent of intestinal infarction and patients with a limited bowel infarction can sometimes be saved late in the course by a bowel resection. Hence, patients with suspicion of acute SMA occlusion should not be refused therapy merely based on time limits.

Diagnosis can be achieved through CT angiography, laparoscopy, laparotomy or angiography. General surgeons need to collaborate with vascular surgeons. In general, intestinal revascularization attempts should be performed liberally, preceding bowel resection, as restoration of pulsatile flow to the SMA may produce remarkable change to the dark appearance of the intestines. Open revascularization, SMA embolectomy or bypass from either aortae or the left iliac artery to the SMA with synthetic graft in case of thrombotic occlusion, seem to be the most feasible options in emergency situations. However, the increased diagnostic accuracy of CT has made emergency endovascular procedures such as aspiration embolectomy, local thrombolysis and stenting possible, and these treatment options may increase in specialized vascular units.

Questions of intestinal viability, whether to resect or not, bowel anastomosis or stoma, and second look, are evaluated individually. Frank bowel necrosis are resected, and if a second look is considered, it may be wise to staple off the infarcted intestine, close the skin but not the aponeurosis, and leave the reconstruction of bowel continuity until the second look. If possible, high diverting stomas should be avoided due to occurrence of short bowel syndrome. Second look is not mandatory, but should be performed by the same surgeons in cases where any segments of the intestines were of questionable viability or if several bowel anastomoses were performed at primary operation. The timing of second look is up to the surgeons at primary operation, but is generally considered to begin 24–48 hours after the first operation.

The length of the ischaemic bowel segment at operation is a risk factor for death. Institutional mortality in a recent series on 27 patients collected prospectively, including detection at autopsy in 4, was 59%. Early diagnosis with CT and increased intestinal revascularization rate may increase survival rates in the near future.

Figure 1 Acute intestinal ischaemia. Distribution of aetiologies in 402 patients between 1970 and 1982.

Training in vascular surgery

TIMOTHY RESCH

Department of Vascular Diseases and Endovascular Center, Malmö University Hospital, Sweden

Background

The field of vascular surgery encompasses the care of patients with all forms of peripheral vascular disease ranging from atherosclerotic occlusive disorders, aneurysmal disease, vascular malformations, traumatic vascular injuries and disorders of the venous system. Secondary preventive medical treatment and operative intervention are the primary tools for the practising vascular surgeon. Traditionally, vascular surgery has been rooted in the field of general surgery, as operative patient care has been the overwhelming treatment modality.

Over the last decade, rapid medical and technical advances within the field of peripheral vascular disease have occurred, placing new demands on the training of a new generation of vascular surgeons. Medical treatment of vascular patients has been established as having an ever more important role in treating atherosclerotic disease and focuses the need on a deepened understanding of this field for the young vascular surgeon.

The overwhelming development of new minimally invasive treatment of vascular disorders as well as the rapid evolution of vascular imaging is however, perhaps the biggest change that has occurred within the field of vascular surgery since its establishment as a unique surgical subspecialty. Minimally invasive treatment of acute and chronic arterial disorders and aneurysmal disease as well as lytic therapy for venous occlusive disease has opened up a whole new arena in which the modern vascular surgeon must evolve parallel to other existing specialities acting in the field, such as interventional radiologists and cardiologists. This development is taking place globally for the benefit of the vascular patients.

Discussion

International societies of vascular surgery as well as national health boards have recognized the changes within the field and are starting to implement them in their training requirements. It is vital that vascular surgeons take a central role in this development, as they are best suited to identify the needs both for patients and those who will practise vascular surgery in the future.

The new developments must directly impact the training that the young vascular surgeon receives. The traditional platform of general surgery, although in many ways vital, is insufficient to meet the needs of the ever‐expanding field of vascular surgery. The basic clinical knowledge of surgical techniques and a holistic view of the patients is the foundation that gives vascular surgeons a unique position when caring for vascular patients. This must, however, be complemented by training in minimally invasive treatment as well as improved training in modern vascular imaging. Only in this manner can the vascular surgeon of the future retain his or her pivotal role in management of vascular disease. A greater focus on areas and topics within general surgery that are of importance for the practice of vascular surgery must be outlined so as to make the basic surgical training more customized. Adequate imaging training and training in endovascular techniques must be made a core area for the future vascular surgeon. This will lead to vast changes in the way that vascular surgical training is constructed, leading away from the general surgeon specifically interested in vascular surgery to the vascular therapist of the future with a broad spectrum of tools to best practise their trade. These changes will be outlined and detailed in the presentation.

Conclusion

Modern vascular surgery is going through rapid changes that will affect the training of new vascular specialists vastly. The vascular surgeon will continue to play a pivotal role in this development only if the changes are embraced and reflected in the future curriculum of vascular surgical training.

Laparoscopic appendectomy

ANN‐CATHRIN MOBERG

Department of Surgery, University Hospital of Malmö, Sweden

There are over 30 randomized studies comparing laparoscopic and open appendectomy in suspected appendicitis. The largest two studies include over 500 patients each, with recovery as the primary endpoint. In both studies the conclusion was that recovery is faster after laparoscopic appendectomy. Laparoscopic appendectomy was associated with fewer wound infections, improved cosmesis and equally short hospital stay for both techniques [1],[2]. Hellberg concludes that laparoscopic appendectomy is as safe as open appendectomy [1].

The median operation time for laparoscopic appendectomy vary between 45 and 61 minutes [3–7]. The majority of the randomized studies were performed during a period when many participating surgeons had not reached the learning curve for the laparoscopic technique and this may be the reason for the somewhat longer operation time.

The frequency of deep abdominal infection has by some been considered to be higher in the laparoscopic appendectomy group, but there is no statistical difference demonstrated in any study. The intra‐abdominal infection rate varies between 1% and 3% [1],[2],[8]. In a Cochrane review by Sauerland et al. it was concluded that in a clinical setting where surgical expertise and equipment are available and affordable, diagnostic laparoscopy and laparoscopic appendectomy (either in combination or separately) seem to offer various advantages compared with open appendectomy. Some of the clinical effects of laparoscopic appendectomy are small and might be of limited clinical relevance. In gangrenous or perforated appendicitis cases, however, laparoscopic appendectomy may possible carry a higher risk of intra‐abdominal infection [9]. This statement refers to Pedersen et al.'s randomized study of over 500 cases where a tendency towards higher intra‐abdominal infection rate at laparoscopic appendectomy compared with open operation was demonstrated, but no statistically significant difference was found [2].

Complicated appendicitis

BOBBY TINGSTEDT

Department of Surgery, University Hospital, Lund, Sweden

Background

Complicated appendicitis (defined as appendicitis with perforation or presence of intra‐abdominal abscess) is subject to treatment protocols at many hospitals. This lecture aims to describe the latest lines of treatment of complicated appendicitis.

Method

Literature review based on Pubmed search using the terms appendicitis, complications, complicated appendicitis, appendiceal abscess and perforated appendicitis.

Results and discussion

Antibiotics should be used as prophylaxis at all appendix operations, given pre‐, peri‐ or postoperatively. Intravenous antibiotics should be administered until the patient is eating and not for a fixed number of days. Routine cultures need not be taken. Antibiotics should cover normal bowel pathogens.

Patients with complicated appendicitis should be operated on according to clinical presentation. Many patients with abscesses could benefit from a conservative approach with less complications and decreased hospital stay. There is no obvious negative effect of laparoscopic appendectomies on complicated appendicitis.

Interval appendectomy should only be performed on selected cases.

Patients with abscesses treated conservatively should be followed and if above the age of 40 routinely checked for malignancies in colon and female genitals.

Medical treatment in upper gastrointestinal bleeding

CHRISTER STAËL VON HOLSTEIN

Department of Surgery, Lund University Hospital, Lund, Sweden

Upper gastrointestinal bleeding is still a substantial clinical problem accounting for a large number of hospitalizations and deaths every year. The main diagnoses in fatal bleedings are peptic ulcer and oesophageal varices, and different medical regimens to stop bleedings from these sources have been tried during the last half century.

In peptic ulcer bleeding much focus has been directed towards the pH level in the stomach. Low pH virtually abolishes normal haemostatic mechanisms and is a prerequisite for the clot‐ dissolving proteolytic activity of secreted gastric pepsin. However, despite numerous studies, it has been difficult to prove the value of therapy against acid secretion, but this has recently changed. There are now six meta‐analyses in support of anti‐secretory therapy and proton pump inhibitors in combination with endoscopic therapy give a substantial reduction in risk of rebleeding. There is also evidence of proteolytic activity through plasminogen activators around bleeding ulcers. This implies a potential role for plasminogen activator inhibitors, i.e. tranexamic acid, and there is some evidence of benefit in peptic ulcer bleeding, but a role as an adjunct to endoscopic therapy has not been established.

In portal hypertension there are several possible bleeding sources and early diagnosis is essential. In acute variceal bleeding vasoactive therapy to alleviate high portal pressure with terlipressin or somatostatin has proven beneficial in several randomized trials to stop bleeding, but there seems to be no added effect on mortality. It has, however, been shown that prophylactic antibiotics reduce infections as well as mortality in these situations.

Surgical and radiological treatment in upper gastrointestinal bleeding

SVEN GUSTAVSSON

Department of Surgery, University Hospital, Uppsala, Sweden

The sophisticated endoscopic interventions together with new pharmacological agents are highly effective in acute upper gastrointestinal bleeding. However, in rare cases therapeutic failure occurs leaving a high‐risk group of patients needing individually tailored treatment. Traditionally, patients who continue to bleed from duodenal ulcer in spite of repeated endoscopic efforts to stop bleeding will require surgery.

At laparotomy the duodenal bulb is accessed through a gastro‐duodenotomy. After ligation of the bleeding vessel in the back wall of the duodenal bulb, gastroduodenal continuity is re‐established by a pyloroplasty. Alternatively a gastric resection of the Billroth type can be performed. However, patients are often old and afflicted by severe concomitant diseases, making them poor surgical candidates. Therefore both mortality and morbidity rates are high after surgery.

For these very sick patients we have sought the attention of interventional radiologists (Rickard Nyman and Lars‐Gunnar Eriksson). During the past 7 years we have used transcatheter arterial embolization as an alternative to surgery in patients with massive peptic ulcer bleeding in whom endoscopic efforts to stop bleeding have failed.

Peptic ulcer bleeding is known to be intermittent. Therefore it is common that angiography cannot identify contrast media extravasation, leading to difficulties in finding the exact site for embolization. In this situation the entire gastroduodenal artery is generally blindly embolized. However, this is an imprecise method and due to a rich collateral network in the area the embolization can be insufficient.

We have found that it is of great benefit for the embolization procedure if the bleeding site can be marked with a metallic clip at endoscopy, thus guiding the radiologist to the correct area.

Fracture management in high‐energy trauma

P. GUSTAFSON

Department of Orthopedics, University Hospital, Lund, Sweden

The orthopedic treatment of patients who have sustained high‐energy trauma is complex and has to be carefully timed both as regards specific orthopedic injuries, but also as regards injuries in other organ systems.

At 20–30 years ago, the opinion was that multitrauma patients with orthopedics injuries often were too ill to undergo surgery; therefore a conservative treatment approach often was used. Since then, a massive body of data has shown that these patients benefit from early total care, including early fracture stabilization, but it still remains to conclude about the optimal fracture treatment. The concept of ‘orthopedic damage control’ is gaining in popularity.

It has to emphasized that few orthopedic injuries are directly life‐threatening (the exceptions are massive bleeding from pelvic or femoral fractures, high spinal injuries or bleeding from damaged vessels), but very often orthopedic injuries are the reason for not returning to a normal life after serious injury.

Modern fracture management in high‐energy trauma therefore comprises resuscitation according to ATLS^® principles. Pelvic fractures should be evaluated as to whether embolization or abdominal packing is needed for hemorrhage control. Fractures of the long bones should be temporarily stabilized, preferably by external fixation. Thereafter, the patient should be resuscitated to a stable state with physiologic parameters returning to normal. The definitive orthopedic treatment should be delayed until this has been achieved, which often can take several days.

Thereafter definitive fixation of fractures can take place. Intramedullary nails, plate osteosynthesis with minimal exposure or definitive treatment using external fixation can be used. Attention has to be paid to the surrounding soft tissues, which must be expected to be damaged as a result of the high‐energy trauma, so that a minimum amount of bone becomes detached from blood supply. Local or free flaps and/or skin grafts may be needed to achieve coverage. Vacuum‐assisted closure of wounds is a new technique which can lower infection rates.

Further research is needed to give better knowledge of which patients can tolerate the ‘second hit’ and when they can tolerate it.

The impact of increasing specialization on emergency preparedness

STEN LENNQUIST

University of Linköping, Sweden

Author's email: [email protected]

Definition of the problem

During the last decades, surgery has – like other disciplines within the field of medicine – faced a rapidly increasing specialization. The consequence of this is not only an increasing number of subspecialist fields, but also more rigid borderlines between these different subspecialties. This development has been more prominent and more rapid in some countries than in others.

In the middle of the 20th century, the majority of ‘general surgeons’ operated on all parts of the body. During the last 20–30 years, specialities like ‘upper GI surgery’, ‘colorectal surgery’, ‘hepato‐biliary‐pancreatic surgery’, ‘endocrine surgery’, ‘breast surgery’, ‘oncologic surgery’ and ‘vascular surgery’ have become well established, in addition to those that already existed, thoracic/cardiovascular, urologic , plastic and pediatric surgery. Young surgeons making a career within one of these fields become more and more unwilling to devote time and energy to training, and even updating of knowledge within, any of the other fields.

This development has without any doubt contributed to the increase in quality in surgery during the last decades. Simultaneously, however, regulation of working hours has reduced the total number of working hours per week for surgeons significantly, in many countries to 40 hours or even less. This means that all these specialists are simultaneously available only during that time, while our patients are hit by trauma or emergencies 168 hours per week. Since most hospitals can afford only two or three surgeons on call in non‐office hours, the question arises as to who will take care of these patients during the 128 non‐office hours, if the trauma or emergency hits an organ system or part of the body outside the field of competence for the specialist who happens to be on call. This has created a problem which has grown faster than, and already is more serious than, many administrators and even surgeons realize.

Possible solutions

There are two ways two approach this problem: Either to establish a group of surgeons with training and skills sufficient to deal with emergencies and trauma within all organs systems who could cover the on‐call system, or to give all surgeons presently participating in this system such a basic training, with assurance of updating of knowledge and skills. Which of these solutions will be selected will most likely vary between countries, regions and even hospitals, depending on differences in organization, tradition, degree of specialization, density of population, geographic structure and economy.

However, whichever of these solutions is selected, it is necessary to better recognize and define these specific fields of competence with regard to requested minimal levels of knowledge and skills, education and training, and also with regard to organization, methodology, development and research. Such definition and recognition is also a prerequisite to get leading surgeons within different fields to devote interest and effort in methodological development, research and education and also leadership within these fields.

The reality today in too many hospitals is that very little attention and interest are paid to this field. This is both unfortunate and difficult to understand, because it is an important field: quantitatively since the majority of the beds in surgical departments today are occupied by emergency patients, qualitatively because this is ‘the face of the hospital to the world outside’ and a sign of quality of the hospital for people in general, economically because complications of emergency cases are common, and they are expensive and resource‐consuming.

Combining trauma and emergency surgery as one field of competence

EATES has in fact been a pioneer in Europe in promoting these fields together as one and the same field of competence, a concept that now rapidly has gained support and acceptance in many parts of the world, perhaps especially in the United States, where a new ‘Acute care curriculum’ including these fields presently is introduced. International collaboration and exchange of experiences within this area are important.

