Nonspecific vasodilatation during iontophoresis is an important confounding factor in experimental pharmacology. In this investigation, we studied the involvement of sensory nerves and histamine-related reactions in causing nonspecific vasodilatation in a model of anodal and cathodal iontophoresis of sodium chloride. Firstly, we applied a mixture of local anesthetic (EMLA) cream to confirm its suppressive effect on nonspecific vasodilatation and to measure its efficacy in three different dosages (duration: 1, 2, and 3 h). We then investigated the role of histamine in nonspecific vasodilatation by giving an oral antihistamine drug (cetirizine) to subjects who had and had not been given EMLA. We found substantial suppression of the nonspecific vasodilatation in all EMLA-treated groups (all dosages) compared with untreated controls (with suppression rates of 60–65%). Dosage had no significant effect. A further suppression of nonspecific vasodilatation was seen after oral cetirizine during anodal and cathodal iontophoresis in both EMLA-treated and untreated groups. The antihistamine effect was most pronounced during anodal iontophoresis. These results suggest a histaminergic increase in perfusion that may be independent of neurogenic mechanisms and depend on polarity (anode or cathode). Local nerve blocks (EMLA) together with cetirizine may therefore be used to reduce nonspecific vasodilatation in both anodal and cathodal iontophoresis.

Background: In a mass casualty situation, medical personnel must rapidly assess and prioritize patients for treatment and transport. Triage is an important tool for medical management in disaster situations. Lack of common international and Swedish triage guidelines could lead to confusion. Attending the Advanced Trauma Life Support (ATLS) provider course is becoming compulsory in the northern part of Europe. The aim of the ATLS guidelines is provision of effective management of single critically injured patients, not mass casualties incidents. However, the use of the ABCDE algorithms from ATLS, has been proposed to be valuable, even in a disaster environment. The objective for this study was to determine whether the mnemonic ABCDE as instructed in the ATLS provider course, affects the ability of Swedish physician's to correctly triage patients in a simulated mass casualty incident.Methods: The study group included 169 ATLS provider students from 10 courses and course sites in Sweden; 153 students filled in an anonymous test just before the course and just after the course. The tests contained 3 questions based on overall priority. The assignment was to triage 15 hypothetical patients who had been involved in a bus crash. Triage was performed according to the ABCDE algorithm. In the triage, the ATLS students used a colour-coded algorithm with red for priority 1, yellow for priority 2, green for priority 3 and black for dead. The students were instructed to identify and prioritize 3 of the most critically injured patients, who should be the first to leave the scene. The same test was used before and after the course.Results: The triage section of the test was completed by 142 of the 169 participants both before and after the course. The results indicate that there was no significant difference in triage knowledge among Swedish physicians who attended the ATLS provider course. The results also showed that Swedish physicians have little experience of real mass casualty incidents and exercises.Conclusion: The mnemonic ABCDE doesn't significantly affect the ability of triage among Swedish physicians. Actions to increase Swedish physicians' knowledge of triage, within the ATLS context or separately, are warranted.

In evaluation of military training and exercises, shortcomings are often expressed in general terms. This makes it difficult to know exactly what needs improvement. Lessons that should be learned are merely observed. It is necessary to apply a systematic and quantitative approach to this problem and tools are now accessible. Performance indicators have already been tested on a military exercise and have proved to be possible to apply. The present study has looked into these performance indicators in more detail. The standards set for civilian use should be able to meet in ten out of eleven cases. The performance indicator where the goal is most likely not to be achieved is to have the first patient evacuated within 15 minutes. The next step is to apply this set of indicators on basic military training, formal pre-mission training as well as applied exercises in the mission area.

BACKGROUND AND OBJECTIVES: Organizations involved in disaster response often have a defined operative level of management (command and control) that can take the overall decisions regarding the mobilization and distribution of resources and distribution of casualties. This level of management can be referred to as strategic management. The aim of this pilot study was to show the possibility, in simulation exercises, to relate decisions made regarding resources to patient outcome. METHODS: The simulation system used measures to determine if lifesaving interventions are performed in time or not in relation to patient outcome. Evaluation was made with sets of performance indicators as templates and all management groups were evaluated not only as to how the decisions were made (management skills), but also how staff work was performed (staff procedure skills). RESULTS: Owing to inadequate response and insufficient distribution of patients to hospitals, 11 'patients' died in the simulated incident, a fire at a football stand with subsequent collapse. The strategic level of management received 16 points out of a possible 22 according to a predesigned template of performance indicators. CONCLUSION: The pilot study demonstrated the possibility to, in simulation exercises, relate decisions made regarding resources to patient outcome. This training technique could possibly lead to increased knowledge in what decisions are crucial to make in an early phase to minimize mortality and morbidity. © 2008 Lippincott Williams & Wilkins, Inc.

