[Admission, initial examination and care of severely injured in Denmark]. / Modtagelse, initial undersøgelse og behandling af svaert tilskadekomne i Danmark.

INTRODUCTION: The aim of this study was to describe the initial care and management of trauma patients in Denmark. MATERIAL AND METHODS: A questionnaire was sent to all 64 hospitals in Denmark in July 1999. All responded. The questionnaire covered 81 questions. RESULTS: The number of severely injured patients received by the hospitals was evenly distributed. Nine hospitals received more than 50 severely injured patients/year. Protocols for trauma care were available in 46 hospitals. Monitoring with ECG and pulse oximetry in the emergency room was possible in most hospitals. Most hospitals were also equipped to perform endotracheal intubation, chest tube drainage, surgical airway, and peritoneal lavage. Radiological and clinical laboratory services were available round the clock in most hospitals. Ultrasonography could be performed in 41 and CT in 36 hospitals. Three hospitals did not transfer patients to other facilities. An estimated quarter of the severely traumatised patients are transferred to a hospital with a higher level of trauma treatment. CONCLUSION: Many Danish hospitals receive trauma patients. However, a number of hospitals do not have the necessary organisation, clinical capabilities, or resources for trauma care. There is a need for regional and national guidelines for trauma care with recommendations ensuring early recognition of patients who may be sufficiently cared for in the local hospital, and those who require transfer to trauma centres for definitive care.

Respiratory changes during treatment of postoperative pain with high dose transdermal fentanyl.

This study made a longterm (72 hours) evaluation of the efficacy and possible side-effects of transdermal delivery of fentanyl (TTS-system) for post-operative pain relief. The study was double-blind, placebo-controlled with either a TTS-system delivering fentanyl 100 micrograms.h-1 and rescue analgesic on demand or a placebo system and analgesic on demand. Analgesic consumption, pain, general satisfaction, respiratory rate, and levels of SpO2 and tcCO2 (pulse oximetry and transcutaneous CO2 measuring) were evaluated. Recruitment was stopped after enrolment of 24 patients, on safety grounds. The Fentanyl group was more satisfied with postoperative pain relief (P = 0.008); they had a lower analgesic demand (P < 0.05) but also a lower respiratory rate (P < 0.05) and a higher level of tcCO2 23 hours after application (P < 0.05). There were three cases (25%) of increased PaCO2 (> 6.5 kPa) in the Placebo group but without low PaO2 levels, sedation or bradypnoea. Conversely, there were three cases (33%) in the Fentanyl group with bradypnoea (< 10 breaths/minute), two without influence on PaO2 or PaCO2, but one (no. 24) with bradypnoea, heavy sedation, a marked decrease in PaO2 (5.8 kPa) and increased PaCO2 (7.5 kPa). These findings terminated the study. The 100 micrograms transdermal fentanyl system is agreeable to the patients, but apparently too potent for routine postoperative pain relief due to a risk of respiratory depression. Respiratory frequency can not be relied upon as sole indicator of insufficient respiration.

Pharmacokinetics and pharmacodynamics of eltanolone (pregnanolone), a new steroid intravenous anaesthetic, in humans.

Eltanolone, a new intravenous steroid anaesthetic agent was administered intravenously in a dose of 0.6 mg.kg-1 over 45 s to eight healthy male volunteers to evaluate some of its pharmacokinetic and pharmacodynamic effects. Drug concentration-time data were analysed by PCNONLIN, a non-linear regression programme, showing data consistent with a three-compartment model with initial distribution half-life t1/2 lambda 1 between 0.3 and 2 min, intermediate distribution half-life t1/2 lambda 2 between 12 and 29 min and terminal half-life t1/2 lambda z between 72 and 212 min. The total body clearance of eltanolone was rapid and with individual values in the range 1.6-2.3 l.h-1.kg-1. Eltanolone was initially distributed into a relatively large central compartment V1 between 0.09 and 0.98 l.kg-1 and then extensively further distributed (Vss between 1.80 and 5.44 l.kg-1 and V between 4.87 and 11.87 l.kg-1). The excretion of unchanged of eltanolone in urine was very small, the renal clearance was less than 0.5% of the total clearance. Induction of anaesthesia was trouble free with onset and duration of anaesthesia between 1-2 min and 6-13 min, respectively. There was slight respiratory depression, a small transient increase in heart rate, and a maximum reduction in arterial blood pressure of 23%, as compared with the resting level. Pain on injection and venous sequelae were not seen. Involuntary movements were seen in one subject. We conclude that eltanolone has a favourable pharmacokinetic profile with relatively rapid half-lives, large distribution volumes and rapid total body clearance.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of acute beta-adrenoceptor blockade with metoprolol on the renal response to dopamine in normal humans.