EATES: emergency surgery: who will do emergency surgery in the future? Definition and role of emergency surgery in Europe

KORHAN TAVILOGLU

Istanbul University, Istanbul Medical School, Department of Surgery, Trauma & Emergency Surgery Service, Istanbul

Author's email: [email protected]

There are different trauma systems in European countries at present. A trauma surgeon in Austria has 6 years training, 3 years of which are in orthopedic trauma surgery, 15 months in general surgery, and 3–6 months each in anatomy, anesthesiology, orthopedics, neurosurgery, and plastic surgery, with electives in vascular and thoracic surgery. A trauma surgeon in Germany is a general surgeon with 3 years additional training in orthopedic trauma surgery. In Italy, Portugal and Turkey, a general surgeon is usually responsible for the care of trauma patients. In the Netherlands a general surgeon with specialized training in trauma care (ATLS® is the standard) attends to polytrauma patients.

In Norway, GI surgeons, orthopedic surgeons, thoracic surgeons, vascular surgeons, urologists, etc. who are all board‐certified general surgeons undergoing (after a 5‐year residency in general surgery) 4‐year further training in one of the above‐mentioned surgical fields. In Sweden, in the majority of cases a general surgeon devoted to trauma attends polytraumatized patients. In Spain specialists are called in depending on the injuries involved. There is a strong trend toward change and improvement in Spain, with particular emphasis on extra‐hospital services. In the UK the immediate care of the polytraumatized patient in larger facilities is usually shared by the members of a multidisciplinary trauma team consisting of a general surgeon, A&E consultant, and orthopedic surgeon. In more remote, smaller hospitals these cases are usually handled by a general surgeon. In the UK, there is strong support for trauma as a recognized specialty in the medical community but the need has not yet been acknowledged by the government.

A trauma patient receives initial care from a general surgeon in some countries (Sweden, Turkey, Portugal and the Netherlands), a multidisciplinary trauma team in some countries (Norway, UK, Romania and Spain), an emergency surgeon and/or anesthesiologist in Italy, and in Austria, from a trauma surgeon who is assisted by a general surgeon and an anesthesiologist. Emergency rooms are often managed by general surgeons (Sweden, Turkey, Portugal, Italy), or by multidisciplinary teams (Norway, Romania), otherwise by ER or ICU specialists or trauma coordinators (UK, Netherlands, Spain) or, in the case of Austria, by a trauma surgeon.

Primary management of distal tibial and ankle fractures in the severely traumatized patient

CHRISTOPH SOMMER

Head of Trauma Surgery, Kantonsspital Graubünden, CH‐7000 Chur

Author's email: [email protected]

General principles of management

The outcome of pilon and ankle fractures depends on the quality of reconstruction of the joint [1–3] and on how well the soft tissues recover. Severe injuries of the distal tibia and ankle are usually associated with moderate or severe closed or even open soft tissue injuries and therefore are managed in a two‐ or more staged procedure [4–9]. Initial management includes a precise assessment of the soft tissues (including the lower leg compartments), a closed reduction of any ankle dislocation (especially common in severe ankle fractures), conventional X‐rays of the ankle in two planes and the application of a temporary ankle‐bridging external fixator. In case of an open fracture, the general management principles (debridement, lavage, covering of soft tissue defects by vacuum‐sealing or skin replacements, 2° look after 48 hours, early free flaps if necessary) are mandatory [10]. In the rare fractures with compartment syndrome (<5%), fasciotomy has to be performed at the same first operation. In case of distal tibia fracture with fibula fracture (in about 85% of all pilon fractures) the fibula can be stabilized at the first operation, if the soft tissues are not too swollen and the fibula fracture is simple. But it must clearly be adressed, that the stabilization of the fibula (if fractured) is a crucial step for the reconstruction of all pilon fractures and therefore has to be done anatomically in case of a simple fracture or correctly aligned (length, rotation, axis) in comminuted fractures. In the latter, we recommend fixing the fibula as the last step of the definitive (second) operation after reconstruction of the tibia and therefore never operate on complex fibulas on day one (Figure 1a–k). Rarely, in very complex fractures with extensive damage to metaphyseal bone as well as to soft tissue, primary shortening may be an alternative for salvage. Secondary lengthening at the metaphyseal fracture site or more proximally will be required [5],[11] (Figure 2a–f). Other protocols with purely closed approaches (percutaneous screw application and bridging rigid or hinged external fixator) for definitive treatment are largely published [12–15], but are not used in our clinic. One of our main goals is to achieve anatomic reduction of the articular surface, which can, in our view, only exceptionally be accomplished by closed means alone.

Definitive stabilization of the fractures

Distal tibia (pilon) fractures

The timing for the definitive reconstruction is crucial. For the great majority of fractures we prefer to delay surgery for 7–14 days as mentioned above [11],[16]. Until the soft tissue edema is gone and the skin begins to wrinkle (Figure 1c), strict bed rest with elevation of the injured leg is recommended.

For the pilon fractures (with simple fibula fracture), we usually follow the classical four steps: 1. ORIF of the fibula (1/3 tubular plate) through a posterolateral streight incision; 2. limited anteromedial (or rarely anterolateral) open approach for open reduction of the tibial articular portion; 3. anteromedial (or anterior or anterolateral) plate fixation, whereby the metaphyseal part is usually bridged with one (rarely two) partially percutaneous inserted locking plate(s) (LCP distal tibia plate 3.5 or LCP pilon plate 3.5); and 4. bone grafting of large metaphyseal bone defects is required. It is crucial, that the soft tissues are handled very carefully (limited use of hooks, periosteal detachment [‘periosteal window’] as minimal as necessary, epiperiosteal position of the plate) (Figure 1g).

In case of comminuted fibula fracture, the fibula is stabilized as last and fourth step of the operation using a minimal invasive plate technique (MIPO) with a locking plate (LCP metaphyseal plate 3.5 or LCP 1/3 tubular plate 3.5). The comminuted fracture zone is not opened and only bridged in respect to a correct alignment (length, rotation, axis in both planes), which is checked under fluoroscopic control (Figure 1h).

Although most fractures can be stabilized adequately by standard (non‐locking) plates, the new generation of fixed angle screw‐plate systems (LCP) offer several advantages in complex fractures as well as fractures in osteoporotic bone. Atraumatic insertion of these preformed plates (MIPO) and the percutaneous placement of screws is also facilitated [17],[18].

Postoperative treatment usually includes a functional aftercare with active assisted physical exercises starting on day 1, ambulation between days 3 and 5 depending on the soft tissue swelling under toe‐touch weight bearing (10–15 kg) for at least 6 (–12) weeks. Full weight‐bearing is allowed after 3–4 months if X‐ray control confirms adequate bone healing.

Ankle (malleolar) fractures

The rules for definitive stabilization of complex malleolar fractures are similar to the ones mentioned above for the pilon fracture. In case of a simple fibula fracture, we start at the fibula by a classical ORIF with a 1/3 tubular plate. In osteoporotic bone, a LCP with angular stable screws is very helpful for preventing screw loosening and early implant failure.

The medial malleolus, if fractured, is stabilized in most cases by two 3.5 cortical screws in lag screw technique.

In case of a comminuted fibula fracture, this fracture is stabilized as last step in a MIPOtechnique using, most recently, a LCP metaphyseal plate 3.5 (or LPC 1/3 tubular plate). The manually contoured plate is inserted through a small incision over the distal end of the fibula from distal to proximal and preliminarily fixed with an angular stable locking head screw in the distal part. Using an inserted drill sleeve in the proximal part of the plate, this can be used as a handle for indirect reduction of the comminuted fracture zone. It is crucial to achieve correct alignment of the fibula (length, rotation, axis), which has to be controlled under fluoroscopy. Larger anterior or posterior syndesmotic fragments (Volkmann, Tillaux‐Chaput) are stabilized as well usually by direct approach and lag screw fixation. Fibulotibial positioning screws are finally inserted in case of remaining syndesmotic instability.

The postoperative regime is usually a functional aftercare with early active‐assisted physical therapy, ambulation on day 2–3 depending on the soft tissue condition under toe‐touch weight‐bearing for 6 weeks. Full loading is mostly allowed after 6–8 weeks.

Cases

Case 1. Pilon fracture with sever closed soft tissue injury ‐ 2‐staged procedure with 1. joint‐bridging ex fix and 2. ORIF tibia and MIPO fibula (Figure 1a–k)

Figure 1

A 63‐year‐old female fell from a ladder and sustained this largely displaced pilon fracture with closed, but posteromedial crushed and degloved soft tissue. Note the comminuted fibula! (Figure 1a). Closed reduction and primary stabilization with joint‐bridging external fixator was performed with CT scan on day 2 demonstrating a C3‐type fracture (Figure 1b). Definitive reconstruction on day 7 could safely be done under ideal soft tissue conditions (skin wrinkling) (Figure 1c). This main operation started with

ORIF of the tibia using direct and indirect reduction manoeuvres over an anteromedial open approach (Figure 1d, e). The tibia was stabilized with a double plate technique (LCP T‐plate 3.5 medial and standard 1/3 tubular plate 3.5 anterior) (Figure 1f, g). Note the small periosteal window which was used for the direct reduction and the epiperiosteal position of the plates. As last step of the operation the fibula was fixed with a LCP 3.5 in a MIPO‐technique (Figure 1h). The postoperative X‐ray confirmed an anatomic reconstruction and stable fixation of the pilon fracture allowing early motion and toe‐touch weight‐bearing for the first 6 (–12) weeks (Figure 1i). A postprimary local soft

tissue flap was necessary to cover a skin defect posteromedial. At 14 months later, after partial implant removal, a complete consolidation with excellent ankle function is confirmed (Figure 1j, k).

Case 2. Complex distal tibia and fibula fracture with large combined defect – Concept of primary shortening and secondary lengthening (Figure 2a–f)

Figure 2

A 33‐year‐old female motor cyclist was involved in an accident in Greece and sustained a 3B‐open comminuted distal tibia and fibula fracture (Figure 2a left). After initial external fixation in Greece, she was referred to our hospital on day 11. The third look operation with adequate debridement resulted in a combined defect with large anterior skin defect (7×15 cm) and segmental bone defect of 7 cm length (Figure 2a right). Primary shortening of 7 cm was performed with tension‐free skin closure (Figure 2b). At 6 weeks later the distal fracture zone (tibia) was stabilized with a LCP distal tibia plate 3.5 in

MIPO‐technique and the initial external fixator was removed. At the same time, a unilateral external fixator (Mephisto) for proximal lengthening with callus distraction was applied (Figure 2c) with continuous distraction of 1 mm/day reaching the desired length on day 131 (Figure 2d). As last operation, a change from the distraction system to a LISS‐PLT in the proximal tibia and an additional stabilization of the distal fibula using a LCP metaphyseal plate 3.5 in MIPO‐technique was performed (Figure 2e and 2f left). At 8 months after the injury full weight‐bearing was allowed with ongoing bony healing on the last X‐ray follow‐up (Figure 2f right).

Case 3. Complex 2° open malleolar C‐type fracture two‐staged procedure with 1. ankle bridging external fixator and 2. definitive reconstruction using a MIPO‐technique for the fibula (Figure 3a–i)

Figure 3

A 60‐year‐old female slipped on ice and sustained a 2° open malleolar fracture AO 44‐C2.3 (Figure 3a, b).

Initial stabilization with two lag screws for the medial malleolus after jet‐lavage and soft tissue debridement medially (Figure 3c). Definitive fixation of the fibula 5 days later with a LPC 1/3 tubular plate 3.5, which is inserted percutaneously through a small distal approach. The plate is first fixed distally with one locking head screw. Using an inserted drill sleeve in the most proximal plate hole, the fracture is indirectly aligned under fluoroscopic control (Figure 3d). After correct alignment was achieved, the position was preliminarilyy fixed with a K‐wire inserted through the distal fibula into the tibia (Figure 3e). After drilling a bicortical hole through the inserted drill sleeve with the drill bit in situ, the axis in the lateral plane is checked and corrected if necessary (Figure 3f right). Finally, the plate is fixed to the bone in this position, inserting further locking head screws at either side of the fracture, which is not further touched (Figure 3g, h). The final X‐ray demonstrates a stable fixation in anatomic position of the ankle (Figure 3i).

Soft tissue problems in the foot

G. KISS

Marcus Ovszky Hospital, Szomathely, Hungary

Injuries to the foot may be isolated or part of a polytrauma, the soft tissue itself may be injured, but all this may come together with joint dislocation or different fractures of the foot.

Treating severe foot trauma, reconstructing bones and soft tissue injuries and defects require intensive cooperation between trauma and plastic surgeons.

Organization is a vital question in the treatment of such injuries. Treatment has to be carried out where the personal and technical conditions and facilities are provided. This is more emphatic in cases where the polytrauma care influences the treatment of the foot.

Trauma to soft tissue can be due not only to the acute event, but also to secondary injury after edema, hematoma, retraction, operative intervention, and fibrosis.

The main goal in case of a closed injury of the foot is to determine the degree of severity and to prevent further damage of the tissues, especially compartment syndromes and their late consequences.

Most of the devasting injuries of the foot associated with compartment syndromes are caused by various crushing forces, which lead to fractures and dislocations of the midfoot.

The incidence of compartment syndromes asssociated with calcaneal fractures is approximately 7–17% in the literature. The only reliable method of diagnosis of the compartment syndromes is based on clinical suspicion, e.g. painful passive dorsiflexion of the toes, etc., and measurement of the raised intracompartmental pressures. In a typical case – if the measured pressure is higher than 30 mm Hg – an urgent fasciotomy is needed. [18], [19]

Perfect timing of skeletal stabilization by external or internal fixation facilitates wound healing.

Our patients can be assessed by complex foot trauma score (CFTS) [28], Maryland Foot Score [23], or Merle d'Aubigné Score [3].

The first order of care is to determine what treatment is best suited for the individual and finally the individual injury itself. Medical problems like diabetes, neurologic disorders, peripherial vascular disease, etc., should be taken into account before surgical planning and reconstruction [17].

What exactly the terms ‘acute’, ‘early’ and ‘delayed’ mean, even the literature is not homogeneous about.

In case of open injuries, preferably early and durable soft tissue coverage has to be applied to reduce infection rate and fibrosis. Obviously, with this better functional outcome may be achieved.

Negative wound pressure therapy may also be applied in certain cases of the lower part of the leg, ankle, and foot [21].

Primary stable osteosynthesis can be performed for first‐ and second‐degree open fractures.

In case of severe complex foot trauma (e.g. third‐degree open fracture) the soft tissue of the foot may temporarily be allowed to heal with external fixation, and a stiffened foot in equinovarus may be avoided in this way. Results of an early resurfacing concerning infection are much better than results of a delayed soft tissue covering [6].

In particular, type III B open fractures of the calcaneus require extensive debridement and prompt soft tissue coverage as soon as possible because the soft tissue injury determines outcome. Early internal fixation should be avoided because of the high rates of osteomyelitis and subsequent amputation [9].

After severe foot trauma Ttscherne suggested primary amputation at the level of injury with a high polytrauma score [24].

The anatomical features of different surfaces of the foot also differ, and they have special functions.

A clear surgical plan is needed with the goal of maximizing function in absence of infection.

Our practice shows that an inexperienced surgeon may underestimate the extent of the zone of injury of the foot.

To determine tissue viability one can perform fluorescein‐labeling, Doppler flowmetry and split thickness skin excision [27].