The aim of the study was to evaluate the Swedish medical systems response to a mass casualty burn incident in a rural area with a focus on national coordination of burn care. Data were collected from two simulations of a mass casualty incident with burns in a rural area in the mid portion of Sweden close to the Norwegian border, based on a large inventory of emergency resources available in this area as well as regional hospitals, university hospitals and burn centres in Sweden and abroad. The simulation system Emergo Train System (R) (ETS) was used and risk for preventable death and complications were used as outcome measures: simulation I, 18.5% (n = 13) preventable deaths and 15.5% (n = 11) preventable complications; simulation II, 11.4% (n = 8) preventable deaths and 11.4% (n = 8) preventable complications. The last T1 patient was evacuated after 7 h in simulation I, compared with 5 h in simulation II. Better national coordination of burn care and more timely distribution based on the experience from the first simulation, and possibly a learning effect, led to a better patient outcome in simulation II. The experience using a system that combines both process and outcome indicators can create important results that may support disaster planning.

Background

Timely decisions concerning mobilization and allocation of resources and distribution of casualties are crucial in medical management of major incidents. The aim of this study was to evaluate documented initial regional medical responses to major incidents by applying a set of 11 measurable performance indicators for regional medical command and control and test the feasibility of the indicators.

Methods

Retrospective data were collected from documentation from regional medical command and control at major incidents that occurred in two Swedish County Councils. Each incident was assigned to one of nine different categories and 11 measurable performance indicators for initial regional medical command and control were systematically applied. Two-way analysis of variance with one observation per cell was used for statistical analysis and the post hoc Tukey test was used for pairwise comparisons.

Results

The set of indicators for regional medical command and control could be applied in 102 of the130 major incidents (78%), but 36 incidents had to be excluded due to incomplete documentation. The indicators were not applicable as a set for 28 incidents (21.5%) due to different characteristics and time frames. Based on the indicators studied in 66 major incidents, the results demonstrate that the regional medical management performed according to the standard in the early phases (1–10 min after alert), but there were weaknesses in the secondary phase (10–30 min after alert). The significantly lowest scores were found for Indicator 8 (formulate general guidelines for response) and Indicator 10 (decide whether or not resources in own organization are adequate).

Conclusions

Measurable performance indicators for regional medical command and control can be applied to incidents that directly or indirectly involve casualties provided there is sufficient documentation available. Measurable performance indicators can enhance follow- up and be used as a structured quality control tool as well as constitute measurable parts of a nationally based follow-up system for major incidents. Additional indicators need to be developed for hospital-related incidents such as interference with hospital infrastructure.

OBJECTIVE: The aim of this study was to show the possibility to identify what decisions in the initial regional medical command and control (IRMCC) that have to be improved. DESIGN: This was a prospective, observational study conducted during nine similar educational programs for regional and hospital medical command and control in major incidents and disasters. Eighteen management groups were evaluated during 18 standardized simulation exercises. MAIN OUTCOME MEASURE: More detailed and quantitative evaluation methods for systematic evaluation within disaster medicine have been asked for. The hypothesis was that measurable performance indicators can create comparable results and identify weak and strong areas of performance in disaster management education and training. Methods: Evaluation of each exercise was made with a set of 11 measurable performance indicators for IRMCC. The results of each indicator were scored 0, 1, or 2 according to the performance of each management group. RESULTS: The average of the total score for IRMCC was 14.05 of 22. The two best scored performance indicators, No 1 "declaring major incident" and No 2 "deciding on level of preparedness for staff" differed significantly from the two lowest scoring performance indicators, No 7 "first information to media" and No 8 "formulate general guidelines for response." CONCLUSION: The study demonstrated that decisions such as "formulating guidelines for response and "first information to media" were areas in initial medical command and control that need to be improved. This method can serve as a quality control tool in disaster management education programs.

BACKGROUND: This study evaluates the effects of early rapid control of multiple bowel perforations on cardiovascular and pulmonary function in high-energy traumatic shock compared with conventional small bowel resection anastomosis.

