The traditional vs "1:1:1" approach debate on massive transfusion in trauma should not be treated as a dichotomy.

Traditional transfusion guidelines suggest that fresh frozen plasma (FFP) should be given based on laboratory or clinical evidence of coagulopathy or acute loss of 1 blood volume. This approach tends to result in a significant lag time between the first units of erythrocytes and FFP in trauma requiring massive transfusion. In severe trauma, observational studies have found an association between increased survival and aggressive use of FFP and platelets such that FFP:platelet:erythrocyte ratio approaches 1:1:1 to 2 from the first units of erythrocytes given. There are considerable concerns over either approach, and no randomized controlled trials have been published comparing the 2 approaches. Nowadays, trauma clinicans are incorporating the strenghts of both approaches and are no longer treating them as a dichotomy. Specifically, "1:1:1" proponents have devised 1:1:1 activation criteria to minimize unnecessary FFP and platelet transfusion and are prepared to deactivate the protocol as soon as patient is stabilized. Similarly, 1:1:1 skeptics are more mindful of the need to be proactive about trauma coagulopathy and the inherent delays in FFP administration in trauma patients.

Laryngoscope manipulation by experienced versus novice laryngoscopists.

PURPOSE: During endotracheal intubation using a Macintosh laryngoscope blade, it has been recommended by some that the best laryngeal view is achieved with a laryngoscope handle angle of 45º from horizontal; however, this may be unnecessary. Novices are rarely taught specifically how or where to grip the laryngoscope handle. This study compared the angle and grip of the laryngoscope handle by experienced vs novice laryngoscopists to determine whether basic differences could be identified that might aid in teaching the nuances of skillful laryngoscope manipulation. METHODS: Laryngoscopists were photographed performing tracheal intubation for elective surgical patients (22 experienced laryngoscopists) and an airway trainer mannequin (22 experienced and 21 novice layngoscopists). The photographs were analyzed for laryngoscope handle angle from horizontal, eye-scope distance, and eye-scope angle. Airway trainer photographs were also assessed for hand rotational angle and distance from the laryngoscope base. RESULTS: The average laryngoscope handle angle for patient tracheal intubations was 23.7º (95% confidence interval [CI]: 21.1 to 26.2), significantly less than 45º (P < 0.001). Compared with novices, experts gripped the laryngoscope handle closer to the hinge at rest and at best laryngeal view (P = 0.001 and P = 0.003, respectively), held the laryngoscope in their fingers vs the palm of their hand (P = 0.005), and used greater eye-scope distances (P = 0.005) for airway trainer intubations. Expert technique was unchanged with patient vs airway trainer laryngoscopy. CONCLUSION: Experienced laryngoscopists used laryngoscope handle angles less than 45º from horizontal for routine intubations. Compared with novices, experts gripped the laryngoscope closer to the hinge and held the laryngoscope more in their fingers vs the palm of their hand. Sharing these important points with novices early in their instruction may improve technique and skill acquisition.

Contamination: a comparison of 2 personal protective systems.

BACKGROUND: The purpose of this study was to examine the difference in self-contamination rates and levels of contact and droplet protection associated with enhanced respiratory and contact precautions (E-RCP) and a personal protective system that included a full body suit, personal protective equipment and a powered air-purifying respirator (PAPR). METHODS: In this prospective, randomized, controlled crossover study, 50 participants donned and removed E-RCP and PAPR in random order. Surrogate contamination consisted of fluorescein solution and ultraviolet (UV) light- detectable paste, which was applied after each ensemble was donned. A blinded evaluator inspected participants for contamination using a UV lamp after removal of each ensemble. Areas of contamination were counted and measured in square centimetres. Donning and removal violations were recorded. The primary end point was the presence of any contamination on the skin or base clothing layer. RESULTS: Participants wearing E-RCP were more likely to experience skin and base-clothing contamination; their contamination episodes measuring > or = 1 cm2 were more frequent, and they had larger total areas of contamination (all p < 0.0001). The anterior neck, forearms, wrists and hands were the likeliest zones for contamination. Participants donning PAPR committed more donning procedure violations (p = 0.0034). Donning and removing the PAPR system took longer than donning and removing E-RCP garments (p < 0.0001). INTERPRETATION: Participants wearing E-RCP were more likely to experience contamination of their skin and base clothing layer. Those wearing PAPR required significantly more time to don and remove the ensemble and violated donning procedures more frequently.

A placebo-controlled randomized clinical trial of perioperative administration of gabapentin, rofecoxib and their combination for spontaneous and movement-evoked pain after abdominal hysterectomy.