‘The spectrum of treatment options is extensive and includes skeletal shortening and primary closure, split‐thickness skin grafting, split‐thickness skin excision, local rotational (transpositional) flaps, free tissue flaps, and cross‐leg flaps … The surgeon should always select a procedure that is simple. The surgeon should not ignore the basic principles of wound and fracture stabilization, preservation of soft tissues, and liberal use of external fixation that has a positive effect on wound healing’ [20].

The flap design was chosen based on the like‐is‐like principle, considering Hidalgo's plantar zones[10].

There are some special demands in the foot resurfacing such as biomechanics of the foot, durability, esthetic requirements, shoe fitting, and last but not least the donor site morbidity. Sometimes this flap should be resistant to weight‐bearing stresses.

For covering relatively small defects transpositional and island flaps work very well [2],[11]. Myerson recommends the abductor hallucis flap on the medial aspect of the foot and the extensor brevis flap to cover small defects on the dorsal and lateral surfaces, but any viable local muscle flap may be used from the foot [20].

In case of large tissue defect, exposed bone, nerve, tendon, etc., a free flap may be required. Most surgeons chose free muscle flaps covered with split thickness graft for defects involving the heel and plantar foot surface [7]. These muscle flaps include latissimus dorsi, rectus abdominis, and gracilis [5],[16]. Sometimes a periodic skin breakdown may occur which should be avoided or minimized by vigilant skin care, footwear modification, and protective orthosis. Return of deep pressure sensation appears to maintain durability. For defects of the heel the fasciocutaneous sural flap is also a very simple and good solution [12],[14],[22].

For a non‐weight‐bearing surface of the foot a lateral forarm flap may also be very useful. Hallock has referred to the radial forearm fasciocutaneous flap as the ‘workhorse for coverage of acute defects of all foot regions’ [8],[25].

The cross leg flap has a certain indication if a free flap transfer is not available or a free flap fails. The prolonged immobilization is better tolerated in children than in adults [13].

The problem of diffuse calcaneal osteomyelitis can be best controlled by muscle flaps; however, sometimes amputation should be considered.

The outcome of an overlooked or untreated compartment syndrome is a dysfunctional, painful extremity. The surgical procedures are difficult and not effective, these deformities should be prevented [1],[4].

Principles of treatment in children's fractures

LUTZR VON LAER¹, WOLFGANGE LINHART², RALF KRAUS³

¹Basel, ²Graz, ³Giesen

Differences between adults and children with remaining growth potential are crucial in setting principles of diagnosis and treatment of fractures. (1) Children do have their own opinion and wishes regarding treatment. (2) They are dependent on parents and the demands of society during their management. (3) Their musculoskeletal system has a growth potential.

Taking these aspects in consideration, one can clearly define the principles of treatment: avoiding damage to the growth potential, respecting their opinion in deciding the treatment options, and treating them according to the principles based on EBM.

To achieve this, some basic knowledge is necessary: the ability to communicate both with the patient and the parents, to be aware of the natural course and to be competent with conservative as well as operative treatment modalities.

The main indications for conservative as well as operative treatment are well known. It seems clear that if reposition needs to be performed under anaesthesia, stability at the fracture should be achieved to permit the patient in any case to functionally load and if possible weight‐bearing of the fracture during the consolidation period. This aim will be achieved by osteosynthesis for diaphyseal shaft fractures and – with restriction – for intra‐articular fractures, but – in the presence of open physes – not for metaphyseal shaft fractures (including the epiphyseal separations).

Nowadays, under DRGs there is a developing trend to avoid conservative treatment (plaster cast), analogous to the treatment choice for adults. It should be known that the occurrence of metaphyseal fractures in children is four times more than diaphyseal fractures and shaft fractures are 50 times more common than joint fractures. Metaphyseal fractures do need, in spite of osteosynthesis in most of all cases, an additional plaster splinting during the consolidation phase.

In conclusion: in order to treat fractures in growing individuals in a optimal manner, one should be aware of the natural history, and to be able to follow the principles of EBM. With this, the fractures can be managed more efficiently; and unnecessary anaesthesia and osteosynthesis can be avoided. On the other hand, we need more innovative and modern methods of osteosynthesis, which protect the growth plate, and permit early functional loading and weight‐bearing in metaphyseal fractures.

To achieve this aim the Li‐La e.V. has developed a documentation system in cooperation with the Institut für Evaluative Forschung in Orthopädische Chirurgie der Universität Bern (Chief: Prof. Dr med. M. Aebi) 2006, and also a classification of children's fractures, which will permit uniform documentation and help in multicenter studies. The first one on the prognosis of growth of Salter I and II injuries of the lower extremity will start in August 2006 (www.li‐la.org).

Fractures of the lower extremity in children

INGO MARZI

Department of Trauma Surgery, University of Frankfurt; Frankfurt, Germany

Fractures of the lower extremity are less frequent than fractures of the upper extremity. In children, the fracture type is mainly dependent on the age of the child due to the changing stability of bones and joint. Nevertheless, numerous specific aspects need to be addressed for the treatment of fractures in childhood.

Fractures of the proximal femur are rare and critical in respect to the perfusion of the femoral head. Dislocations should be reduced and fixed by screws or specific plates as soon as possible to reduce the rate of avascular necrosis. In contrast, fractures of the pertrochanteric region – even necessary to stabilize – may be treated by retrograde elastic stable intramedullary nailing (ESIN). In addition, ESIN is in most cases the first choice for stabilization of femur fractures in children older than 3 years. In particular the 3‐point principle should be applied in most cases. In complex fractures as well as under specific conditions such as open fractures or multiple trauma, external fixation should be the first choice. In small children, younger than 3 years, the overhead extension followed by a cast seems to remain the initial treatment.

In tibia fractures, a discrimination should be made between shaft fractures and very proximal and distal fractures. Shaft fractures presented as complete lower leg fractures may be treated conservatively, operatively with ESIN or external fixation. Younger children may be treated more easily by cast than older children, and instability leading to pain and immobilization often require operative stabilization. The full theoretical concept of ESIN – the 3‐point concept – is only applicable in transverse and short spiral fractures. Complex, unstable fractures as well as shortened isolated tibial fractures may be treated more safely by external fixation. A specific aspect is the prolonged healing in proximal metaphyseal fractures of the tibia, thus leading to a valgus deformity. In these cases a compression of the metaphyseal area with protection of the physis should be undertaken.

Fractures of the distal tibia belong either to epiphyseolysis with or without metaphyseal fragments (Salter I and II) or to joint fractures (Salter III and IV). Epiphyseolysis only requires the reduction and in a number of cases stabilization with metaphyseal screws with an overall good prognosis. Articular fractures during childhood (Salter III and IV) compromise the joint; however, mostly outside the main load area. These fractures should be reduced and fixed by screws parallel to the physis. In adolescence, these articular fractures are more complex, due to the partial occlusion of the physis, leading to specific fracture patterns. These specific and characteristic fractures should be treated by reduction and screw fixation, in the knowledge that the occlusion of the physis has been started already.

Taken together, fractures of the shaft as well as fractures of the epiphysis and the joint should be interpreted and treated specifically. Age is one responsible factor for fracture type and treatment options. However, tolerance of various axis decreases with age and in general, in children older than 10–12 years an almost anatomical reduction should be intended. Joint fractures with dislocation should always be reduced to prevent arthritis.

Health problems in complex emergencies

REMI RUSSBACH

Geneva, Switzerland

Mortality and morbidity are seriously increased in armed conflicts. Paradoxically, this increase in current conflicts is not due to the direct effect of weapons on the military and civilian population but to the dissuasive effect of weapons used to deprive civilians from their vital resources.

In fact, the risk of dying from a bullet shot or shrapnel is far lower than that of death from malnutrition or infectious disease.

The surgical treatment of war wounds differs from that applied in usual civilian surgery, because all war wounds are potentially infected, a large excision of dead tissue is a must. The large numbers of patients as well as insufficient means make it important for the concept of triage to be well known and implemented by the surgical staff.

If the surgical response in a war situation needs specific training, the other disciplines such as sanitation, nutrition, public health and epidemiology are similar in other kinds of disasters.

The lack of access to essential needs, water (quality and quantity), food, energy ( fuel, electricity), shelters, and to official services (banks, public transport, communications, tribunals, health services) increase the number of medical cases and drastically reduce the effectiveness of the health system.

Medical and humanitarian assistance in armed conflicts is also limited by this lack of access to the right people in the right place and could be targeted by the armed forces (in violation of the Geneva Conventions) considering this assistance as contrary to their hidden aim – this being to cut the population off from its vital resources.

Security constraints and limited access to war zones are seriously disturbing humanitarian assistance. To be of use, the basic conditions require a minimum of security and respect for the health personal, the hospitals and the ambulances. Permanent negotiation with the armed forces involved to obtain these basic conditions is mandatory.

Governmental responses to the tsunami disaster in South‐East Asia: Sweden

STEN LENNQUIST, TIMOTHY HODGETTS

University of Linköping, Sweden and Royal Centre for Defence Medicine Birmingham, UK

Author's email: [email protected]

Background

The tsunami disaster in South‐East Asia December 26 2004 killed 543, and injured more than 1500 Swedish citizens who were on holiday in Thailand. The Swedish Government and authorities were criticized for a slow and insufficient response both in supporting Swedish citizens and the host country Thailand in their difficult task of handling the extensive number of injured, both tourists and citizens from their own country.

Aims

On behalf of the Swedish Parliamentary Commission for evaluation of the Governmental response to the disaster, evaluate specifically the response of the Swedish Health Care system with special reference to:

• The need of support to Swedish citizens and to the host country

• How these needs were met

• If these needs could have been met better

• Consequences of delayed/insufficient support from Swedish Health Care

• Suggestions for improvement in future similar events.

Methods

The following methods were used:

• Structured questionnaires to Thai hospitals

• Structured questionnaires to injured Swedish citizens and Swedish voluntary workers on‐site

• Semi‐structured interviews with representatives of relevant authorities, regional health care centres, hospital command centres and hospital staff in involved hospitals on‐site

• Semi‐structured interviews with Swedish citizens treated for injuries sustained at the tsunami and with volunteer workers involved with supporting the injured

• Semi‐structured interviews with involved authorities and regional hospital command centres in Sweden responsible for receiving injured citizens from the disaster zone

• On‐site visits in the disaster zone.

Results

The load of casualties from the tsunami disaster was extensive in the affected provinces in Thailand. The major hospitals in the Phang Nga, Phuket and Krabi provinces, where the majority of Swedish citizens were cared for, received during the 3 first days after the disaster a total of 11 000 injured, 3000 of these requiring in‐patient care. The total number of available beds in these hospitals was 1400. Almost 1400 surgical operations were performed during the same time in a total number of 33 available surgical theatres.

This load of casualties was unevenly distributed, so that by far the highest load was in the Northern Province, Phang Nga, which also had the smallest resources for health care. Here the needs for medical care far exceeded available resources. It was also difficult primarily to evacuate injured patients from here because of damage to roads, the long distance to the airport and fear of new waves.

The load of casualties remained high during the 4–5 days following the disaster, with a continuous inflow of moderate to minor injuries, many of these early wound infections requiring surgical intervention.

Even if the Thai health personnel did a marvellous work with regard to the circumstances, a need for support from countries like Sweden with a large number of tourists in the area could be clearly defined:

• Early evacuation of injured to release the pressure on the Thai health care system

• Mediation of information between local health care staff and Swedish patients

• Psychological support (many had lost relatives and friends)

• Consulting support in trauma management in peripheral hospitals

• Medical support (staff and equipment) in peripheral hospitals

• Medical support to Swedish patients in assembly areas waiting for evacuation (hotels, airports).

These needs, clearly indicated both by Thai health care staff and Swedish injured, were met very late and only to a very limited extent. Sweden had by far the highest number of injured tourists in Thailand. Many other countries with tourists in the area showed an earlier and more effective response of benefit both for their citizens and for the host country.

Thanks to very competent work by the Thai health care services, the delayed and insufficient response did not lead to any confirmed avoidable loss of Swedish life, but it did lead to considerable avoidable suffering among Swedish citizens and to a lack of a well needed support to the host country.

Conclusions

The late and insufficient response from the Swedish Government and authorities was not caused by the unpredictability of the scenario, lack of experiences from similar scenarios, lack of information from the scene, lack of assessment teams and other resources to send or lack of transport facilities. All this was available, but not properly used, either in planning or in the actual situation. A better response in a similar event in the future does not require a new organization, but it requires staff with competence to make rapid and proper decisions at critical levels. If that is not secured, the risk is apparent for the same failure to occur again, maybe with even more fatal consequences.

Governmental response to the tsunami disaster in South‐East Asia: Finland

ARI LEPPÄNIEMI

Department of Surgery, Meilahti Hospital, University of Helsinki, Finland

Based on the information from representatives of the Finnish Red Cross and private relief agencies sent to Thailand immediately after the tsunami disaster, a group of about 10 or more Finnish severely injured patients treated in Thai hospitals was identified. A decision was made to equip a special aeroplane with intensive care capacity to evacuate these patients as soon as possible back to Finland. The Helsinki University Hospital, Finnair and representatives of the Finnish government (Prime Minister's Office, Ministry of Foreign Affairs, Ministry of Health) were the principal parities involved.

Within 4 hours a Finnair B‐757 aeroplane was transformed into a 22‐bed hospital with 7 intensive care beds (including ventilators) and 15 regular hospital beds. The medical material was collected from the Helsinki University Hospital Material Center and transported to the airport within 6 hours of the evacuation decision. A medical team of 13 doctors (3 surgeons, 9 intensivists/anesthesiologists and 1 infectious disease specialist) and 24 mostly intensive care and operation theatre nurses was called from the Helsinki and Tampere University Hospitals. The team was ready for briefing and departure in 8 hours from the evacuation decision.

The plane left Helsinki 10 hours after the evacuation decision. A close co‐ordination with the local representatives of the Finnish Red Cross and private relief agencies sent to Thailand from Finland a few days earlier ensured that the previously identified patients were delivered to Bangkok and Phuket airports at the expected time of arrival.

On arrival at the Bangkok airport, previously designated treatment teams moved the medical material from the cargo area of the aeroplane to the main cabin and started receiving patients. The loading of the six patients lasted 30 minutes. The flight continued to Phuket where another eight patients (including two on ventilators) were loaded into the plane in 80 minutes.

Before departure of the plane from Phuket, detailed information on the general condition, required level of treatment and evacuation plans from Helsinki airport was communicated to Finland via private mobile phones.

During the flight surgical procedures (external fixation of extremity fractures, fasciotomy, wound excision), that could not wait 12 hours without risking the life or limb of the patients, were performed. Intensive care including ventilator management, blood and blood product transfusions, use of vasoactive drugs and point‐of‐care laboratory tests were performed on the four most severely injured patients treated in the ICU section of the plane.

On arrival at Helsinki airport less than 42 hours from the evacuation decision, the patients were transferred to ambulances and taken to pre‐determined hospitals according to the severity of the injuries and home location of the patients. All patients survived the flight and there were no patients whose condition worsened during the evacuation.

In conclusion, a rapidly equipped temporary aeroplane with sufficient and experienced medical personnel can safely evacuate more than 10 severely injured patients from a long distance provided that close co‐ordination with a team identifying and transporting the patients to the airport can be established.

Disasters affecting citizens in foreign countries. Part I: Governmental response to the tsunami disaster in South‐East Asia – Germany

ULRIKE WAGNER

Medical Services of German Airforce, Cologne, Germany

After the seaquake in South‐East Asia on December 26 2004, the numbers of injured and killed people were corrected many times, nearly meticolous in ever‐increasing numbers of victims. Even then the first messages and information from the catastrophe reached Germany, the Federal Ministry of Defense and the national Patient Evacuation Coordination Center started planning a strategical aeromedical mission, to repatriate heavily injured German or European people back to Europe, especially back to Germany.