METHODS: Fifteen anesthetized pigs, 10 to 12 weeks old, were exposed to a reproducible high-energy trauma and were divided into two groups. In the first group, the resection anastomosis group (RA, n = 8), small-bowel injuries were treated with resection and anastomosis; in the second group, the multiple bowel ligation group (BL, n = 7), small-bowel injuries were treated by resection and ligation. Repeated measurement analysis of variance was used to study the within group change overtime, the between group difference, and the interaction between them. Mean outcome measures were intravascular pressures, cardiac output, vascular resistance, lactic acid, and blood gases.

RESULTS: The high-energy injuries caused traumatic shock in both groups with reduced cardiac output (p < 0.001) and lactic acidemia (p < 0.001). The BL group had a trend for higher cardiac output (p = 0.06). The rise in systemic and pulmonary vascular resistance was significantly reduced in the BL group compared with the RA group (p < 0.05). The BL group had a strong trend for higher oxygen extraction ratio (p = 0.06). There was a trend for less oxygen consumption in the BL group (p = 0.07). There was no difference in the lactic acidemia between the two groups.

CONCLUSIONS: Early rapid control of multiple bowel perforations after high-energy trauma resulted in less impairment of cardiovascular function than conventional resection anastomosis of the bowel.

Background: Abdominal compartment syndrome (ACS) may lead to bacterial translocation and possibly be of importance for development of multiorgan failure. However, the underlying mechanisms have not been fully elucidated. In a porcine model we recently demonstrated preserved intestinal mucosal blood flow during experimental short duration ACS. In the present study we used the same model to determine mucosal barrier function and morphology in the small bowel and colon of pigs before and after short term ACS.

Methods: The study comprised 12 anaesthetized pigs exposed to experimental ACS and 6 control animals. Via laparotomy, samples of small bowel and colon were taken out for studies before short term ACS, where the abdomen was inflated with CO2 and IAP was increased stepwise by 10 mm Hg at 10-minute intervals up to 50 mm Hg, and again 10 minutes after exsufflation. Mucosal microcirculation was measured by laser Doppler flowmetry, and mucosal tissues were mounted in modified Ussing chambers for assessment of barrier function (E. coli K12 uptake and 51Cr-EDTA permeability). Specimens were also fixed in formaldehyde, stained with eosin-hematoxylin and evaluated blindly using an 8-grade scale for assessment of mucosal damage.

Results: Transmucosal passage of E. coli was three-fold increased in the small bowel after ACS (22.6 [18.2 – 54.4] units) vs. baseline (8.1 [2.0 – 13.9]; P< 0.050) with a significant correlation to alterations of mucosal microcirculation. In the colon bacterial passage was unchanged, whereas 51Cr-EDTA permeability after ACS increased to 181% of baseline (P<0.05) and was correlated to significant mucosal histopathological changes (P<0.03).

Conclusion: Short term ACS with reperfusion induced significant dysfunction of the intestinal mucosal barrier. The response patterns concerning barrier dysfunction differed between small bowel and colonic mucosa, with increased bacterial passage and paracellular permeability, respectively.

Aims: The aim of this study was to evaluate the effects of early rapid control of multiple bowel perforations on cardiovascular function in combined abdominal missile trauma and haernorrhagic shock compared with conventional surgery.

Methods: Eighteen anesthetised pigs were injured with a standardised abdominal missile trauma. The animals were bled to a mean arterial pressure of 50 mm Hg for 30 minutes, after which they were resuscitated and had laparotomy. They were divided into conventional surgery group (n=9) with primary resection and anastomosis of bowel injuries and early rapid multiple bowel ligation group (n=9). Repeated measurement analysis of variance was used for analysis.

Results: There was profound hypotension, reduced cardiac output, increased vascular resistance and lactic acidaemia in both groups. Lactic acidaemia persisted longer in the early rapid multiple bowel ligation group. There were no significant differences in mean arterial pressure, cardiac output, stroke volume or systemic vascular resistance between the groups. The mean operation time was significantly shorter in the early rapid multiple bowel ligation group (13.3 (1.5) (SEM) minutes, compared with 116.4 (1.74) (SEM) minutes in the conventional surgery group, p = <0.001).

Conclusions: Damage control principles have shortened the operating time in our model but did not improve the cardiovascular function and caused more lactic acidaemia than conventional repair.