The present study investigated the contribution of adrenergic beta 1-receptor stimulation to the cardiovascular and renal effects of low-dose dopamine in eight normal, water-loaded humans. Metoprolol (100 mg) or placebo was administered orally at 08.00 h in a randomized, double-blind fashion on two different days. Renal clearance studies were performed during a 1 h baseline period, two 1 h periods with dopamine infusion (3 micrograms kg-1 min-1), and a 1 h recovery period. Cardiac output was measured by an ultrasonic Doppler method, and lithium clearance (CLLi) was used to estimate proximal tubular outflow. Baseline values of heart rate, systolic pressure and mean arterial pressure decreased with metoprolol compared with placebo, but cardiac output, effective renal plasma flow (ERPF) and glomerular filtration rate (GFR) were not significantly changed. Metoprolol significantly decreased baseline CLLi and sodium clearance (CLNa) by 19% (P < 0.01) and 34% (P < 0.01), respectively. Metoprolol blunted the dopamine-induced increases in heart rate and systolic pressure, but cardiac output increased to the same extent on both study days by 26% (placebo, P < 0.05) and by 31% (metoprolol, P < 0.01), respectively. With and without metoprolol, dopamine did not significantly change GFR, and the percentage increases in ERPF were similar on the two study days (40% (P < 0.001) and 42% (P < 0.001), respectively). Dopamine increased CLLi and CLNa by 31% (P < 0.01) and 114% (P < 0.01), respectively, with placebo, and by 36% (P < 0.01) and 114% (P < 0.01), respectively, with metoprolol. Values during infusion remained significantly lower with metoprolol compared with placebo.(ABSTRACT TRUNCATED AT 250 WORDS)

Cardiovascular function measured by ultrasound Doppler in healthy young men after ingestion of dextropropoxyphene napsylat.

In a double blind cross-over study 10 healthy male volunteers were given either 300 mg dextropropoxyphene napsylat (DP) or placebo daily for 16 days. The serum levels of DP and the metabolite nordextropropoxyphene were measured on day 3, 6 and 16. Haemodynamic measurements were made on day 1 and day 16, both at rest and during exercise. The measurements were made non-invasively, with a pulsed ultrasound Doppler. Blood pressure, heart rate, velocity, cardiac output, left cardiac work, increased during work, but showing no significant differences between the groups. The systolic time intervals were also measured by the ultrasound Doppler. The preejection period increased significantly in the DP-group, whereas the ratio preejection period/left ventricular ejection time which reflects the contractility of the heart did not differ significantly. It is concluded that DP taken daily in a normal dose for 16 days did not affect the heart function in healthy young men.

Monitoring of cardiac output and cardiac work during anaesthesia by means of pulsed ultrasound Doppler.

During anaesthesia haemodynamic measurements were performed with pulsed ultrasound Doppler in six patients with a Swan-Ganz catheter. Cardiac output (CO), heart rate (HR), arterial blood pressure (AP), systemic vascular resistance (SVR) and left cardiac work (LCW) were measured simultaneously with the velocity measurements of the bloodstream in the ascending aorta. Six to fourteen (median 9) simultaneous measurements were done in each patient. Sixty-two measurements were made. The velocity (V) and the product of velocity and heart rate (VHR) were compared with CO in order to establish a non-invasive index of the cardiac output. The product of velocity, the heart rate and the arterial blood pressure (VHRAP) was compared with LCW, showing a good correlation between VHR and CO (V = maximum velocity) (rho = median 0.85), as was the case between VHRAP and LCW (rho = 0.88). Furthermore, a negative correlation between V and SVR was found, illustrating that the velocity of the bloodstream in the aorta obviously depends on the afterload. It is concluded that pulsed ultrasound Doppler in combination with HR and AP can measure relative changes in CO and LCW.

Blood flow velocity and systolic time intervals measured by pulsed Doppler ultrasound: reproducibility of measurements.