In the following days three missions of aeromedical evacuation by an specialized airbus A310 from the German Airforce, deployed in Cologne, evacuated a total of 133 patients from 8 nations during the period December 28 2004 to January 4 2005. In expecting more than one rotation, the Patient Evacuation Coordination Center provided a second MedEVac‐Airbus from the Airbus A310 MRT (multi‐role transporter) from the flying group in Cologne, usable up to December 31 2004. Four medical crews with more than 140 soldiers from the German Airforce and the Joint Medical Service were on standby or rather in action.

After landing back in Germany the civilian part of second transport of the patients was organized hand in hand with the military side of the chief of emergency physician of the city of Cologne. Some patients were airlifted to hospitals within Germany or to nearby European cities, most of them were transported by ambulance cars to hospitals in the area from Cologne and Bonn for the connecting care.

It will be shown in the report, how to start effective working with a first absolutely unstructured flood of information in case of such a disaster, a great number of affected persons and an extremely high effort of coordination with all concerned institutions, military, national and internatonal groups for a good result for the patients to be under medical intensive care treatment and evacuated as quickly as possible in a mission. This mission took the medical crew to the limits of its physical and of course its psychic strain and fatigue capacity. Thanks to good planning in the run‐up and in‐flight, enormous team spirit and a needful pinch of luck, the Airomedical System has worked as well, again. Based on the lessons learned, clear procedural systems must be developed, of course worldwide in international frames.

Disaster affecting citizens in foreign countries. Governmental response to tsunami disaster in South East Asia: Italian experience

M ESPOSITO

ARES, Ancona, Italy

At 07.58 am on 26 December 2004, a tremendous earthquake, measuring 8.9 on the Richter scale, caused a tsunami which devastated a large area of South East Asia and a few smaller regions of Africa. At 10.30, local time, the tsunami reached the West cost of Thailand, in particular Phuket Island, where a lot of European tourists were spending their Christmas time.

As many others, the Italian Government immediately decided to send relief to the affected area. The National Civil Protection (NCP) asked the Marche Regional Government, through the Regional Civil Protection (RCP), to send its sanitary facilities and a team of logistic and sanitary professionals by ARES. This association, which works in convention with the regional and national Government, was already involved in other situations of disaster and sent professional volunteers (MD and nurses) with disaster training and specific specializations (emergency, anaesthesiology, surgery, internal medicine, orthopaedics, gynaecology).

We left Ancona at 3.00 am on 27 December, 5 hours after the NCP activation, with the sanitary material, to Rome military airport. We departed from Rome at 12.00 (the weather was very bad in the morning and we had to wait 5 hours at the airport!). The aircraft was a Boeing 707 provided by the Italian Military Force. We arrived at Phuket at 10.00 pm, Italian time, on 27 December 2004.

Our team consisted of five NCP officers, two logistics of RCP and the sanitary staff which consisted of three medical doctors and three paramedics, all members of ARES association.

We had an equipment comprising 3 pneumatic tents, 30 beds, sanitary materials for about 150 serious patients and 150 non‐serious patients (as indicated in NCP guidelines for II° level of advanced medical point). In our supplies there were two ventilators, one monitor defibrillator and three automatic defibrillators, oxygen, six pulse oximeters, all the necessary materials to reanimate and intubate serious patients and for medications and a little surgery; drugs for principal problems. We also had one generator group, portable radios and a satellite telephone, water and some food for immediate survival.

We did not know anything about what kind of emergency was present at the moment in the place we were going to, but after a meeting with the NCP chefs, who had arrived some hours before us, we understood that our mission was to recognize every Italian injured person present in the hospitals of Phuket region and in other regions of Thailand, in order to treat and transfer them to Italy.

We formed three sanitary teams, each of them consisted of a doctor and a nurse, who had a sanitary bag with supplies to treat and reanimate serious patients. One of our teams reached the North of Phuket Island after they had travelled for many hours and looked for injured Italian people without assistance or recovered in hospitals or dead.

We controlled every day about 11 hospitals and we treated about 50 injured people. We also transferred some critical patients via Thailand military helicopters from Krabi to the Phuket hospital. When possible, we transferred the patients from Thailand hospitals to our base in a hotel in Patong (Phuket Island), where we had created an ambulatory for medications and first aid. We also had some rooms used as recovery for Italian people who were not intensively injured. We used these rooms until all these people were transferred from Thailand to Italy.

The Italians who were in good health conditions also used to come to this centre, ready to fly back to Italy on aeroplanes provided by the Italian Government.

On 30 December a Boeing B777 with 86 passengers on board departed from Phuket. Among them there were also 11 injured patients, 3 of them on stretchers, assisted by sanitary staff of ARES and later transferred, by domestic flights, to Cervia, Venice and Milan.

After 4 days of stabilization in local hospitals or in our sanitary base, the last injured patients departed from Phuket on January 3, 2005: they were assisted, nobody was ventilated, but two patients had oxygen, during the flight, up to their destinations – the hospitals of Milan, Venice and Bologna.

In total we evacuated from Thailand about 50 injured people and 220 people without injuries. In Thailand we left two logistics of NCP and a sanitary team with a doctor and a nurse, ready to help possible new patients and to provide assistance to the forensic Italian technicians who were working on the identification of the deceased in Thailand. On 8 January they also returned to Italy. The NCP contemporarily operated in three countries of this area: Thailand, Maldives and Sri Lanka. In Sri Lanka, after the phase of the assistance to the tourists and the search for survivors, it operated for the assistance and help to the local population too. As a final result, the NCP organized the transport of 4308 passengers, among which there were also many Europeans, to the Italian airports.

Considerations

As in every emergency situation, time plays an essential role, but it is hard to think of achieving a mission so far away and in such a short time. We think it is a good result to have activated our sanitary supplies for an intervention 8000 km away within 5 hours, with complete equipment. This is the result of a long job both of education of the sanitary staff about disaster medicine and of organization of the materials that can be useful in any emergency, We reached this result thanks to the integration of the specialized sanitary staff with the institution, of the Regional Civil Protection of Marche and with the Department of the National Civil Protection. A particular help was offered by the Italian residents in Thailand, who immediately collaborated with their cars, transporting our sanitary staff to the hospitals, also driving for long distances, as well as making contacts with the local authorities easier and helping to solve logistic problems.

Our ability to change our mission according to the situation was also very important: when we left we thought we were going to manage a little field hospital, helping a large number of patients. We looked for them in a vast territory, with a classic action of search and rescue, to guarantee them a suitable sanitary treatment and an express repatriation. The biggest difficulties were represented by the communication among the different teams, the local language and the necessity to go around in an unknown territory. The disaster medicine doctrine foresees this ability of adaptation: also departing from the fundamental principles of emergency medicine, it manages the clinical cases in the context of the general situation. This let us recognize what must be done in different situations.

The mission of ARES is:

1. Forming those professional people who intend to offer their help in disaster situations.

2. Informing all professional sanitary people about what must be done in every disaster situation (also including any possible disaster which may occur in our countries).

Emergency care at the terrorist attack in Beslan, North Ossetia, Russian Federation, 2004

JOHAN VON SCHREEB¹, AZRET KALMYKOV², LOUIS RIDDEZ³, HANS ROSLING¹

¹Department of Public Health Sciences, Division of International Health, Karolinska Institutet, Stockholm, Sweden, ²Department of WHO Office, Nazran, Russian Federation, ³Department of Surgery, Karolinska University Hospital, Stockholm, Sweden

Introduction

On 1 September 2004, >1300 people were taken hostage in a school in the town of Beslan in North Ossetia, Russia. The crisis ended 52 hours later in extreme violence with gunshots, grenade explosions and fire that directly killed 329 persons, including 164 children, and injured many hundreds. As external assessors we rapidly assessed the medical care provided to the injured.

Results

We found that more than 500 doctors, 1000 regular hospital beds and 100 intensive care beds were well prepared to care for the victims at 4 hospitals situated within 20 km of the school in Beslan. In the rapidly unfolding emergency, with many hundreds of injured people, only limited on‐site triage was carried out. Civilians took the majority of injured directly to the hospitals in private cars despite 57 ambulances being available at the site. Following a few chaotic hours adequate emergency care was available to all the injured. Of the 661 hospitalized victims, 110 required intensive care. Seven deaths were recorded during the first 24 hours and 12 more during the next 6 days, yielding a case fatality rate of 3%. Within 7 days all 110 injured patients in intensive care had been adequately evacuated to more specialized care in Moscow or Rostov. In contrast to earlier emergencies, Russia requested international assistance and up to 11 September, 15 cargo planes from 10 countries delivered medical materials, drugs and food to Beslan, but an estimated 70% of the drugs were deemed inappropriate. Substantial amounts of toys and other goods were delivered to aid the victims. Within a month private initiatives also raised more than 30 million USD in cash, mainly from Russian sources. Following the first week of emergency care the focus in Beslan was to provide psychosocial support through a variety of national and international initiatives.

Conclusion

We conclude that the medical emergency care was well handled by local and national health staff under the coordination of the Ministry of Health and the Russian Ministry for Civil Defence and Emergencies (EMERCOM). The international response was largely in excess and not adapted to the local needs, probably because the international community underestimated the local and national capacity and the Russian authorities underestimated the international willingness to help.

Experiences from the 2005 earthquake in Kashmir

JOHAN VON SCHREEB, NIKLAS KARLSSON, HANS ROSLING

Department of Public Health Sciences, Division of International health IHCAR Karolinska Institutet, Stockholm Sweden

[Material based on data collected by JvS in his capacity as medical coordinator for Medecins Sans Frontieres Belgium in Kashmir]

Background

On October 8, 2005 at 08.50 an earthquake (EQ) measuring 7.6 on the Richter scale struck Pakistan's North West Frontier Province, the Pakistan‐administered autonomous state of Azad Jammu and Kashmir (AJK), and part of Indian Kashmir. The affected area was approximately 30 000 square km, (two‐thirds the size of Switzerland) and had a population of 3–4 million. The Kashmir EQ qualifies as the fifth largest earthquake in terms of number of affected and as the seventh most deadly earthquake in the last 100 years. An estimated 60 000–70 000 people died and an equivalent number of people were wounded.

Due to the massive destruction of infrastructure and the politically sensitive location, access to the EQ area was initially limited for international relief agencies. Data on size and location of the affected population and their needs was scarce. In combination with only limited international pre‐EQ aid activities in the area and lack of detailed maps it was challenging for international relief agencies to set up and target their interventions.

The international humanitarian organization Medecins Sans Frontieres (MSF) rapidly started relief activities in three of the most affected districts. MSF Belgium (MSF‐B) started to work at the district hospital and at two health centres in Bagh district on October 13. To better target the intervention MSF‐B conducted a survey among the EQ‐affected population in Bagh tehsil (subdistrict), focusing on the impact of the EQ and the perceived priorities of needs.

We present findings from 196 semi‐structured interviews conducted in Bagh tehsil, discuss methodological challenges for needs assessments following EQs and report experiences and challenges from the initial relief work in Bagh.

Methodology and results

Using a one‐page semi‐structured questionnaire we interviewed haphazardly selected visitors to the health facilities where MSF‐B was providing assistance. Those interviewed came from all over Bagh tehsil, which had a pre‐EQ population of 225 000. The 196 interviewees represented 1847 household members from all parts of the tehsil. They reported 61 EQ‐related deaths (3.8%), equally divided between men and women, while a total of 70 (3.7%) were reported as severely wounded. Only 7% reported that they could use their house for sleeping and consequently the main concern reported by 99% of the respondents was lack of shelter. Only 8% of those interviewed had access to any form of heating system, while 40% reported not having any blankets in the household. A total of 90% reported having access to multiple types of food, mainly rice, flour and pulses. Sufficient food was reported for a mean of 9 days.

Discussion

We found our results on mortality and injuries to correspond well with those from an exhaustive house‐to‐house survey done by the Pakistan Army in Bagh tehsil, reporting 2.9% mortality and 3.4% wounded. The MSF assessment, although lacking a random sampling framework, turned out to provide representative EQ impact results. The explanation for this is not clear but it could be that free quality health care attracts a representative sample of the population. Among the perceived needs of those interviewed, the lack of shelter was without doubt the main concern. The result from the survey was useful for adapting the operational focus of MSF‐B intervention. It reinforced the focus on the supply of winterized shelter.

We observed that humanitarian assistance was provided by a multitude number of actors, making coordination very difficult. We recorded four emergency‐focused field hospitals within 4 weeks after the EQ, deployed without prior needs assessment or coordination, while the need for their service was largely over when they became operational. The experience from Kashmir highlights the challenges to provide adequate and needs‐based humanitarian assistance following an EQ. This requires not only experience and coordination but also data on the geographical distribution and needs of the affected population and a clear understanding of the changing needs in different phases following an EQ.

The terrorist attack in Madrid

TORE VIKSTRÖM

Centre for Teaching and Research in Disaster Medicine and Traumatology, University Hospital, Linköping, Sweden

Author's email: [email protected]

On the morning of March 11, 2004, explosive charges detonated on four different trains in the city of Madrid with only minutes between each explosion. The Emergency Call Centre in Madrid was alerted directly by people on the separate disaster scenes within 10 minutes, and received the first alarm at 7:39, which concerned the first explosions at the Atocha station in the centre of Madrid. When this alarm came in, all available personnel and equipment were sent to the scene. Within minutes it was clear that there were four different disaster scenes and re‐arrangements of resources took place.

The switching of personnel in rescue and hospital units took place at 8.00. This meant that personnel from two working shifts were available early in the rescue process. In this organization work is done initially by prehospital personnel from two main cooperative organizations: SAMUR and SUMMA 112, with a total of 1400 people which partly consist of: 316 medical officers and 213 trained nurses. The two organizations are in charge of over 303 vehicles, 56 of them being ALS ambulances, plus 2 helicopters.

The first unit reached the disaster scene of Atocha 7 minutes after being alerted, and the first critically injured patient was transported 23 minutes after SAMUR had arrived at the disaster scene. Before then a great number of injured people had been able to get to a hospital by themselves, by taxi or by private vehicles. Assembly points were established where injured people could be stabilized before transport to hospitals. The general idea was that by doing this, lives were saved and it also relieved the pressure on the ERs, since the injured had been primarily stabilized at these assembly points. However, the rescue work became more difficult when two undetonated explosive charges were discovered. This led to an interruption of the rescue work and the area was evacuated while the objects were taken care of by the police. SAMUR's own Command Central held contact with the disaster scenes and the hospitals through the radio systems otherwise used on a daily basis. At the hospitals there is radio equipment in the ICU and/or in the ER. There was no direct communication with the hospital management, but the reports from the hospitals showed that the ability to attend injured patients was adequate. No overall distribution key of injured was made, and this led to an uneven distribution of patients and their transport to different hospitals. Spontaneous evacuation of injured (estimated to be approximately 30% of all those injured), combined with a high inflow of patients to the larger hospitals, meant that the workloads on the key functions of the hospitals at times were pretty heavy. Although, there was never a lack of hospital resources, including intensive care resources.

The terrorist attack on March 11, 2004, in Madrid was the most severe incident in Spain and Europe in modern times, with a death rate of 191 and 1500 wounded. Nevertheless, it looks as if there are plenty of prehospital resources and competence in the region of Madrid, such as the organizations mentioned above. All the injured were taken care of and transported within 2 hours and 25 minutes. There was never a need to send hospital personnel out to the disaster scenes.

