[Hurricane Ike and the University of Texas Medical Branch Hospital's evacuation]. / Hurrikan Ike. Evakuierung des Universitätsklinikums der University of Texas Medical Branch.

In September 2008 the University of Texas Medical Branch at Galveston was threatened by Hurricane Ike. The incident commander decided to evacuate the hospital. This is a report on how this was accomplished and the lessons learned. An adequate disaster preparedness plan, sufficient logistics, a comprehensive incident command center and the use of complex communication systems were crucial for success. Within 11 h a total of 469 patients had been evacuated using 143 ambulances, 23 helicopters, 2 fixed wing aircraft, buses and numerous passenger vans. The authors encourage physicians, as responsible members of the health care team, to be prepared to respond to disasters.

Radiological validation of tracheal tube insertion depth in out-of-hospital and in-hospital emergency patients.

We performed a 5-year, retrospective study using records of 1081 patients admitted to the trauma emergency room at a University Hospital to investigate the occurrence of tracheal tube malpositioning after emergency intubation in both the inpatient and outpatient settings, using chest radiographs and CT scans in the trauma emergency room. Prehospital patients and inpatients referred from peripheral hospitals were compared. This study showed that tracheal tube misplacements occur with an incidence of 18.2%, of which almost a third (5.7%) were placed in a main bronchus. We further show that tracheal intubation in emergency patients approximates the misplacement rates in the prehospital or in-hospital settings. We speculate that the skill level of the operator may be critical in determining the success of tracheal intubation. Based on our findings, all efforts should be made to verify the tube position with immediate radiographic confirmation after admission to the emergency room.

[Pathophysiology of acute lung injury in severe burn and smoke inhalation injury]. / Pathophysiologie des akuten Lungenversagens bei Schwerbrandverletzten mit Inhalationstrauma.

This review article describes the pathophysiological aspects of acute lung injury (ALI) and acute respiratory distress syndrome (ARDS), induced by combined burn and smoke inhalation and examines various therapeutic approaches. The injury results in a fall in arterial oxygenation as a result of airway obstruction, increased pulmonary transvascular fluid flux and loss of hypoxic pulmonary vasoconstriction. The changes in cardiopulmonary function are mediated by reactive oxygen and nitrogen species. Nitric oxide (NO) is generated by both inducible and constitutive isoforms of nitric oxide synthase (NOS). Recently, neuronal NOS emerged as a major component within the pathogenesis of ARDS. NO rapidly combines with the oxygen radical superoxide to form reactive and highly toxic nitrogen species such as peroxynitrite. The control of NO formation involves poly(ADP-ribose) polymerase and its ability to up-regulate the activity of nuclear transcription factors through ribosylation. In addition, present data support a major role of the bronchial circulation in the injury, as blockage of bronchial blood flow will also minimize the pulmonary injury. Current data suggest that cytotoxins and activated cells are formed in the airway and carried to the parenchyma.

[Treatment strategies for acute smoke inhalation injury]. / Behandlungsstrategien des akuten Rauchgasinhalationstraumas.

Most fatalities from fires are not due to burns, but are a result of inhalation of toxic gases produced during combustion. Fire produces a complex toxic environment, involving flame, heat, oxygen depletion, smoke and toxic gases such as carbon monoxide and cyanide. As a wide variety of synthetic materials is used in buildings, such as insulation, furniture, carpeting, electric wiring covering as well as decorative items, the potential for poisoning from inhalation of products of combustion is continuously increasing. The present review describes the pathophysiologic effects from smoke inhalation injury as well as strategies for emergency treatment on scene and in the intensive care setting.

Positive end-expiratory pressure ventilation increases extravascular lung water due to a decrease in lung lymph flow.

Positive end-expiratory pressure (PEEP) is used to improve gas exchange, increase functional residual capacity, recruit air spaces, and decrease pulmonary shunt in patients suffering from respiratory failure. The effect of PEEP on extravascular lung water (EVLW), however, is still not fully understood. This study was designed as a prospective laboratory experiment to evaluate the effects of PEEP on EVLW and pulmonary lymph flow (QL) under physiologic conditions. Twelve adult sheep were operatively prepared to measure haemodynamics of the systemic and pulmonary circulation, and to assess EVLW In addition, the lung lymphatic duct was cannulated and a tracheostomy performed. The animals were then mechanically ventilated in the awake-state without end-expiratory pressure (PEEP 0). After a two-hour baseline period, PEEP was increased to 10 cmH2O for the duration of two hours, and then reduced back to 0 cmH2O. Cardiopulmonary variables, QL, and arterial blood gases were recorded intermittently; EVLW was determined two hours after each change in PEEP. The increase in PEEP resulted in a decrease in QL (7 +/- 1 vs 5 +/- 1 ml/h) and an increase in EVLW (498 +/- 40 vs 630 +/- 58 ml; P<0.05 each) without affecting cardiac output. As PEEP was decreased back to baseline, QL increased significantly (5 +/- 1 vs 10 +/- 2 ml/h), whereas EVLW returned back to baseline. This study suggests that institution of PEEP produces a reversible increase in EVLW that is linked to a decrease in QL.

[An unexpected difficult intubation. Bonfils rigid fiberscope]. / Eine unerwartet schwierige Intubation. Das starre Intubationsfiberskop nach Bonfils.

A solution to managing intubation difficulties during anaesthesia induction is described in this article. After two attempts at laryngoscopy had failed, endotracheal intubation was achieved by the combined use of a laryngoscope and the Bonfils rigid fiberscope. The successful technique involved two anaesthesiologists, one who displaced the patient's tongue to the left ventral part of the mouth with a laryngoscope and cleared the airway by suctioning, and one who accomplished the intubation using the Bonfils rigid fiberscope by following the blade of the laryngoscope to the larynx. After securing a good view of the vocal cords, the tube was successfully inserted into the trachea. The entire procedure of intubation was accomplished within 20 s.