Finnish National Training Centre for Emergency Services.

This is a review of the facilities and programmes of the Finnish National Centre for Emergency Services in Kuopio, Finland. It includes the Emergency Services College that provides all of the training for emergency service workers in Finland and provides some services for the international community. There are needs for training by the medical community in Finland that relate both to skills and knowledge. Education and training focus on the demonstration of evidence-based competence. The facility includes a training ground for the provision of immediate emergency medical care, scene safety, extrication, industrial accidents, and water rescue. It is used for the training of paramedic students, nurses, medical students, firefighters, dispatch center staff, and officers. Computer-aided simulations are used to enhance the learning process. Plans are underway for adding tele-education and/or virtual-reality facilities. Close liaison is maintained with the University of Kuopio, Kuopio University Hospital, and with the Pohjois-Savo Polytechnic Institute.

Interactive computer-aided training of emergency care tactics: an experimental study with medical students.

INTRODUCTION: It is important to know which level of tactical preparedness is reached after completing lectures and training included in a medical curriculum. A computer-based interactive programme aimed for tactical training of emergency care tactics at the scene (Matimed, Matimed Ltd, Kuopio, Finland) was used in testing the skills of 20 medical students. METHOD: In this standardised test, every student first received guided introduction on the technical use of the programme. The test included four severely injured victims. The traumas used were hepatic rupture, flail chest, haemothorax, and femoral fracture. The students were tested in making decisions on the priority of care and transportation and in keeping the patients alive with appropriate emergency care until they were transported to a trauma centre. RESULTS: Only five of 20 (25%) succeeded in this task, 50% lost one victim and 25% lost two. The results show that the tactical preparedness of medical students is far from what is presumed. A more detailed analysis shows serious deficiencies in decision-making, priority order of actions, and in the use of available resources. CONCLUSIONS: This type of interactive computer-aided training of tactics appropriately supplements theoretical lectures, and partially fills the need for practical training.

Introduction of a new patient monitoring system during dental procedures: pulse oximetry.

This paper describes three cases of early detection of hypoxia with pulse oximeter during intravenous sedation. In the main study group over 40 patients were monitored by pulse oximetry during large dental operation under i.v.-sedation. Diazepam with soybean oily solvent and midazolam were used as intravenous sedative agents in this study. The first signs of hypoxia were seen by pulse oximetry. In three healthy patients some periods of remarkable hypoxia was detected and those cases are reported in this paper. Two of the patients were treated by a surgical operation and one patient underwent large conservative dental treatment under sedation because of dental care phobia. During the dental treatment period external oxygen was added for all these three patients to avoid more complications as a result of hypoxia. Two of the patients received an injection of benzodiazepine antagonist, too. One patient needed further follow up but non of these patients developed any additional complications. As a conclusion pulse oximetric monitoring was found to be extremely sensitive as a predictor for coming complications as well as allowing early intervention in ventilation problems.

Lidocaine and prilocaine with vasoconstrictors as cause for cardiovascular reactions. A pulse oximetric study. Preliminary report.

MATERIALS AND METHODS: Cardiovascular effects of two local anesthetic agent solutions containing 2% lidocaine with 1:80,000 epinephrine (LE) and 3% prilocaine with 0.54 microgram/ml felypressine (PF) used separately and in combination were observed. We made 38 separate monitoring sessions (30 minutes each) with healthy voluntary dental students. Participants were monitored with Cardiocap multiparameter physiological monitor. The monitored values were heart rate, systolic and diastolic blood pressure, SaO2 and peripheral blood flow. Values were registered into computer memory for further analysis. Group 1 received 7.2 ml of PF to the buccal sulcus just distal of the second upper right molar and 7.2 ml of LE to the left buccal sulcus ten minutes later. Group 2 had the same injection positions but they received 3.6 ml of PF to both sides of maxilla and then, ten minutes later, 3.6 ml of LE to each side. RESULTS: There were no radical changes in systolic or diastolic blood pressure. The blood oxygen saturation values were constant and the displayed SaO2 values were between 96-98% during the measurement period. Mean heart rate decreased about 10 beats/min after PF injection and increased about 10 beats/min after injection of LE in both groups. The peripheral blood flow (pbf) was the most sensitive parameter in our measurements. In general, pbf diminished in the period preceding the injection. It showed lowest values during the injection phases in both groups. CONCLUSIONS: Despite large doses of local anesthetics SaO2, systolic and diastolic blood pressure showed no clinically important changes, which suggests that local anesthetics have only a minimal effect on parameters mentioned above. This means that if the effect of one local anesthesia preparate (PF) is not sufficient, it is possible to safely reinforce the anesthesia with another substance (LE) in young healthy patients. Additionally, heart rate and pbf demonstrated quite clearly the symphatetic stimulation effect of the stress of injection and the stimulating action of epinephrine was seen clearly in heart rate values in both groups.