Prehospital care: less is more

MOISHE LIBERMAN

Department of Surgery, McGill University Health Centre – Montreal Quebec, Canada

Background

Prehospital care for trauma patients is provided by emergency medical personnel using either Basic Life Support (BLS) or Advanced Life Support (ALS) techniques. BLS for the seriously injured trauma patient most notably involves ‘scoop and run’, in which medical interventions are performed while en route to an appropriate hospital. These interventions are non‐invasive and include wound dressing, immobilization, fracture splinting, oxygen administration, and non‐invasive cardiopulmonary resuscitation. ALS encompasses all of the previously mentioned BLS techniques in addition to minimally invasive procedures such as endotracheal intubation, intravenous access for fluid replacement, and administration of medications. System protocols often dictate that ALS providers ‘stay and play’ at the scene of a serious trauma in order to carry out these more advanced procedures.

The rationale for the use of on‐site ALS in trauma is that these interventions will reduce the rate of physiological and haemodynamic deterioration, thus stabilizing the patient before arrival at the hospital. It is expected that this will subsequently result in increased chances of survival. The paradox is that on‐site ALS increases the amount of time that is spent on the scene, and hence increases the delay to definitive in‐hospital care.

Controversy and literature

The controversy regarding the prehospital care of trauma patients between ALS and BLS is ongoing. Due to this unresolved controversy, as well as historical, cultural and political factors, significant variations exist in the prehospital care available to trauma patients. Prehospital care throughout the world is therefore inconsistent and is provided in different ways by different crews with different equipment, protocols, and training. The presentation will focus on the controversies that occur in the urban setting with regard to the overall approach to prehospital care as well as for specific prehospital interventions. The discussion will consist of an evidence‐based approach to the topic of prehospital care and topics discussed will be based on past and current literature.

A meta‐analysis of peer‐reviewed studies concerning prehospital trauma outcomes between 1966 and 1998 concluded that for patients receiving ALS compared to those receiving BLS the odds ratio for dying was 2.59. This odds ratio was adjusted for strength of study methodology. The crude odds ratio is 2.92. The mean on‐scene time for ALS‐treated patients (number of patients = 11 323) was 18.5±3.8, and for BLS patients (n = 4784) was 13.5±2.4 minutes (p = 0.005). The overall conclusions of this meta‐analysis support the ‘scoop and run’ approach – the aggregated data in the literature failed to demonstrate a benefit for on‐site ALS provided to trauma patients [1].

To try and shed some light on this controversy, we conducted a multicenter Canadian study of prehospital trauma care, which was completed recently [2]. This was undertaken to evaluate whether the type of on‐site care a trauma patient receives affects outcome. The study consisted of a prospective cohort study comparing three types of prehospital trauma care systems. Montreal, where physicians provide ALS (MD‐ALS), Toronto, where paramedics provide ALS (PMD‐ALS), and Québec City, where emergency medical technicians provide BLS only (EMT‐BLS). The study took advantage of this variation to evaluate the association between the type of on‐site care and mortality in patients with major life‐threatening injuries. All patients were treated at highly specialized tertiary (level I) trauma hospitals. The main outcome measure was death as a result of injury and follow‐up was to hospital discharge.

The overall mortality rates by type of on‐site personnel were: physicians, 35%; paramedics, 24%; EMTs, 18% (p = 0.001). For patients with major but survivable trauma, the overall mortality rates were: physicians, 32%; paramedics, 28%; and EMTs, 26% (p = 0.001). The overall mortality rate of patients receiving only BLS at the scene was 18% when compared to 29% for patients receiving ALS (p = 0.001). For the subgroup of patients with major but survivable injuries, the mortality rates were 30% for ALS and 26% for BLS. The adjusted increased risk for mortality in patients receiving ALS at the scene was 21% (p = 0.01). We concluded that in urban centers with highly specialized level I trauma centres, there is no benefit in having on‐site ALS for the prehospital management of trauma patients.

Prehospital endotracheal intubation for head‐injured patients has also recently come into question in the literature. Bochicchio et al. have shown that prehospital intubation in traumatic brain‐injured patients is associated with a significant increase in morbidity and mortality [3]. Fakhry et al have recently shown a mean increase in prehospital scene time for rapid sequence intubation of 6 minutes [4]. This calls into question the necessity of these interventions in urban settings where transport times to hospital are short.

Advanced versus basic prehospital trauma care has long been debated in the medical literature; however, advanced prehospital care has been almost universally accepted as the ‘gold standard’ for the care of the prehospital cardiac arrest patient. However, as external automated defibrillation (AED) has become more readily available and is now considered a BLS technique in many EMS systems (some systems still classify it as an ‘intermediate’ prehospital skill), the advantage of ALS in the prehospital treatment of cardiac arrest has begun to be re‐examined. Steill's group has clearly demonstrated that the addition of ALS to a system with a rapid defibrillation program does not improve survival to hospital discharge (BLS survival = 5.0%, ALS survival = 5.1%, p = 0.83) [5]. This challenges a concept that has widely been accepted by most as the untouchable standard of care and calls into question the advanced care of injured patients in the prehospital setting even further.

Conclusion

There is no convincing evidence that prehospital advanced life support in the urban setting provides any benefit to injured patients in terms of either morbidity or mortality. In fact, most of the evidence available suggests that it may be deleterious to the injured patient. In a 2006 review of all available literature concerning advanced prehospital trauma care, the Cochrane Injuries Group concluded that: ‘In the absence of evidence of the effectiveness of advanced life support, strong argument could be made that it should not be promoted outside the context of a properly concealed and otherwise rigorously conducted randomised controlled trial’ [6].

Questions to be discussed

• Is there a proven advantage to advanced prehospital care for trauma patients?

• Do head‐injured patients benefit from advanced interventions?

• Do blunt trauma patients benefit from advanced interventions?

• Do penetrating trauma patients benefit from advanced interventions?

• Is there an advantage to advanced techniques in the rural versus urban environment?

• What is the cost of advanced prehospital care?

• Does advanced prehospital care increase scene time and if so, by how much?

• What is the future of prehospital care for injured patients?

The benefit of advanced prehospital care

POUL KONGSTAD

KAMBER, Lund, Sweden

Prehospital care is undergoing a rapid transformation in most countries towards being a profession involving specialized teams of paramedics, nurses and physicians.

This development springs from the subspecializing of the health care system. This can be clearly seen in trauma care, where many hospitals not unwillingly receive trauma patients because of the inability to diagnose and treat this group sufficiently. Several trauma systems with early triage have been built up. Twenty years ago most trauma patients were transported to the nearest hospital, but today, with the need for more additional diagnostic evaluation early in the health care chains, trauma patients are directed to higher‐level trauma centres. The prehospital organizations face rapidly increasing demands for early and secure diagnostic skills due to the growing geographical distance between hospitals with adequate trauma care.

As trauma care is one of the most specialized, multidisciplinary and expensive disciplines, systematic change in the health care organization can clearly be defined for the trauma patient, but these experiences will also be realized for other critically ill patients. The lecture will discuss prehospital diagnostics from a wider perspective with modern trauma care in focus.

Prehospital methods of airway management

T NÆSHEIM

Department of Anaesthesiology, University Hospital Northern Norway, Tromsø, Norway

Background

Even short periods of apnoea may cause death despite an otherwise survivable injury. Tracheal intubation has been preferred for prehospital airway management because of its protection of the lungs against aspiration. However, tracheal intubation is a relatively difficult skill to acquire and maintain. Randomized prehospital studies of tracheal intubation compared to less invasive airway methods have not shown significant differences in outcome.

The laryngeal mask airway (LMA) is an alternative to mask‐bag‐ventilation and orotracheal intubation. Training in use of the LMA is quicker and easier than for tracheal intubation and also offers some protection against aspiration compared with mask‐bag‐ventilation.

The Combitube is a double lumen tube. The tube is generally passed into the oesophagus and offers ventilation of the trachea between an upper supraglottic cuff and a lower oesophageal cuff. Success rates of placement by paramedics tend to be higher compared with orotracheal intubation and LMA

Discussion

Morbidity after unidentified oesophageal intubations is unlikely to be counterbalanced by the marginal benefit the tracheal intubation might offer over other methods of airway management. LMA and Combitube are excellent alternatives. Given limited opportunity for training, these methods are probably easier to master, and safer for the patients.

The diagnostic and therapeutic evaluation of saline infusions in prehospital care

POUL KONGSTAD

Kamber, Lund, Sweden

Hypotensive resuscitation is recommended for most trauma patients except neuro‐traumatized patients. The reason for this in modern trauma care is often said to depend on known factors, for example, the coagulation might be threatened by high blood pressure in areas of bleeding, dilution and hypothermia. It is also often mentioned that the beneficial constriction of peripheral vessels in the shock situation is disturbed by aggressive fluid treatment.

In the prehospital segment of trauma care the main question remains unanswered; when should the trauma patient receive aggressive fluid treatment according to the ATLS/PHTLS concept? Can the balance between dangerous hyper‐resuscitation and beneficial hypotensive resuscitation be achieved in the prehospital setting or is it impossible just using your clinical judgement? The lecture will put some clinical key features into discussion and also interpret the diagnostic part of giving a bolus of intravenous fluid to trauma patients.

The Helicopter‐Borne Intensive Care Unit in Uppsala, Sweden

JOHANN VALTYSSON

Helicopter Services, Uppsala, Sweden

Uppland, or Uppsala County, located in the middle of Sweden, has an area of 12 764 sq km and the population is 1.2 million people. Most of the people live in and around the bigger cities of Stockholm and Uppsala. Aside from the city areas, the regions are thinly populated, dominated by rural areas and the people living there may have to travel long distances to the nearest hospital. In 1985 an Ambulance Helicopter Service started in Uppsala, in collaboration between the Helicopter Rescue Division in the Swedish Air Force and anaesthesiologists from the Department of Anaesthesiology and Intensive care at the Uppsala University Hospital. At first, this service worked during office time or from 8 am to 15 pm Monday to Thursday and Friday between 8 am and 12 am. The criterion for calling the service was accidents or serious medical conditions with a distance of >10 km from the nearest ambulance station. In case of a major trauma or severely ill children it was also possible to call the helicopter at shorter distances than 10 km. In the beginning the helicopter service performed about 50 missions per year, but at the end of the 1980s the number of missions decreased dramatically. During the same time period the number of accidents including personal damage increased. The reason for the reduction in missions is not clear but could be explained by the fact that the helicopter service was seldom used, and was only available during limited hours, and so personnel forgot to call the helicopter. In order to create a helicopter service that works, the first thing to do was to improve the routines for the alarm operators. One way to do so was to introduce a daily test alarm. Thereby the alarm operators were made aware of the existence of this service. The second thing to do was to increase the accessibility of the service and make the helicopter available 24 hours, 7 days a week. To increase the number of missions other kinds of tasks were also needed.

Uppsala University Hospital provides specialist care for a large region of Sweden which means that severely ill patients are transported to and from the hospital on a daily basis. The transportations are often long distance and the patients have to be transported in an ambulance, often for several hours. These transportations were most suitable for a helicopter service.

In 1993, Uppsala University Hospital established the Helicopter Borne Intensive Care Unit (HBICU) in collaboration with a civilian helicopter company to provide the region with 24‐hour accessibility. For security reasons, the helicopter has a two‐pilot system. The tasks for the HBICU was in the beginning: 1) intensive care transportations, 2) primary ambulance service within the county, and 3) search, but the latest is now taken care of by a special search and rescue organization. There is always one anaesthesiologist and one intensive care/anaesthetic nurse on board. To maintain the experience and skills of the medical team the group was limited to 10 anaesthesiologists and 10 nurses specially trained for air‐borne transports and prehospital missions. The helicopter contains advanced intensive care equipment for full intensive care from one hospital to another. A neonatal team is also associated with the HBICU, comprising paediatricians and neonatal nurses for transport of infants in incubators. In the near future the helicopter will also have the possibility to carry patients in ECMO.

During the first 9 months after the start in 1993 the HBICU fulfilled 120 intensive care transports and 198 ambulance missions in Uppsala County. Intensive care transports have increased since then. During the same time ambulance missions have decreased until the last 2 years when they started to increase again after we started cooperation with Stockholm. Last year the HBICU fulfilled 600 missions: 326 intensive care transports, 111 transports of infants in incubators and 163 primary ambulance missions in Uppsala County and Stockholm. The motto for the organization has always been ‘Scientia, Securitas et Velositas’ or ‘Knowledge, Security and Speed’. Today the HBICU provides the Uppsala region with acute ambulance transportations, and the region and nation with highly qualified intensive care transportations, all over Sweden and when needed between the Scandinavian countries.

Organization and performance in the trauma room. Experiences from different settings – the Turkish model and experience

KORHAN TAVILOGLU

Istanbul University, Istanbul Medical School, Department of Surgery, Trauma & Emergency Surgery Service, Istanbul

Author's email: [email protected]

The trauma team in Turkey consists of several members and disciplines as in several countries. These members are: trauma team leader, airway managing doctor, procedure doctor, circulation nurse, orthopedic doctor, neurosurgery doctor, radiographer, and registration clerk. The trauma team leader may be of several disciplines, but is the general surgeon in most circumstances; other disciplines may also coordinate, such as emergency medicine or anesthesiology. The trauma leader is generally observing and coordinating the team. The leader also provides the communication between the trauma room and the operating room, intensive care unit, other disciplines or radiology suite. The airway managing doctor may be an emergency doctor, practitioner, anesthesiology doctor or a general surgery doctor. The procedure doctor applies all required catheters to the patient, and considers ultrasound exam of the patient. The circulation nurse is aimed to have vast experience and knowledge in the field of trauma. The orthopedic doctor, neurosurgery doctor and anesthesiology doctor are generally present in the ER in many hospitals. The radiographer is present on the field, conventional X‐rays and ultrasound may be applied on site; however, the patient is usually transferred for CT to another sector, but in limited centers CT is present at the same sector. The models may vary in university hospitals and state hospitals in many regions of the country.

The impact of drug abuse in trauma management

JAN‐ERIK KULL

Lund University Hospital, Sweden

Amphetamine

Background: An indirect sympathomimetic with both alfa‐ and beta‐effects. It causes increased release of catecholamines and inhibition of their reuptake, leading to increased alertness and decreased fatigue, improved ability to concentrate, euphoria, decreased need of sleep and appetite suppression.

Chronic use leads to depletion of depots and down‐regulation of catecholamines – a very essential issue when it comes to trauma and anesthesia. This can give rise to refractory hypotension – inability to respond physiologically to hypovolemia and venodilatation by induction of anesthesia. There is furthermore an attenuating response to direct acting vasopressors such as ephedrine – use phenylephrine and norepinephrine instead!

Amphetamine also has medical indications: narcolepsia, MBD/ADHD and adipositas

An overdose can lead to anxiety, psychosis, CNS irritability (hyperactivity, hyperreflexia and seizures), proteinuria (the combination with convulsions makes this an important differential diagnosis to pre‐eclampsia), hypertensive crisis and intracerebral hemorrhage.

Special considerations for anesthesia: An acute influence means increased MAC (minimum alveolar concentration) for gases, although a chronic influence means reduced MAC.

Avoid spinal/epidural due to risk of hypotension. There is a risk of unexpected postoperatively hypotension and an attenuated response to ephedrine – use norepinephrine or phenylephrine instead. Intra‐arterial blood pressure monitoring is recommended. Avoid hemodynamic instability by careful titration of drugs.