The objective of this paper is to demonstrate a possible tool for the use of a quantitative research method that can be applied in disaster medicine.

Method: Stepwise, using the technique of concept and process modelling, key processes in forms of performance indicators for command and control at disaster and major incidents were identified. A standard was linked to each indicator. Based in these indicators, an educational program was developed. In this program results from examinations were expressed in numbers and can thereby allow statistical methods to be applied.

Results: Application of this model on prehospital command and control demonstrated weak and strong points. The method has been implemented in 13 out 21 regions and is used as a quality control tool.

Conclusions: The use of performance indicators developed by using results from modelling processes could possibly serve as a tool for conducting quantitative research in disaster medicine.

Objective. The 'Swede information system' was introduced in a county with approximately 450,000 inhabitants in April 2000. The implementation of this information system, intended to be operative in major incidents and disasters, has included the introduction of new technologies as well as new standard operating procedures for both ambulance crews and hospital staff. The objective of this study was to see how this information system with digitally mediated transmission was used as a daily routine during a 2-month period, 1 year after its introduction. Methods. The Swede information system sends on-line information from ambulances to emergency wards in the county. The technique used is a LAN (local area net) for communication within the site of the accident, Mobitex® from the ambulances to a data server and from this by Internet to the hospitals. During March and April 2001 all events when an ambulance was dispatched were recorded. All cases when the system was used to notify the receiving hospital were recorded as well as all cases when the ambulance crew alerted the hospital through the alert function. All technical problems and any period of time when the system was 'out of use' were noted. Results. During the period of the study, the system was successfully used to transfer data from the scene to hospital in a total of 3353 missions, including transport of a patient from the scene to an emergency department. Of these, in 150 transports the transferred data served as a base for immediate support on arrival at the hospital that was of critical importance for primary management in the hospital. In all, 2883 different kinds of medical data were transmitted. The local help-desk was notified of problems with the system on 11 occasions; six of these were technical problems and the rest were user-related. The IS Swede system was not operational during parts of 3 days (<5%) of the time. Conclusions. Despite the introduction of new equipment and new standard operating procedures, IS Swede was accepted within the organization to a degree which could be considered operational in major incidents. Technical problems with IS Swede caused only minor disturbances during the study period.

Objectives: To determine if an on-line information system is superior to a conventional ambulance file system regarding the possibility of retrieving information as follow-up in daily use and also with reference to disaster situations.

Materials and methods: The study was designed as a prospective study where two systems that have been operational for several years were compared. One system was a system primarily built for on-line registration and the other a conventional ambulance file system.

Results: In all aspects data regarding ambulance missions and patients were more thoroughly registered in the conventional file system. Also data were easier to retrieve with less time consumption compared to the on-line system.

Conclusion: The on-line information system studied was less accurate for storing and retrieving information than a conventional ambulance file system. Thus, more technical development is needed before this on-line system can be recommended for use in major incidents or disasters.

The objective of this study was to determine if a set of performance indicators could indicate what part of medical command and control needs to be improved in a training concept designed for medical officers at major incidents. A set of 11 different performance indicators previously proposed was used as a template when examining ambulance staff in medical command and control. The results were graded 0 to 2 where 0 = not acceptable, 1 = partially correct and 2 = correct. A total of 46 examinations comprising more than 200 students was included. Performing a correct second report (score 1.15), the ability to establish general guidelines for medical response (score 1.20), setting level of medical ambition (score 1.24) and informing media (score 1.33) had significantly lower scores than the other performance indicators. Performance indicators for medical management in a major incident can be used in a training setting for identifying areas that need improvement.

INTRODUCTION: In stressful situations such as the management of major incidents and disasters, the ability to work in a structured way is important. Medical management groups initially are formed by personnel from different operations that are on-call when the incident or disaster occurs.

OBJECTIVE: The aim of this study was to test if performance indicators for staff procedure skills in medical management groups during simulations could be used as a quality control tool for finding areas that require improvement.

METHODS: A total of 44 management groups were evaluated using performance indicators in which results could be expressed numerically during simulations.

RESULTS: The lowest scores were given to documentation and to the introduction of new staff members. The highest score was given the utilization of technical equipment.

CONCLUSIONS: Staff procedure skills can be measured during simulations exercises. A logging system may lead to enhancing areas requiring improvement.