Effect of dihydroergotamine on leg blood flow during combined epidural and general anaesthesia and postoperative deep vein thrombosis after cholecystectomy.

The effects of dihydroergotamine (DHE) on the circulation of the leg during combined epidural and general anaesthesia were studied to determine if DHE would enhance leg blood flow and prevent postoperative deep vein thrombosis in a double-blind trial of 40 elderly female patients subjected to cholecystectomy. Central and big toe temperature, arterial blood pressure, heart rate, calf volume and arterial inflow of the leg by electrical impedance plethysmography and the venous outflow by Doppler method were measured. DHE 0.5 mg subcutaneously reduced the volume of the leg, i.e. increased the electrical impedance, probably due to venous vasoconstriction. Simultaneously the need for etilefrine hydrochloride was reduced. No significant changes in the pulsatile inflow of the leg or the outflow were detected. Deep vein thrombosis (DVT) was detected by fibrinogen uptake test in five patients (three in DHEH and two in the control group) and verified by ascending phlebography in four patients. Intraoperative characteristics in patients with postoperative DVT were tachycardia (P < 0.001), enhanced need for etilefrine (P < 0.01) and a more rapid increase in big toe temperature (P < 0.05) after induction of epidural analgesia, compared with patients without DVT. Femoral vein flow velocity remained at the preinduction level, whereas pulsatile arterial inflow slightly increased. Together with a low basal impendance of the leg, the changes were indicative of a more intense vasodilatation, probably leading to stagnant flow and development of postoperative deep vein thrombosis.

Introduction of a new patient monitoring system during dental procedures: pulse oximetry.

This paper describes three cases of early detection of hypoxia with pulse oximeter during intravenous sedation. In the main study group over 40 patients were monitored by pulse oximetry during large dental operation under iv-sedation. Diatsepam with soybean oily solvent and midatsolam were used as intravenous sedative agents in this study. The first signs of hypoxia were seen by pulse oximetry. In three healthy patients some periods of remarkable hypoxia was detected and those cases are reported in this paper. Two of the patients were treated by a surgical operation and one patient underwent large conservative dental treatment under sedation because of dental care fobia. During the dental treatment period external oxygen was added for all these three patients to avoid more complications as a result of hypoxia. Two of the patients received an injection of bentsodiatsepine antagonist, too. One patient needed further follow up but non of these patients developed any additional complications. As a conclusion pulse oximetric monitoring was found to be extremely sensitive as a predictor for coming complications as well as allowing early intervention in ventilation problems.

Ultrasound-facilitated central venous cannulation.

OBJECTIVE: To compare the conventional method for cannulation of the internal jugular vein with the ultrasound-aided technique. DESIGN: Prospective, randomized trial. SETTING: Medical and surgical patients requiring central cannulation in a university hospital. PATIENTS: Consecutive medical and surgical patients in whom central venous cannulation was indicated. INTERVENTIONS: Cannulation of the internal jugular vein was performed by one anesthesiologist. During the first 6 months, the ultrasound-aided technique (n = 29) was used, and during the second 6 months, the conventional technique (n = 27) was applied. MEASUREMENTS AND MAIN RESULTS: The venous lumen was reached with fewer punctures (1.2 +/- 0.5 vs. 3.3 +/- 3.0 punctures per patient) and the cannulation time was shorter (35 +/- 19 vs. 198 +/- 211 secs) while using the ultrasound-aided technique. The ultrasound-aided method showed that the large-bore (diameter greater than 2.0 mm) needles invariably perforated the medial wall of the internal jugular vein, increasing the risk of perforating the adjacent carotid artery. CONCLUSIONS: Ultrasound guidance reduces both the duration of time and the number of punctures required to cannulate the internal jugular vein. The Seldinger technique appears safer for catheterization of the internal jugular vein.

Double blind comparison of transdermal hyoscine and placebo for the prevention of postoperative nausea.