Conclusion: Depletion of depots and down‐regulation of catecholamines means risk for refractory hypotension with inability to respond physiologically to hypovolemia.

Cocaine

Background: Cocaine is derived from the Coca shrub from South America. It has traditionally been used to increase endurance and reduce pain. It is metabolized by plasma choline‐esterase.

Cocaine stimulates CNS by excitatoric amino acids: glutamate and aspartate, with the desired effects of excitement, euphoria and increased alertness. It also inhibits the reuptake of norepinephrine, dopamine and serotonine, which stimulates the sympathetic nervous system.

Cocaine causes sympathetic nervous system stimulation (SNSS), leading to peripheral vasoconstriction, dysrhythmias, mydriasis (dilated pupils), hyperthermia and myocardial ischemia with angina and myocardial infarction.

A cocaine overdose can lead (by SNSS) to uncontrolled hypertension, intracerebral hemorrhage, pulmonary and cerebral oedema, angina pectoris and platelet aggregation.

Cocaine causes, through the platelet aggregation, a functional thrombocytopenia.

Cocainists die of apnea, seizures, dysrhythmias (including ventricular fibrillation), rhabdomyloysis (muscle necrosis) and metabolic acidosis.

Cocaine also has pharmacologic use: a local anesthetic (by blocking sodium channels) and a vasoconstrictor. This means that it is very useful for nose and throat surgery.

Special considerations for anesthesia: Avoid drugs stimulating the sympathetic nervous system like ephedrine, norepinephrine, ketamine, atropine and halothane. There is a risk of ventricular dysrhythmias and VF. The patients are sensitive for myocardial ischemia. They should be deeply anesthetized. Avoid spinal/epidural due to thrombocytopenia. Intra‐arterial blood pressure monitoring is recommended. Like cocaine, an acute influence means increased MAC for gases, and a chronic influence means reduced MAC.

Conclusion: Cocaine causes an excessive sympathetic response to hypovolemia and light anesthesia, with severe peripheral vasoconstriction and unmeasurable BP, worsened by

giving dopamine/epinephrine.

Ecstasy

Background: methylenedioxymethamphetamine (MDMA) is a synthetic amphetamine derivate and used as a dance‐ and sex‐drug.

It was initially used as an appetite suppressant drug, but was later used as an antidepressive agent. However, it was prohibited by the US FDA due to neurotoxicity.

Ecstasy causes a depletion of depots of norepinephrine, dopamine and serotonin – the latter accounts for the neurotoxicity by destroying the serotonerge nerve terminals.

Initially it has a stimulating effect due to norepinephrine and dopamine that accounts for the following symptoms: tachycardia, mydriasis, increased muscle tonus (trismus, rigidity), akathisia, agitation, nausea, diarrhea, excessive sweating and anxiety. Soon this is followed by the desired serotonin effects: euphoria, energy and a wish to be social and loyal.

Ecstasy has a number of deleterious complications: not only the same as for cocaine and amphetamine, but also toxic hepatitis, liver necrosis and hyperthermia. Serotonin influences heat production. By inhibiting the serotonin reuptake it increases intracellular calcium, which prevents mitochondrial respiration, i.e. to build ATP (cell fuel) and instead producing heat. This will trigger rhabdomyolysis and convulsions and start cascade reactions – releasing cytokines and free radicals that give rise to SIRS reaction with DIC and MOF.

The hyperthermia is the most important predictor for lethality. There might be a genetic predisposition for heat stroke among those who are affected. Sometimes the patients have only taken 1–3 tablets; however, they can have used the drug earlier without any problem.

Special considerations for ICU: Use dantrolene if temperature is >39°C (1 mg/kg < 3–4 mg/kg in total) combined with internal and external lowering of temperature. The hypovolemia might be severe and need aggressive treatment. Seizures are frequent and need to be treated, sometimes with relaxation. Use active charcoal, alkalinization of urine (u‐pH 6–8), give forced diuresis and droperidole (serotonin receptor blocker)

Conclusion: Fast and aggressive treatment of hyperthermia!!!

Further reading

Anesthesia and co‐existing disease. Stoelting (general).

Anesthesia & Uncommon Diseases. Benumof (general).

Intensive Care Med 2004;30:1526–36 (general).

J Clin Anesth 2003;15:382–94 (general).

Anesth Analg 2000;91:758–9 (amphetamine).

Ann Intern Med 1991;115:797–806 (cocaine).

Can J Anesth 1993;40:2:160–4 (cocaine).

Anaesthesia 1992;47:686–7 (ecstasy).

Lancet 1992;340:384‐87 and 725–6 (ecstasy).

Anaesthesia 1993;48;1057–60 (ecstasy).

Anaesthesia and Intensive Care 1997;25:No. 2 (ecstasy).

Anaesthesia 1993;48:83 and 179–80 (ecstasy).

Anesth Intensive Care 1997;25:156–59 (ecstasy).

Intensive Care Med 1996;22:670–1 (ecstasy).

Pain relief

PETER DAHM

Department of Anaesthesiology and Intensive Care, Pain Section, Sahlgrenska University Hospital, Gothenburg, Sweden

Author's email: [email protected]

Pain definition

Pain is defined by the International Association for the Study of Pain (IASP) as ‘an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage’. Inability to communicate verbally or in other ways (i.e. a trauma patient) does not negate the possibility of an individual experiencing pain. Acute pain is defined as ‘pain of recent onset and probable limited in time duration. It usually has an identifiable temporal and causal relationship to injury or disease’. Acute pain is a symptom that signals real or imminent tissue damage. Pain treatment is required not only for ethical reasons but to modify the response of the injury. The magnitude of the injury response is often proportional to the degree of the tissue damage. The injury response leads to physiological as well as psychological changes.

The physiological response of pain

The physiological response results in changes in both the peripheral and the central nervous systems. The evoked stress leads to a systemic metabolic response due to the release of neuroendocrine hormones and the local release of cytokines at the site of injury, leading to alternations in all major organs. Sympathetic efferent nerves can be activated by pain stimuli. This could lead to increased heart rate, inotropy and blood pressure, which may induce increased myocardial oxygen demand and reduce myocardial oxygen supply. In patients with pre‐existing cardiac disease this increases the risk of cardiac ischemia. Increased sympathetic activity may also reduce gastrointestinal motility and contribute to ileus. Severe pain also contributes to an inability to cough and a reduction in functional residual capacity resulting in atelectasis and ventilation‐perfusion abnormalities, hypoxemia, and an increased incidence of pulmonary complications. The stress response also contributes to a suppression of cellular and humoral immune function and a hypercoagulable state. Patients at greatest risk from acute unrelieved pain are the young and elderly and patients with concurrent medical illness. Current studies have shown reduced respiratory problems with adequate pain relief but have not shown a reduction in mortality.

The psychological effects of pain

The psychological effects of acute pain are just as harmful although they may be less obvious. These changes have received less attention than those of chronic pain. Failure to relieve acute pain may result in increasing anxiety, inability to sleep, demoralisation, a feeling of helplessness, loss of control, and inability to think and interact with others. In the most extreme situations the patient can lose their autonomy. In some forms of acute pain psychological and environmental responses in the acute phase may be major determinants of progression to persistent pain.

Acute pain can develop into chronic pain

It is increasingly recognized that acute and chronic pain may represent a continuum rather than distinct entities. Acute pain states that may progress to chronic pain include postoperative and post‐traumatic pain, acute back pain, and acute herpes zoster. The pathophysiological processes that occur after tissue or nerve injury mean that acute pain may become persistent. Such processes include inflammation at the site of tissue damage with a barrage of afferent nociceptor activity that produces changes in the peripheral nerves, spinal cord, higher central pain pathways and the sympathetic nervous systems.

Pain treatment

Adequate and rapid pain relief in the trauma and postoperative patient is essential due to many factors as discussed above, which include minimizing physiological and psychological responses and decreasing the risk of acute pain becoming chronic. Studies show that ‘preventive analgesia’ in acute pain phases produces pain relief longer than the expected duration of action of a target drug. This means that good clinical pain relief in trauma and postoperative patients leads to less need for pain treatment in the subacute phase than in those patients who receive inadequate pain treatment. Pre‐emptive analgesia has not shown any significant effect on postoperative pain relief. Regular assessment and measurement of acute pain, implementation of acute pain service, staff education and use of guidelines improves acute pain management. A great variety of pain‐relieving methods are available today for the patient with acute pain. An individual assessment of each patient is therefore necessary in every case. Questions that need to be asked relate to: trauma genesis, medical history, age of the patient, organ dysfunction, communicable patient, pre‐existing co‐morbidities? After the assessment, an individual pain‐relieving method is chosen. Drugs (opioids, paracetamol, NSAIDs, adjuvants, local anesthetics) can be administered systemically, locally, regionally and by different routes and techniques.

Nutritional support to the critically ill patient

CARITA HEDAR

Department of Anesthesiology and Intensive Care, University Hospital, Lund, Sweden

Background

Nutritional support in association with intensive care can have a major effect on the clinical course of events because the patient is often in a hypermetabolic state, due to the body's increased energy and nutritional needs linked to injury and/or infection. Nutritional solutions are given parenterally and or entrally. Both these regimes are associated with numerous problems and complications, which can result in the patient not receiving the best possible provision of calories. Owing to this the patient's ability regarding healing and recovery be impaired [1].

The intensive care patient's hypermetabolism leads to an increased breakdown of protein stores, leading to a significant loss of body tissue, that is to say a hypercatabolism. This condition can be reduced through treatment of the underlying cause. Nutritional support often cannot reverse a catabolic state to an anabolic state because the hormones and proteins produced by the immunological system impede this process. The goal with nutritional support to intensive care patients is therefore to provide nutritional solutions that reduce tissue loss, maintain vital functions and optimize the prospect of patient recovery [2].

Adequate nutritional support is of vast importance so as to meet the specific metabolic needs of the intensive care patient. Inadequate nutrition with insufficient energy intake in relation to the patient's needs entails continued tissue loss; with a significant loss of muscle mass and here the loss of respiratory muscles be mentioned specifically. Nutritional support which exceeds the patient's metabolic capacity can among other things result in pyrexia and an increased carbon dioxide production, increasing demands on the circulatory and respiratory system [2].

Recent studies

There are a number of studies that show that intensive care patients have been prescribed an inadequate energy intake in comparison with the recommended amount. Adam and Batson [3] studied problems associated with enteral nutrition in patients cared for on five different intensive care units in Great Britain. There were significant differences in the calorie intake prescribed to patients cared for on the different units. The prescribed calorie intake varied between 76% and 96% of the recommended dose. When McClave et al. [4] carried out a similar study the result showed that 66% of the recommended calorie intake was prescribed. The authors could not explain the reason for this phenomenon [3],[4]. Garvin and Brown [5] speculated that it could be due to the fact that a standard training programme for doctors regarding nutritional support with intensive care did not exist. Nutrition can be seen as a secondary component in the treatment of other more acute problems in the critically ill patient, which have greater precedence. Similar arguments are put forward by other authors [4],[6].

Recent research has shown that early enteral nutrition is vital for intensive care patients. Apart from the nutritional aspects, enteral feeding can reduce morbidity with sepsis. As early as the 1970s it was shown in animal experiments that the lack of enteral nutrition could damage the permeability of the gastrointestinal tract [7]. However, this defect could be reversed with the administration of enteral nutrition. Enteral nutrition affects among other things the mechanisms that control the local production of immunoglobulin A (IgA) in the gut, which in turn protects the systemic circulation from pathogens [7],[8]. Even in humans it has been established that a lack of enteral nutrition influences the gut's integrity, resulting in an increased permeability of the mucous membrane. Hadfield et al. [9] recognized that the permeability of the mucous membrane of the gut was reduced in patients receiving enteral nutrition but remained in those patients not receiving enteral nutrition. This study was performed on 24 intensive care patients, but a significant statistical difference in mortality between the two groups could not be established by the authors. Similar results were also shown by other authors [10]. Kudsk et al. [11] performed a study on 98 patients with the intention of evaluating the effect of early enteral nutrition on the complications associated with sepsis, like pneumonia, inter‐abdominal abscess and sepsis after trauma. The study showed that morbidity with sepsis was reduced in the patients who had received enteral nutrition compared with those who had only received parenteral nutrition. This knowledge has resulted in the initiation of enteral nutrition as quickly as is feasible in the treatment of intensive care patients [11],[12].

However, a number of studies have shown that enteral nutrition for intensive care patients is often encumbered with a variety of problems. The most common reason that enteral nutrition is unable to fulfil the intensive care patient's energy needs is gastrointestinal intolerance, with nausea, vomiting and diarrhoea. The consequence of this is that the prescribed amount of calories is not administered [3],[4],[13].

Psychological reactions post intensive care

KARIN SAMUELSON, INGRID CORRIGAN

Lund University Hospital, Lund, Sweden

Introduction

During the last decade there has been an increasing interest in the psychological effects following accidental injury or life‐threatening illness in medical settings. The traumatic experience of being critically ill or injured might lead to different stress reactions and/or anxiety and depression. From the patient's perspective suffering from psychological reactions can be very distressing and significantly impair physical and psychological recovery [1].

Traumatic stress involves the definition of events as traumatic and confounds two distinct constructs; stress and mental traumatization [2]. Acute stress disorder is a psychological reaction in the immediate aftermath of the trauma. For acute post‐traumatic stress disorder (PTSD) the unique symptom configuration consisting of intrusion/re‐experiencing, avoidance and hyperarousal symptoms, has to persist for >1 month and for chronic PTSD 3 months or longer [3],[4].

Recent research

In particular, the development of PTSD has been recognized as a possible sequel for critically ill patients surviving intensive care. According to recent research estimates of the prevalence of PTSD in survivors of intensive care treatment vary from 3% to 20% for the general intensive care population and from 5% to 83% for specific diagnostic groups [5],[6]. A variety of risk factors have been described for the development of PTSD‐related symptoms in intensive care patients such as aetiological factors, ICU clinical and subjective factors [7],[8]. Also the number of traumatic events perceived and the presence of delusional memories without factual recall have been described as risk factors [9],[10].

In our research 226 intensive care patients who had been mechanically ventilated were contacted 2 months after ICU discharge and asked to complete a telephone assessment of the Impact of Event Scale‐Revised (IES‐R). Preliminary results showed that female sex, the receiving of midazolam, signs of agitation during ICU stay, feelings of fear perceived as extremely stressful and increasing levels of anxiety shortly after ICU discharge were significantly associated with high acute PTSD‐related symptom levels [11].

Fourteen patients with IES‐R scores⩾30 agreed to take part in a phenomenological study [12]. The aim of this qualitative study was to describe the meaning of post‐traumatic stress reactions as experienced by patients following a critical illness or injury and intensive care. The essence of the phenomenon of post‐traumatic stress reactions was understood as a transition to a life‐situation beyond control, where the traumatic experiences have a profound impact and are ever‐present. Six variations of the phenomenon presented themselves, e.g. being haunted by the trauma and a strong need to escape from the traumatic memories. The findings suggest that these patients' life situations are strongly affected and that the suffering is substantial.

Clinical implications

At the scene of the accident, as well as in the ICU, it is important to lessen the impact of the stressors, which could contribute to traumatic stress. Reducing the patient's distress and fear might prevent the stress from becoming traumatic, with the attendant risk of traumatic memories forming which could subsequently cause post‐traumatic stress reactions. The significance of supportive and caring strategies, e.g. through constant reassurances, has previously been emphasized [13] and is further underlined by our studies [11],[12]. It is equally important to support patients following discharge from the ICU. Consequently, after‐care clinics have been set up following ICU treatment [14] to help patients come to terms with their traumatic ordeals and aid their recovery. At the ICU in Lund University Hospital, Sweden, the after‐care programme follows general recommendations [14] and consists of the following measures. A diary containing photographs helps to give the patient a realistic picture of what actually happened in the ICU. Ward visits a few days after discharge from the ICU can identify early psychological problems. A few months later, patients are invited back to discuss their memories and the rehabilitation process. If need be, referrals to counsellors or psychologists can be made at this point.