Current treatments for post-injury movement-evoked pain are inadequate. Non-opioids may complement opioids, which preferentially reduce spontaneous pain, but most have incomplete efficacy as single agents. This trial evaluates efficacy of a gabapentin-rofecoxib combination following hysterectomy. In addition to IV-PCA morphine, 110 patients received either placebo, gabapentin (1800 mg/day), rofecoxib (50 mg/day) or a gabapentin-rofecoxib combination (1800/50 mg/day) starting 1 h pre-operatively for 72 h. Outcomes included pain at rest, evoked by sitting, peak expiration and cough, morphine consumption and peak expiratory flow (PEF). For placebo, gabapentin, rofecoxib and combination, 24 h pain (100 mm VAS) was: at rest-23.6 (P<0.05 vs. all treatments), 13.8, 14.4 and 12.1; during cough-50.7 (P<0.05 vs. all treatments), 41.5, 44.8 and 30.8; 48 h morphine consumption (mg) was: 130.4 (P<0.05 vs. all treatments), 81.7, 75.6 and 57.2 (P<0.05 vs. gabapentin and rofecoxib) and 48 h PEF (% baseline) was: 63.9 (P<0.05 vs. all treatments), 77.2, 76.7 and 87.5 (P<0.05 vs. gabapentin and rofecoxib). Adverse effects were similar in all groups except sedation which was more frequent with gabapentin. Combination and rofecoxib reduced pain interference with movement, mood and sleep (P<0.05) and combination was superior to gabapentin for all these three (P<0.05). These data suggest that a gabapentin-rofecoxib combination is superior to either single agent for postoperative pain. Other benefits include opioid sparing, reduced interference with movement, mood and sleep and increased PEF suggesting accelerated pulmonary recovery. Future research should identify optimal dose-ratios for this and other analgesic combinations.

Evaluation of the Bullard, GlideScope, Viewmax, and Macintosh laryngoscopes using a cadaver model to simulate the difficult airway.

STUDY OBJECTIVE: To assess the performance and cervical (C)-spine movement associated with laryngoscopy using the Bullard laryngoscope (BL), GlideScope videolaryngoscope (GVL), Viewmax, and Macintosh laryngoscopes during conditions of a) unrestricted and b) restricted C-spine and temporomandibular joint (TMJ) mobility. DESIGN: Prospective, controlled, randomized, crossover study. SETTING: University teaching hospital. SUBJECTS: 21 cadavers with intact C-spine anatomy. INTERVENTIONS: Each cadaver underwent to total of 8 intubation attempts to complete the intubation protocol using all four devices under unrestricted and restricted C-spine and TMJ mobility. MEASUREMENTS: Laryngoscopic view was graded using the modified Cormack-Lehane system. Time to best laryngoscopic view and total time to intubation were recorded. C-spine movement was measured between McGregor's line and each vertebra from radiographs taken at baseline and at best laryngoscopic view. MAIN RESULTS: During both intubating conditions, the BL achieved the highest number of modified Cormack-Lehane grade 1 and 2A laryngoscopic views as compared to the other three devices (P < 0.05) and had fewer intubation failures than the Viewmax or Macintosh laryngoscopes (P < 0.05). The GVL had superior laryngoscopic performance as compared to the Viewmax and Macintosh laryngoscopes (P < 0.05) and had fewer intubation failures than those two devices (P < 0.05). All devices except the Macintosh laryngoscope in restricted mobility achieved median times to intubation in less than 30 seconds. For both conditions, BL showed the least total absolute movement between Occiput/C1 and C3/C4 of all the devices (all P < 0.05). Most of the difference was seen at C1/C2. CONCLUSIONS: In cadavers with unrestricted and restricted C-spine mobility, the BL provided superior laryngoscopic views, comparable intubating times, and less C-spine movement than the GVL, Viewmax, or Macintosh laryngoscopes.

Combitube rescue for Cesarean delivery followed by ninth and twelfth cranial nerve dysfunction.

PURPOSE: The Combitube has been shown to be effective in many airway management scenarios. We describe its use as a rescue device in a "cannot intubate cannot ventilate" (CICV) situation that was encountered during a Cesarean delivery (CD) followed by transient cranial nerve dysfunction. CLINICAL FEATURES: A 24-yr-old gravida 4 para 1 (weight 112 kg, body mass index 44 kg.m(-2)) at 34 weeks gestation, with pregnancy induced hypertension and a prior history of uneventful airway management, presented for urgent CD. She refused regional anesthesia and attempts at awake laryngoscopy and intubation. Following rapid sequence induction, attempts at direct laryngoscopy and intubation failed. Ventilation via facemask and laryngeal mask also failed. A Combitube was inserted and inflated according to manufacturer's instructions and resulted in successful ventilation of the patient. The Combitube was in place for approximately three hours and then removed uneventfully. The following day, the patient presented with signs and symptoms consistent with bilateral glossopharyngeal and unilateral hypoglossal nerve dysfunction. Three months later the patient's nerve dysfunction had completely resolved. CONCLUSION: Although this patient's transient nerve dysfunction was most likely due to the Combitube, we believe its inclusion as part of any difficult airway armamentarium should be encouraged. Training in its use should be promoted. It has an important role in emergency airway management and can be effective when other non-surgical ventilation techniques fail. Despite this, clinicians must remain vigilant for complications following its use.