Transdermal hyoscine (Scopoderm, Ciba-Geigy) has been compared with placebo in 283 female patients. The hyoscine patch had no significant effect on postoperative nausea or vomiting. In contrast with earlier studies, there was no correlation between previous experiences of nausea (motion, pregnancy or surgery related) and nausea caused by the surgery or anaesthetic in this study. No correlation was found between nausea or vomiting and the type of operation.

[Comparison of bupivacaine hydrochloride 0.5% and bupivacaine carbonate 0.5% in interscalene plexus anesthesia]. / Vergleich von Bupivacain Hydrochlorid 0.5% und Bupivacain Carbonat 0.5% in der interscalenären Plexusanaesthesie.

Carbonated local anesthetics are less acidic than the hydrochlorides and require less buffering by the tissues. Rapid buffering and diffusion of the carbon dioxide enables free base to be deposited in high concentrations on nerve fibres. Carbon dioxide increases the intracellular hydrogen ion concentration, thus increasing the amount of active cation at the receptor site. The interscalene approach to the brachial plexus was chosen for comparison of bupivacaine hydrochloride 0.5% and carbonated bupivacaine 0.5%. The interscalene route has many potential advantages, including anesthesia of the shoulder and reliable block of the musculocutaneous nerve, but large volumes of local anesthetic solutions are needed. The use of such volumes may exceed the limit of toxicity. Therefore, the plasma concentrations produced by 40 ml of local anesthetic solution were studied in 42 patients for whom brachial plexus block was considered a suitable technique. The latency of onset of sensory analgesia was shortest and with the least variability in the dermatomes C5-C7. The first analgesia was detected by pinprick 5.1 +/- 0.4 (SE) min and complete analgesia in 19 +/- 1 min after bupivacaine hydrochloride and 4.7 +/- 0.5 min and 15 +/- 1 min after bupivacaine carbonate. The more caudad nerves showed a significantly longer latency time than the more cephalad ones. The duration of sensory analgesia varied between 6 and 12 hours, the more caudad nerves showing the shortest duration.(ABSTRACT TRUNCATED AT 250 WORDS)

[Peridural anesthesia with bupivacaine-CO2 and bupivacaine-HCl. A comparative study]. / Periduralanaesthesie mit Bupivacain-CO2 und Bupivacain-HCl. Eine vergleichende Untersuchung.

Carbonated bupivacaine and bupivacaine hydrochloride were used for epidural anaesthesia in patients undergoing surgery of the lower extremities. Thirty patients received 20 ml 0.5% bupivacaine hydrochloride and 32 patients 20 ml 0.42% carbonated bupivacaine. Carbonated bupivacaine had a more rapid onset of action and spread of both sensory and motor blockade than its hydrochloride salt. The differences were statistically significant.

Venous sequelae after intravenous propofol ('Diprivan')--a comparison with methohexitone in short anaesthesia.

Propofol, in emulsion formulation, was compared with methohexitone for short duration anaesthesia with the main emphasis on acute and long-term venous tolerance. Flunitrazepam and fentanyl were given to all the patients. Fifty-two female patients undergoing short gynaecological procedures were randomly allocated to two groups to receive propofol or methohexitone as the intravenous anaesthetic agent. The dose of propofol was 2.0 mg/kg at induction with an average total dose of 2.58 mg/kg and the dose of methohexitone was 1.5 mg/kg and 2.20 mg/kg, respectively. Propofol or methohexitone were given through a 1.0 mm Teflon indwelling cannula in a superficial vein of one hand. All other drugs were given through a similar cannula in the other hand. There were no significant differences in acute or late tolerance between the propofol and methohexitone or control (all other drugs) groups. Because there was no thrombophlebitis following either drug the venous tolerance of both drugs can be regarded as good. Moreover this type of short anaesthesia was characterized with fast recovery and high patient acceptance.

Midazolam vs lorazepam and placebo as hypnotic premedication before surgery. A controlled, double-blind study.

The efficacy of midazolam vs lorazepam and placebo was studied in 60 patients in a comparative, double-blind study. Midazolam 15 mg and lorazepam 2.5 mg were given orally in a single dose the night before operation. Sleep latency was shortest on midazolam but the mean duration of sleep longest on lorazepam. Four patients on lorazepam complained of headache and one reported tinnitus. Three patients receiving midazolam complained of headache. Headache was observed also in one patient given placebo and another experienced tachycardia. Midazolam administered the night before surgery is a preferable hypnotic for transient insomnia caused by preoperative anxiety.