In summary, the findings of our research suggest that assessment of patients' subjective status at follow‐up ward visits, including patients' perceptions of fear and levels of anxiety, might identify patients at risk for the development of acute PTSD‐related symptoms. Supportive and caring strategies to reduce agitation, anxiety and fear throughout the whole process (before, during and after the ICU stay) are essential, and targeted interventions for patients at risk should be considered.

Psychological management in trauma: psychological approach to patients and relatives

B. ERIKSSON

Director of Hospital Chaplaincy, USIL(Sweden)

‘Hope is not optimism.

It is not a conviction that

something will be right

It's a confidence that something

has a meaning –

regardless of what is coming on.’

(Vaclav Havel ur ‘Fjärrförhör’)

The requirement of hope in the approach to patient and relatives: ethical attitude in creating contact with patients and relatives

The art of being a caregiver is to:

1. Help the patient to anchorage in reality

2. Bring relief of discomfort (pain, indisposition, fever, shivering, etc.)

3. Recreate confidence (presence, trust, respect)

4. Permission of feelings

5. Attend to use of non‐verbal language

6. Encourage cultural, existential, spiritual needs

7. Attend to belief, faith, rites and symbols, if so.

The art is to create contact, and that you make through observation and authentic/sincere presence. You can only learn the art by practising it and by competent supervision.

‘The art of being a healing presence.’

Mental training in challenging situations

ANETTE REHNSTRÖM

Department of Anaesthesiology, Lund University Hospital, Lund, Sweden

Imagine your are going on a flight …

At the beginning of every flight, when your have sat down and put your seat belt on, the staff have you at their mercy and they go through the safety procedures. At this point the frequent fliers bury themselves in the in‐flight magazine, because they have heard it all before. But remember one thing about those safety procedures – if the cabin loses pressure, oxygen masks drop down and you should put them on before helping anyone else. Why? Because if you don't put your own mask on, you could pass out and then you are no good for anyone so … self‐development is the equivalent to putting your own mask on first. The more you know about yourself the more you are able to help others.

The way you look at the problem/challenge, that is the frame you give it, can make it easier or harder to solve. Outcomes rather than blames?

To make any change you need to know:

Where you are now – your present state

Where you want to be – your desired state

The resources you need to move from one to the other

Your plan of action to narrow the gap between the present state and desired state.

For example:

Outcome frame questions are

Where am I now?

What do I want?

How can I get from where I am to where I want to be?

The opposite is the blame frame (outcomes look at the future, blame to the past)

Blame frame questions are

What's wrong?

Who's to blame?

Who's going to fix it?

We all have choices – which ones are yours?

Training programmes and certification in the UK: an EU perspective

JANE TIPPETT

Emergency Department, Chelsea and Westminster Hospital, London

Training for nurses caring for trauma patients has changed significantly in the last 16 years. National and international adoption of the ATLS® model has helped to standardize the approach to patient assessment and treatment.

At the end of this session participants will have:

• Reviewed the current training available in the UK and Europe

• Reflected upon the efficacy of such programmes

• Explored the potential to use other educational methods such as simulation and e‐learning

• Considered the need to explore the impact of training and education for the benefit of all trauma patients.

Training programmes and certification in Scandinavia

AGNETA BRANDT

RST, Stockholm, Sweden

Author's email: [email protected], [email protected]

Introduction

Scandinavia is a region in Northern Europe, named after the Scandinavian Peninsula and is also often called ‘the Nordic countries’. The most common definition includes continental Denmark (5.4 million habitants), mainland Norway (4.5 million) and Sweden (9 million). Finland (5.4 million) is sometimes included even in official contexts.

This brief review will mainly focus on Sweden and Swedish trauma care, although some details will be raised over the other countries.

In Sweden, trauma is the most common cause of death for people younger than 45 years. There are about 800 000 people injured each year and >2000 people die annually from trauma‐related causes.

Time is the single most important factor for survival from trauma. There are several studies that show this relation. This is why the expression ‘golden hour’ often is used in the planning and training for efficient trauma care and management. This means definitive medical treatment (e.g. operation) within 60 minutes from the injury. This time factor demands that treatment at the scene of the accident, transportation and treatment at the best hospital need to be quick and efficient. Within cities there is often the possibility of reaching a nearby hospital and giving the necessary treatment within the critical time frame. The problems occur in rural areas and Scandinavian countries have a lot of rural areas – islands, mountains, bad roads for several months during the year, etc.

Studies also show that the best outcome is to take an injured person to a level 1 hospital; a trauma centre. The largest trauma hospital in Sweden is Karolinska University Hospital in Solna (Stockholm). This trauma unit takes care of about 1000–1200 trauma victims every year.

Several regulations in Sweden state that the healthcare system must give priority to patients with life‐threatening illness or injuries. This means that the healthcare system must include well organized prehospital care as well an organized trauma team approach at the hospital. According to the Health Care Law (HSL 1982:763), all habitants have an equal right to treatment on the same conditions.

About 85% of the 9 million habitants live in the southern half of Sweden and the rest in rural areas. This means that the need for efficient trauma care in other parts of the country is crucial to fulfil the equal rights of all habitants.

The cornerstones for efficient trauma care are: basic knowledge including individual training, team training and national/international exchange.

Basic knowledge in trauma care

The RST (Swedish Association for Trauma Nurses) was created 9 years ago with the purpose of supporting these cornerstones. To find the best course possible, we contacted the American College of Surgeons – that started the courses Advanced Trauma Life Support (ATLS) in Sweden 1997. The result of these discussions was a recommendation to start with TNCC – Trauma Nursing Core Course – in Sweden. TNCC is based on the same algorithm as ATLS, and coordinated with the nursing science. The course manual is translated into Swedish and will be renewed within the next year. TNCC started 1997 in Sweden with support from ENA (Emergency Nurses Association) in USA and SSF (Swedish Society of Nursing) in Sweden.

During these 9 first years, just about 10 000 nurses have been educated in TNCC. Very many enrolled nurses have attended the courses – without the evaluation part – in purpose to give all the nursing and caring members in the trauma team the same core knowledge.

The Swedish Association for Trauma Nurses supported their Norwegian colleagues in the years 2003–2004 to start TNCC in Norway. Since 2004 the Norwegian Air Ambulance has been responsible for the courses, together with the Norwegian Association for Nurses in Anaesthesia.

Many hospitals in Sweden have started local education in trauma care. Sometimes together with an international course like TNCC, as a complement, but there are also examples of ‘homemade’/local education, based on the ATLS concept.

Denmark has – since 2001 – chosen another type of trauma education, called ATCN, Advanced Trauma Care for Nurses. This is also based on the ATLS concept and complemented with two separate days for nurses.

Finland has a request to get the same help from RST as Norway, to start TNCC in Finland. No decision has been made at the time of writing (May 2006).

Team training

Trauma is a ‘disease’, requiring a multidisciplinary team response. Every team member around the trauma patient – from the scene of an accident to definitive care and rehabilitation – needs the same knowledge and focus.

Experience from trauma care worldwide shows the importance of team training for the trauma team. The purpose of the team training is to find the best team approach possible according to coordination, communication and decision making and also gives the leader an opportunity to optimize his/her leadership skills.

The team training can be performed within very specific areas and labs with computerized human patient simulator. Team training can also be performed in more simple sessions with manikins or moulaged persons.

National/international exchange

For purposes of quality assurance and care development it is necessary to compare with other hospitals, both nationally as well as internationally. To compare results there are several types of register. One trauma register system is KVITTRA; a specially designed register for trauma patients. Another way of national/international exchange of both personal and experiences is if everyone has the same core knowledge and level of skills. Unfortunately there is a lack of an evaluation system to carry out a long‐term follow‐up. Statistics today are limited to the amount of nurses educated in different trauma programmes. There is still a need to evaluate long‐term knowledge and skills in trauma care for all members of the trauma team.

Need for certification?

With the background of the discussion above – the answer to this question is yes. The Swedish Association for Trauma Nurses (RST) in Sweden is firmly convinced that an international certification is the right way. TNCC gives an international certification, to be renewed every 4 years. We have both provider and recertification courses in Sweden.

There is no national demand for a trauma nurse in Sweden to have a certification as a trauma team member. However, some hospitals require a minimum of knowledge – such as local training, TNCC, etc. – to work in the trauma bay; e.g. University Hospital in Umeå (northern part of Sweden) and Karolinska University Hospital in Solna/Stockholm (level 1). At KS, a new trauma team member will get 1+1 day with introduction and training in trauma care during the first year of employment. The goal is to have TNCC after the first year to get the international certification. An example from Skåne: at the University Hospital in Lund there is a rule that all nurses with the assignment to take ambulance alarm should have at least TNCC training.

Trauma registration in Europe

PER ÖRTENWALL

Department of Surgery, Sahlgrenska University Hospital, Sahlgrenska

Author's email: [email protected]

Trauma registries have proven their value in benchmarking trauma care. The US Major Trauma Outcome Study (MTOS) is still used as reference despite the fact the data are more than 20 years old.

In Europe, the creation of and feedback from trauma registries have been problematic and only partially successful. The exceptions to this are the UK TARN and the German Trauma Registry, both standing out as excellent examples as to how registries can be used for audit and improve results.

Despite the fact that the EU (European Union) has agreed upon a common programme to improve traffic safety and reduce the fatalities on European roads, approaches to the EU to sponsor a European‐wide trauma registry have so far been unsuccessful.

Euro‐TARN, co‐ordinated in the UK, is an attempt to gather data from different trauma registries within Europe into a common database.

Incidence reporting and root cause analysis – experiences from Denmark

ELISABETH BROEGGER JENSEN

Copenhagen Hospital Corporation, Unit for Patient Safety

‘No day passed not one – without a medication error.

Tests were repeated, data misread, information lost.

And this was at a top hospital.

The errrors were not rare; they were the norm’

Dr Donald Berwick. Time Magazine May 1, 2006.

(His wife was hospitalized with a rare spinal‐cord problem).

Incidence Reporting

In January 2004 a national reporting system for adverse events was launched in Denmark. The system is based on the Danish Act on Patient Safety, which was unanimously passed in the Danish Parlament in June 2003.

The purpose of the act is to gather, analyze and communicate knowledge of adverse events in order to reduce the number of adverse events in the Danish Health Care System. The act obligates frontline personnel to report adverse events, the hospital owners to act on the reports, and the National Board of Health to communicate learning from the reports.

The reporting system is:

1. Mandatory

2. Confidential

3. Sanction‐free

4. Learning‐oriented.

The act contains an important protection of health care professionals: ‘A frontline person who reports an adverse event cannot be subjected to disciplinary action as a result of reporting an adverse event’.

Root cause analysis

Nurses who have taken part in root cause analysis are satisfied that the method provides an opportunity to carry out a factual review of an adverse event, in which a patient has suffered from severe injuries.

A root cause analysis answers three essential questions:

1. What happend?

2. Why could it happen?

3. How do we prevent it from happening again?

The individual analysis is carried out by an interdisciplinary team with frontline persons either directly or indirectly involved in the actual adverse event. Leadership members from the involved unit must always be represented on the team, as the analysis will bring about proposals for change in order to optimize the safety systems. Decision‐making competence is therefore required. Data collection, flow diagramming, and report writing are the responsibility of a patient safety officer who is trained in the methodology.

The method extracts learning from a specific adverse event, but most important of all: root cause analysis creates an organization with a memorry and a safety culture.

Examples of root cause analysis conducted in Copenhagen Hospital Corporation – six hospitals in the Copenhagen area:

1. Suffocation due to restraint with a belt

2. Surgical fire

3. Unexpected cardiac arrest

4. Helpless patient left in a bathroom for 7 hours

5. Anaesthesia awareness

6. Wrong site surgery

7. Delay in transferring a trauma patient

8. Suicide

9. Aspiration.

Definition

Adverse event: Undesired incident involving harm or potential harm to the patient, caused by medical management rather than by the underlying disease or condition of the patient.

Literature

1. An organization with a memory. Report of an expert group on learning from adverse events in the NHS. London: Department of Health, 2000.

2. Jensen EB. Kerneårsagsanalyser. Kompendium for risikomanagere og andre med ansvar for analyse af utilsigtede hændelser. Dansk Selskab for Patientsikkerhed August 2004. www.trygpatientdk

3. Root cause analysis tools. version: August 2002. Department of Veterans Affairs National Center for Patient Safety. www.patientsafety.gov

Links

1. Copenhagen Hospital Corporation: www.hosp.dk

2. Danish National Reporting System: www.dpsd.dk

3. Danish Society for Patient Safety: www.patientsikkerhed.dk

4. Web M&M Morbidity & Mortality Rounds on the Web: www.webmm.ahrq.gov

Acute pancreatitis – what is new?

ARI LEPPÄNIEMI

Department of Surgery, Meilahti Hospital, University of Helsinki, Finland

Viewing the recent literature of the new concepts in the surgical management of necrotizing pancreatitis emphasizes the evolving importance of the recognition of abdominal compartment syndrome (ACS) as a significant contributor to early development of organ failure.

Under‐diagnosed and untreated ACS is a potential contributing factor to the development of early organ failure seen in patients with severe acute pancreatitis, and warrants routine measurement of intra‐abdominal pressure in all patients treated for severe pancreatitis. The current estimate of the prevalence of intra‐abdominal hypertension in severe acute pancreatitis is about 40%, with about 10% overall progressing to ACS associated with increased hospital mortality rates. Early surgical decompression via vertical midline laparostomy without exploring the pancreas further seems to be the most effective treatment. Primary fascial closure of the abdominal wall following abdominal decompression can be attempted, but in most cases the prolonged inflammatory process in the abdomen and the risk of recurrent ACS favors the use of gradual closure or delayed reconstruction of the abdominal wall.

In the planned hernia approach, early skin grafting over the exposed bowel will enhance the recovery of the patient and seems to tune down the inflammatory process. After maturation of the graft and complete recovery of the patient, the graft can be easily removed, usually 9–12 months after the initial procedure, and the abdominal wall reconstructed with pedicular tensor fascia lata flap.

A promising new method based on subcutaneous linea alba fasciotomy through three small skin incisions preserving the cutaneous cover seems to decrease the intra‐abdominal pressure sufficiently to overcome the ACS and avoid the morbidity associated with the open abdomen.

Prehospital management of hypothermia

T NÆSHEIM

Department of Anaesthesiology, University Hospital Northern Norway, Tromsø, Norway

Pathophysiology

Body core temperature below 35°C is associated with deterioration of oxygen delivery to vital organs. On the other hand hypothermia decreases metabolism and oxygen consumption. Outcome after hypothermic accidents is dependent on the balance between impaired oxygen delivery and decreased oxygen consumption.

Resuscitation

Conventional monitoring may fail to detect vital signs in severely hypothermic patients, thus making the diagnosis of cardiopulmonary arrest dubious. Cardiopulmonary resuscitation should be provided according to the latest ‘normothermic’ algorithm. Encouraging results have been achieved after several hours of reanimation. The use of drugs in hypothermic resuscitation is discouraged. Drug potency is decreased under these circumstances; furthermore, drug elimination is reduced. Accumulation of drugs during hypothermia may result in serious side effects during rewarming.