The reproducibility of measurements of blood flow velocity in the aorta and systolic time intervals using pulsed ultrasound Doppler was determined in 10 subjects. Measurements were made in both the ascending aorta and the aortic arch, and instant maximum as well as instant mean velocities were measured. The smallest variation was found when the maximum velocity was measured in the ascending aorta. The coefficient of variation in measurements was between 6.9% and 13.1%, when determined at intervals of 10-15 min. Again the smallest variation was when the maximum velocity was measured in the ascending aorta. The intraobserver variation was smaller than the interobserver variation (6.9% compared with 10.6%) in the ascending aorta. Both the intraobserver and interobserver variations in systolic time intervals were very small. The mean coefficients of variation were 1.7% for the pre-ejection period (PEP), 1.7% for left ventricular ejection time (LVET), 1.4% for electromechanical systole (QS2), and 2.9% for the PEP:LVET ratio. The mean values of pre-ejection period and left ventricular ejection time were 154 ms and 377 ms, which are a little longer and shorter respectively than measurements made by phonocardiography and pulse pressure monitoring, whereas QS2 was the same (531 ms). The interobserver variations were 2.6%, 2.0%, 1.4%, and 3.9% respectively. It is concluded that pulsed Doppler ultrasound is a reliable method of measuring blood flow velocity and systolic time intervals. Changes in blood flow velocity of 10-12% can be detected by this method.

The effect of intranasally administered nitroglycerin on the blood pressure response to laryngoscopy and intubation in patients undergoing coronary artery by-pass surgery.

The effect of intranasally administered nitroglycerin (NTG) on the cardiovascular response to laryngoscopy and intubation was studied. Thirty patients scheduled to undergo coronary artery by-pass surgery under thiopentone, enflurane and pancuronium anaesthesia were randomly divided into three groups. Group I received lignocaine 1.5 mg/kg i.v. prior to laryngoscopy and intubation (control group). Group II received lignocaine 1.5 mg/kg i.v. and in addition 2 mg nitroglycerin (NTG) was given intranasally. Group III received only 2 mg NTG intranasally. In Group I laryngoscopy and intubation caused a significant increase in mean arterial pressure (MAP) (P less than 0.01), heart rate (HR) (P less than 0.01) and rate pressure product (RPP) (P less than 0.01) compared to preoxygenation values. In Group II and III MAP and RPP remained unchanged, whereas HR increased (P less than 0.01 and P less than 0.01 respectively). It can be concluded that intranasally administered NTG effectively attenuates the pressor response to laryngoscopy and intubation in patients presenting for coronary artery by-pass surgery and that it is more effective and convenient method than intravenous lignocaine.

Stroke volume measured by pulsed ultrasound Doppler and M-mode echocardiography.

The velocity of the bloodstream in the ascending aorta was measured by pulsed ultrasound Doppler. The diameter of the aorta was measured by M-mode echocardiography. Forty-three measurements were performed in six patients, who all had a Swan-Ganz catheter. The calculated stroke volumes from the Doppler-Echo method were compared with the stroke volumes measured by the thermodilution technique, which was performed simultaneously with the Doppler measurements. The correlation between the measurements was good (r = 0.08). It is concluded that it is possible non-invasively to measure stroke volume (and cardiac output) by means of ultrasound Doppler and an echocardiograph.

Systolic time intervals measured by pulsed ultrasound-Doppler.

A new method for measuring systolic time intervals (STI) is presented. By using a pulsed ultrasound Doppler-velocity-meter, which is able to differentiate the velocity signals, it is possible to pick up signals just above the aortic valve. Combining the velocity signals and an ECG, the STI can be measured. The STI measured by this method were compared with STI measured by using a phonocardiograph. The results showed no significant difference.

The cardiovascular effects of pancuronium during halothane and cyclopropane anaesthesia.

The effect of pancuronium 0.1 mg/kg i.v. on heart rate (HR) and mean arterial blood pressure were investigated in two groups of eight patients, each receiving inhalational anaesthesia with either halothane or cyclopropane. A more pronounced effect on HR in the cyclopropane group with a mean increase of 104% occurred. The mean increase in the halothane group was 54%. There was a statistically significant difference (P less than 0.05) between the HR increases The vagolytic effect of pancuronium and the influence of halothane and cyclopropane on the autonomic nervous system are discussed.

Primary and secondary displacement of central venous catheters.

The purpose of this study was to investigate the frequency of primary and secondary displacement of central venous catheters. One hundred and two central venous catheters, inserted through a peripheral or a central vein before surgery or in the intensive care unit, were controlled by chest X-ray 5-720 min after insertion. The number of primarily displaced catheters was 27. Of these, the position was corrected in 8. Thereafter, the 83 correctly placed catheters were observed for 4-560 h. The number of X-ray controls was 2-24. The number of secondary displacement was 2, whereas 12 catheters showed minimal secondary displacement. The rate of complication was very low. We conclude that chest X-ray immediately after insertion of central venous catheters is absolutely necessary, but since the number of secondary displacements is very low, daily chest X-ray control is not necessary. We also conclude that the internal jugular vein is the best route for introducing a central venous catheter, since complications are very few and the number of displacements is very low.