One year ago not business as usual: wound management, infection and psychoemotional control during tertiary medical care following the 2004 Tsunami disaster in southeast Asia.

INTRODUCTION: Following the 2004 tsunami disaster in southeast Asia severely injured tourists were repatriated via airlift to Germany. One cohort was triaged to the Cologne-Merheim Medical Center (Germany) for further medical care. We report on the tertiary medical care provided to this cohort of patients. METHODS: This study is an observational report on complex wound management, infection and psychoemotional control associated with the 2004 Tsunami disaster. The setting was an adult intensive care unit (ICU) of a level I trauma center and subjects included severely injured tsunami victims repatriated from the disaster area (19 to 68 years old; 10 females and 7 males with unknown co-morbidities). RESULTS: Multiple large flap lacerations (2 x 3 to 60 x 60 cm) at various body sites were characteristic. Lower extremities were mostly affected (88%), followed by upper extremities (29%), and head (18%). Two-thirds of patients presented with combined injuries to the thorax or fractures. Near-drowning involved the aspiration of immersion fluids, marine and soil debris into the respiratory tract and all patients displayed signs of pneumonitis and pneumonia upon arrival. Three patients presented with severe sinusitis. Microbiology identified a variety of common but also uncommon isolates that were often multi-resistant. Wound management included aggressive debridement together with vacuum-assisted closure in the interim between initial wound surgery and secondary closure. All patients received empiric anti-infective therapy using quinolones and clindamycin, later adapted to incoming results from microbiology and resistance patterns. This approach was effective in all but one patient who died due to severe fungal sepsis. All patients displayed severe signs of post-traumatic stress response. CONCLUSION: Individuals evacuated to our facility sustained traumatic injuries to head, chest, and limbs that were often contaminated with highly resistant bacteria. Transferred patients from disaster areas should be isolated until their microbial flora is identified as they may introduce new pathogens into an ICU. Successful wound management, including aggressive debridement combined with vacuum-assisted closure was effective. Initial anti-infective therapy using quinolones combined with clindamycin was a good first-line choice. Psychoemotional intervention alleviated severe post-traumatic stress response. For optimum treatment and care a multidisciplinary approach is mandatory.

The long-distance tertiary air transfer and care of tsunami victims: injury pattern and microbiological and psychological aspects.

OBJECTIVE: On December 26, 2004, a giant earthquake shocked Southeast Asia, triggering deadly flood waves (tsunami) across the Indian Ocean. More than 310,000 people have been reported dead and millions left destitute. Shortly thereafter, European governments organized airborne home transfer of most severely injured tourists using MedEvac aircraft. On arrival, patients were distributed to various medical centers. One cohort of the severely injured was admitted to the Cologne-Merheim Medical Center (Germany) for further surgical and intensive care treatment. The objective of this report was to characterize typical injury patterns along with microbiological findings and psychoemotional aspects unique to the tsunami disaster. DESIGN: Observational study. SETTING: Adult intensive care unit of a university hospital. PATIENTS: Seventeen severely injured tsunami victims were screened on arrival for characteristic injury patterns. In parallel, multifocal microbiological assessment was performed to identify pathogens responsible for high-level wound contamination. INTERVENTIONS: Standard clinical management. MEASUREMENTS AND MAIN RESULTS: The predominant pattern of injury comprised multiple large-scale soft-tissue wounds (range, 2 x 3 to 60 x 60 cm) of lower extremities (88%), upper extremities (29%), and head (18%). Additional injuries included thoracic trauma with hemopneumothorax and serial rib fractures (41%) and peripheral bone fractures (47%). A major problem associated with wound management was significant contamination. Microbiological assessment identified a variety of common (Pseudomonas 54%, Enterobacteriae 36%, Aeromonas spp. 27%) but also uncommon isolates that were often multiply resistant (multiply resistant Acinetobacter and extended-spectrum beta-lactamase-positive Escherichia coli, 18% each). Upper respiratory tract specimens contained a high rate of multiply resistant Acinetobacter species but also methicillin-resistant Staphylococcus aureus, Aeromonas hydrophilia, Pseudomonas species, and Candida albicans. Apart from these findings, all patients displayed severe signs of posttraumatic stress response. CONCLUSIONS: Individuals who survived their initial injuries and who were evacuated to Europe had traumatic injuries to head, chest, and limbs that were often contaminated with highly resistant bacteria.

Reduced colonization and infection with miconazole-rifampicin modified central venous catheters: a randomized controlled clinical trial.

OBJECTIVE: Central venous catheters (CVC) are a major cause of nosocomial bloodstream infections. Catheters modified with miconazole and rifampicin that constantly and slowly release antimicrobial substances are assumed to be beneficial in reducing rates of colonization and catheter-related infections. DESIGN AND SETTING: Prospective controlled non-blinded randomized clinical trial in two German university hospitals. PATIENTS: 223 adult inpatients with CVC between October 2000 and February 2002. Baseline characteristics, APACHE II score and therapeutic interventions were comparable. INTERVENTION: Randomization to receive either a miconazole and rifampicin modified catheter (n=118) or a standard triple-lumen CVC (n=105). MEASUREMENTS, DEFINITIONS: Microbiological evaluation was done after CVC removal. A catheter was considered colonized if growth of > or =15 cfu was found by semi-quantitative roll-plate technique from a proximal or distal catheter segment. A catheter-related infection (CRI) was defined as a colonized catheter with local signs of inflammation. A catheter-related bloodstream infection (CR-BSI) was defined as a colonized catheter with isolation of the same organism from the patient's blood with accompanying clinical signs of infection. RESULTS: A colonization of CVC was observed in six patients (5.1%) with a modified catheter and 38 patients (36.2%) with a standard catheter (P < 0.001). Five patients in the modified group (4.2%) and 18 in the standard group (17.1%) developed CRI (P=0.002). One assumed CR-BSI was detected in the standard group, with none in the modified group. No adverse effects related to the modified catheters and no antimicrobial resistance were observed. CONCLUSION: CVC supersaturated with miconazole and rifampicin were associated with a significantly lower risk for catheter colonization and catheter-related infections compared to standard catheters.