Rewarming

In the spontaneously circulated, hypothermic patient it is crucial to preserve cardiovascular stability. Prehospital rewarming in these patients might contribute to stabilize the circulation and reduce the likelihood of malignant arrhythmias. Conversely, patients in cardiac arrest profit by lowered metabolism and should not be rewarmed until adequate circulatory support can be offered.

Transport

Hypothermic, well circulated patients can be stabilized in the nearest hospital. Hypothermic patients in cardiac arrest, or circulatory instability, on the other hand, should be urgently referred to a tertiary hospital experienced in rewarming from deep hypothermia by cardiopulmonary bypass.

Diverticulosis – diagnosis and treatment

GUDRUN LINDMARK

Department of Surgery, Helsinborgs Hospital, Helsingborg, Sweden

Diverticulosis coli, i.e. pseudodiverticulae with mucosal herniations through the weakened colonic wall, is present in one‐third of the population older than age 45 and in up to two‐thirds of the population older than 85 years of age, and 10–25% of subjects with diverticulosis will be affected by diverticulitis. Diverticulitis is most common in the sigmoid colon, although the disease may occur in any segment of the colon. The very likely pathogenesis of diverticulitis is entrapment of faeces and a secondary inflammatory reaction causing peridiverticulitis or phlegmon in uncomplicated cases, and abscess, free perforation, obstruction, fistula or stenosis in complicated cases. Diverticulitis but not diverticulosis only is probably associated with colon cancer.

The mild form of diverticulitis usually presents gradually increasing symptoms from the left lower quadrant of the abdomen occasionally with a palpable mass, fever, and leucocytosis. Other related symptoms may include nausea, vomiting, constipation, diarrhoea, dysuria, and urinary frequency. Although in general a mild and self‐limiting disease, diverticulitis frequently causes life‐threatening problems that require immediate surgery. Acute, complicated diverticulitis is characterized by fulminant onset of abdominal pain, followed by fever within a few hours. Most often the course of severe forms is very rapid and the complication is already established at admission. Usually, these patients have no previous history of diverticulitis. Differential diagnoses must be considered, such as colon cancer, appendicitis, gynaecologic and urologic diseases, ischaemic colitis, and inflammatory bowel disease.

The diagnosis is achieved by assessment of clinical findings combined with complete blood count, urinalysis, and plain abdominal X‐ray predominantly exploring the possibility of colon obstruction and signs of a free perforation. CT scan, ultrasound, and water‐soluble contrast enema may be performed to secure the diagnosis and to estimate the severity of the disease. Endoscopy should be avoided because of risk of perforation with the instrument or by insufflation of air.

A conservative regimen with bowel rest and intravenous antibiotics is indicated when there are signs of sepsis. A clear liquid diet may be acceptable. Usually, there are gram‐negative rods and anaerobes, usually Bacteroides fragilis. Single intravenous antibiotic with activity against aerobes and anaerobes has been shown to be as effective as combination therapy in acute diverticulitis. Whether antibiotic treatment of patients with diverticulitis not fulfilling sepsis criteria is indicated or not has not been fully investigated. After 24 hours, improvement is usually observed in acute, uncomplicated diverticulitis. For a selected number of acute, uncomplicated cases, treatment may be given on an out‐patient basis. Conservative treatment leads to resolution of acute, uncomplicated diverticulitis in at least 70% of patients. After recovery, flexible sigmoidoscopy and double‐contrast enema or colonoscopy should be performed. Fibres, and possibly lactobacilli and/or mesalazine, discontinuing smoking, alcohol and non‐steroidal agents, have been suggested to prevent recurrences and complications.

A CT scan and water‐soluble contrast enema (CE) may, according to Ambrosetti, classify the severity of acute diverticulitis into moderate, when CT scan shows thickening of the colonic wall (5 mm or more) and inflammation of pericolic fat and CE shows segmental lumen narrowing and tethered mucosa, and into severe when abscess and/or extraluminal air and/or contrast is observed on CT scan and when one or both of the latter signs are seen on CE. Abscess formation and extracolonic contrast or air are findings that may be used to predict failure of medical treatment during the first admission and a high risk of secondary complications after initially successful medical management of acute diverticulitis. Moreover, the various presentations of acute diverticulitis may be further staged according to the Hinchey classification system. Characteristically, there is an aggressive inflammation of the bowel wall that causes a phlegmon or microabscesses in the bowel wall (Hinchey stage I). When this aggravates, the bowel perforates. It is then of advantage if the perforation and the following abscess formation is enclosed by the pelvic wall, abdominal wall, or another bowel wall or mesentery (Hinchey stage II). If the inflammation progresses, the abscess perforates and a purulent peritonitis develops (Hinchey stage III). If the bowel perforation occurs into the free abdominal cavity, the most severe form of diverticulitis, faecal peritonitis, is established (Hinchey stage IV).

Emergency surgery is indicated for acute, complicated diverticulitis, comprising failure of medical treatment, abscess formation that cannot be resolved by percutaneous drainage, and large perforation with purulent or faecal peritonitis. In Hinchey stages I–II, symptoms are similar to those in the acute, uncomplicated form. No clinical improvement is, however, observed as expected in 24 hours. A CT scan or ultrasound is then indicated; CT scan with the advantage of comparable investigations over time and ultrasonography with the simultaneous possibility of percutaneous drainage. Diverticulitis in Hinchey stage I may recover on conservative treatment similar to that in the acute, uncomplicated form, and in Hinchey stage II, additional percutaneous drainage usually resolves the status. Only rarely, these patients require a laparotomy. A single‐stage procedure with primary resection and anastomosis with or without a protecting stoma is the method of choice for acute, uncomplicated diverticulitis and for acute, complicated diverticulitis with a localized abscess/mesocolic abscess. On‐table lavage may facilitate and secure safety of this procedure. In Hinchey stages III–IV with purulent or faecal peritonitis, a laparotomy should be performed without any delay after necessary resuscitation. The mortality rate from purulent peritonitis is approximately 6% and from faecal peritonitis 35% in large materials. Usually, resection and diversion (Hartmann's procedure) is performed. An alternative that is becoming more and more frequent in purulent peritonitis is a primary resection with anastomosis and a proximal diverting stoma. A review of the literature suggests that surgical resection and primary anastomosis in acute diverticulitis with peritonitis compares favourably with Hartmann's procedure in terms of perioperative complications.

Timing of the sigmoid resection after a short course of conservative treatment for obstruction is advisable, then allowing a one‐stage surgical procedure of the decompressed sigmoid colon in well prepared patients with low anaesthetic risks, and Hartmann's procedure in patients with an intermediate risk. If the obstruction is complete, resection and faecal diversion is strongly recommended. However, on‐table lavage, resection and anastomosis may be performed in selected cases.

In some cases, there are indications for surgery after conservative treatment of acute, uncomplicated diverticulitis or acute, complicated diverticulitis in Hinchey stages I–II. About 25% of these patients will have a recurrent diverticulitis. Wide recommendations for an elective, prophylactic resection after two to three attacks have been questioned, as the severe diverticulitis often occurs already at the primary attack. Thus, there is no evidence to support the idea that elective surgery should follow two attacks of diverticulitis. The natural history of uncomplicated diverticulitis is not known. In recent reports, it has rather been suggested a prophylactic resection for conservatively treated complicated diverticulitis in patients younger than 50 years of age and, especially, when the diverticulitis has been complicated with a pelvic abscess. Moreover, immunocompromised patients may benefit from early resection. The increased risk for later sigmoid cancer after diverticulitis requires alertness for bowel‐related symptoms after conservative treatment.

General principles for surgical management for elective or non‐urgent cases are as follows: all of the sigmoid colon should be removed; all thickened, affected colon, but not the proximal, otherwise normal, diverticula‐bearing colon must be removed; and anastomosis should be made to normal rectum as anastomosis to the distal sigmoid colon is associated with recurrent diverticulitis. The laparoscopic approach has been introduced in the diagnosis and treatment of especially uncomplicated diverticulitis, with lower morbidity and mortality rates, and less hospitalization.

Late complications are strictures and fistulas. A sigmoid stricture is associated with persistent symptoms that affect 5% of patients after a first sigmoid diverticulitis and 7% of patients who have had two or more attacks. The stricture may be resected to exclude the occurrence of cancer and to provide relief of symptoms. Approximately 2% of all patients with diverticulitis will develop a late fistula; 20% of all surgery for diverticulitis is indicated by a fistula. The most common fistula is the colovesical fistula. Other entities are colovaginal, colocutaneous, coloenteric, and colouterine fistulas. Most of these fistulas are associated with no or only mild symptoms. Faeces and air via the urethra are pathognomonic signs for a colovesical fistula. A single‐stage resection and anastomosis is the standard elective treatment for symptomatic fistulas and strictures.

There are two main issues in the focus of attention: are there particular patient profiles for elective surgery after conservative treatment for acute, uncomplicated diverticulitis, and for resection and diversion or resection and primary anastomosis with or without a protecting stoma in acute, complicated diverticulitis with purulent or faecal peritonitis?

Bowel obstruction and the role of minimally invasive surgery

KAYA SARIBEYOGLU

Istanbul University, Cerrahpasa Faculty of Medicine, Department of General Surgery, Emergency Unit

Introduction

Bowel obstruction represents a significant workload for emergency units. The etiologies consist mostly of postoperative adhesions, hernias and tumors. Laparoscopic management is being commonly used in the elective treatment of these diseases. Herein, the role of emergency laparoscopy for bowel obstruction is reviewed.

Laparoscopic management of postoperative adhesive bowel obstructions

• Current indications and limits

  Postoperative adhesive disease is the leading cause of bowel obstructions in developed countries [1]. Laparoscopy can be used in any patient who suffers from postoperative adhesive small bowel obstruction (PASBO). As the experience in laparoscopy grows, the number of studies that are focused on minimally invasive treatment of PASBO increases [2–8]. There is no absolute contraindication for laparoscopy but open approach can be preferred in patients with severe adhesions which have been documented during previous operations. In addition, there is no straightforward relationship between the number or type of the previous operations [9]. Undoubtedly, the experience of the surgical team is the key factor in achieving a successful laparoscopic management and this defines the indications and limits as well.

• Surgical technique

  There are many tips that should be taken into account in laparoscopic surgery for the adhesions. The first step is choosing optimal localization for the first trocar. Imaging modalities (plain X‐ray, enteroclysis, abdominal computed tomography ,etc.) can be helpful in estimating topographic features of the intra‐abdominal adhesions. Furthermore, an easy way to choose the site is staying away from the incision scar. The first trocar is usually inserted by open (Hasson) technique or with optical access trocars [2]. Some surgeons prefer to use Veress needle pneumoperitoneum, away from the previous incision scar [7] or routinely at left upper quadrant [8]. However, it seems that this has no further benefit apart from shortening the procedure by just a few minutes, but along with additional risks of bowel injury.

  The set‐up of the operating theater is also quite important. The operating surgeon and the camera assistant work at the opposite site of the adhesions; the patient's arm of the side where the surgical team work and the legs are kept open, and these small details dramatically improve the surgeon's comfort. An angled laparoscope should be used since dense adhesions are usually present and maneuvers of the optical view are almost always needed. Sharp adhesiolysis by scissors and limited use of electrocautery are suggested, as ischemia is a strong promoter of adhesion formation. As for the investigation of the pathological obstruction (because there may be many innocent adhesions), the transition zone between the dilated and collapsed bowel segments indicates the responsible area in acute SBO. However, this finding is not observed in recurrent non‐acute SBO or when the acute obstruction is somewhat decompressed. Therefore enteroclysis or abdominal CT findings become extremely important in these circumstances in order to define the main site of obstruction.

• Advantages and disadvantages

  Along with the well‐known advantages of a minimally invasive approach (less pain, excellent cosmesis, short recovery and short hospital stay) laparoscopy is also associated with less de novo adhesion formation [10–12]. A major disadvantage is the need for an experienced surgical team and advanced armamentarium for performing laparoscopic adhesiolysis.

• Brief review of clinical studies

  So far, numerous studies have been reported with good results concerning laparoscopic management of SBO [2–9], [13–19]. Borzellino et al. reported 12.3% morbidity and 20% conversion rate [5], while in the series from Franklin et al., the intraoperative morbidity was 3.5% and conversion rate was 7.8% [4]. Furthermore, Wullstein and Gross compared laparoscopic with open procedures in the treatment of acute PASBO [13]. In this study, laparoscopy was found to be superior in terms of recovery time, length of hospital stay and postoperative complications. Only intraoperative complications were found more often in the laparoscopy group. Pekmezci et al. suggested the use of enteroclysis as a guide to a selective laparoscopic adhesiolysis in recurrent PASBO [2]. The rationale of this novel approach is that it is difficult to find the pathological site in recurrent cases and a non‐selective adhesiolysis would eventually lead to new risky adhesions; therefore lysis of the innocent adhesions should be avoided. The results of this ‘enteroclysis‐guided’ laparoscopic adhesiolysis were good and the obstruction was relieved by this selective laparoscopy in all patients. Kirshtein et al, recently report their series of patients who underwent laparoscopy for SBO [3]. The majority of SBOs were related to adhesions and an excellent mean operation time (40 minutes) and low complication rate (6.4%) were reported.

• Our experience

  In the Emergency Unit‐Department of General Surgery of Cerrahpasa Medical Faculty, Istanbul University, 24 patients underwent laparoscopic adhesiolysis between January 1998 and March 2006. Enteroclysis‐guided laparoscopic adhesiolysis was performed in 17 patients and the remaining 7 patients underwent laparoscopic adhesiolysis for acute intestinal obstruction. The procedure was converted to laparotomy due to excessive adhesions and technical problems in 2 of 24 patients (8.3%). Iatrogenic intestinal injury had taken place in two patients and they were repaired by intracorporeal sutures and a mini‐laparotomy in one case each. Mean hospital stay was 4.2 days [2–7]. All of the patients, except one who experienced transient non‐mechanical intestinal obstruction on postoperative day 34, recovered well. No other morbidity or mortality was observed postoperatively.

Laparocopic management of large bowel obstruction

Laparoscopy can be a useful tool in the management of large bowel obstructions in selected cases, although it is not performed in large bowel obstructions (LBO) as often as in PASBO. Currently, laparoscopic colectomy for colorectal cancer or diverticulitis are commonly carried out. Laparoscopy is also practicable in complicated colorectal cancer in emergency settings. In a series from Gonzalez et al. laparoscopy was successfully used for the treatment of bleeding, perforation and obstruction in colorectal cancer patients [20]. Colostomy can also be performed via laparoscopy [21]. Moreover, laparoscopic treatment of colonic volvulus is feasible. There are anectodal cases in the literature reporting sigmoidopexy or sigmoid resection but no standard approach is yet established [22],[23]. It seems that LBO can be safely and efficiently managed by laparoscopy but surgeons who are skilled in this field are undoubtedly needed.

Incarcerated hernia

Video‐endoscopic surgery has been used for the treatment of every type of hernias for a long time. Thus today, incarcerated inguinal or ventral hernias are well managed by laparoscopic techniques [24–27]. Obese patients with ventral hernias (including incisional hernias) are good candidates for laparoscopic surgery. Although further studies are needed to compare open and laparoscopic techniques, the role of minimally invasive surgery is growing in emergency patients. Another potential of laparoscopy is performing abdominal exploration in spontaneously reduced hernias [28].

Others

Laparoscopy can be used in any indication for bowel obstruction. Unusual causes of small or large bowel obstructions such as bezoars, congenital bands, etc., can be managed by laparoscopy as well [29],[30].