Intravenous premedication with diazepam. A comparison between two vehicles.

Two preparations of diazepam, Valium Roche mixed Micelles and Diazemuls, were compared as intravenous premedicants in 119 patients undergoing minor gynaecological surgery. There were no differences between the formulations with regard to anxiolytic effects and systemic tolerance. There were no symptoms typical of thrombophlebitis in the Valium Roche Mixed-Micelles group and only one case in the Diazemuls group. Acute local tolerance was similar with both trial drugs and superior to conventional diazepam preparations. Based on the favourable results of the present study it can be concluded that such vehicles should be considered for any injectable preparation with a known tendency to produce venous irritation.

Effect of hydroxyethyl starch and dextran on plasma volume and blood hemostasis and coagulation.

Six healthy male subjects were given in a crossover fashion medium molecular weight (HES 125) and low molecular weight (HES 40) hydroxyethyl starch, dextran, and balanced salt solution by intravenous infusion. The plasma volumes were determined using labeled albumin and plasma protein measurements. Three properties of factor VIII protein complex and indices of blood coagulation and hemostasis were measured before and after the infusions. Both the salt solution and HES 40 increased plasma volume, but their effect wore off within 3 hours. Dextran and HES 125 increased plasma volume significantly (P less than 0.001) more than the salt solution did, and the expansion was maintained for 24 hours. Plasma volume increases (dextran and HES 125) were associated with high nonglucose carbohydrate levels in plasma and low levels in urine. No or slight increases in plasma volumes (HES 40), on the other hand, were associated with low and high carbohydrate levels in plasma and urine, respectively. Serum alpha-amylase activity increased significantly after both HES preparations as compared to salt solution. Dextran and HES 125 decreased all the three values of factor VIII, these decreases being maximal 3 to 6 hours after administration and highest (about 25 per cent) for F VIII R:Ag and F VIII R:cof. It is concluded that HES 125 and dextran are equally effective plasma expanders.

Midazolam and fat-emulsion diazepam as intramuscular premedication. A double-blind clinical trial.

Sixty female patients were given, in random order, under double-blind conditions, either midazolam or fat-emulsion diazepam, intramuscularly, as premedication, 1 h before general anaesthesia. The dose of midazolam used was 0.13 mg/kg and that of diazepam 0.17 mg/kg. The degree of sedation, mood of the patient, and time at which onset of effect was perceptible were assessed before induction of anaesthesia, together with skin temperature and concentrations of midazolam or diazepam in plasma. Patients were interviewed postoperatively to discover their subjective evaluation of the premedication and to assess its amnesic effects. Midazolam was significantly superior (P less than 0.05) to diazepam as regards sedation. There were no differences in effects on mood of the patients between the two groups. Sixteen patients in the diazepam group and four in the midazolam group had no perception of onset of effect. The difference is significant (P less than 0.01). The skin temperature was, on average, 2 degrees C higher in the midazolam group than in the diazepam group (P less than 0.005). The mean plasma concentration was 67.8 +/- 24.5 micrograms/l in the midazolam group and 44.8 +/- 25.7 micrograms/l in the diazepam group. In only two cases was the concentration of diazepam above 100 micrograms/l (arbitrarily defined as the minimum sedative concentration). Subjective evaluation of efficacy significantly (P less than 0.002) favoured midazolam. Local pain was evident in two patients in the diazepam group, and three patients experienced nausea immediately after administration of the drug.(ABSTRACT TRUNCATED AT 250 WORDS)

The efficacy and plasma concentrations of flunitrazepam after oral or intramuscular premedication.

Flunitrazepam premedication administered orally or intramuscularly was compared in 41 surgical patients. The effect of the premedication was assessed both subjectively and objectively. The plasma concentrations were determined just before induction. The mean (+/-SD) plasma concentration in the oral premedication group was 8.2 +/- 2.2 ng/ml and 7.9 +/- 4.6 ng/ml in the intramuscular premedication group. There was a highly significant correlation (p less than 0.001) between the sedative effect and plasma concentration of flunitrazepam in all patients. Oral flunitrazepam was equal to i. m. flunitrazepam as an anxiolytic and sedative with a rapid onset of action. However, the oral route of administration of flunitrazepam is preferable because it is painless and easy to administer.