There is controversy over the “ideal” electrical energy needed for defibrillation. Furthermore, too massive an electrical shock decreases the possibility of survival by direct damage to an already ailing myocardium and too little energy results in further deterioration of myocardial physiology and metabolism. Therefore, delivery of an erroneous amount of electrical energy decreases the likelihood of successful defibrillation and survival. All 190 defibrillators within 3 medical school hospitals were investigated. Each defibrillator was analyzed at four selected settings ranging from 100-400 Joules (J). Only 29 of 190 defibrillators delivered 100% of the energy selected, while 161 of the 190 (85%) delivered an average of 74% of the energy selected. This discrepancy between selected and delivered energy should be corrected by regulations and standards for manufacturers.

Three hundred cases of polytrauma were investigated to evaluate the reliability of the Lindsey severity index. This simplified injury score can be used by paramedics or low-skilled emergency practioners to obtain a correct screening of patients and an initial prognosis on the basis of a simple injury severity scale. An evaluation by the Lindsey index was done in the field and at the emergency care unit. Results compare the final status of the patient which was obtained using the Patel score, derived from the patient's chart after his discharge. The Lindsey index demonstrated a correct assessment of the patient's status in 60% of the cases at the scene of the accident and 77% in the emergency unit. Most of the errors were due to underevaluations of the skull and spinal trauma. Patel's scale emphasizes locomotor sequellae, while skeletal injuries seldom provide life-threatening events, widely considered in the Lindsey index. Lindsey's index is a simple and reliable tool for initial assessment and a useful method of teaching.

Mass disasters are exceptional situations, requiring exceptional efforts of medical services and institutions, to overcome the problems and consequences of those affected. According to a commonly accepted definition, a disproportion between objectively required and actually possible aid is the main distinguishing mark. In such a situation, the target function of health systems must change as much as possible to help save injured persons lives and to avoid severe consequences, because simultaneous aid for all is temporarily impossible.

Activity in nociceptive nerve fibers does not only trigger the sensation of pain but it also starts a variety of nocifensive reflexes to protect the organism from the noxious agent. Some of these reflexes may, if active long enough, be harmful themselves, causing ischemia in visceral organs or other inadvertent reactions. Recently, several endogenous mechanisms have been discovered that can inhibit the transmission of nerve impulses from nociceptive afferents to other nerve cells, thus not only preventing the pain sensation but also modulating the nocifensive reflex responses. Several such mechanisms may involve the release of endorphins. These are small peptides, with opiate-like activity that were first discovered in 1975 by Hughes and Kosterlitz in Great Britain and by Terenius in Sweden. The distribution of such endorphins in the central nervous system was first investigated by Hökfelt and his coworkers. They found terminals and cell bodies containing endorphins in several areas of interest from the point of view of nociception. Thus the dorsal horn of the spinal cord, the corresponding area of the fifth cranial nerve and the periaqueductal gray matter contained such material.

The concept of using Intravenous Regional Analgesia (IVRA) in the mass casualty situation is potentially an attractive alternative to the use of general anesthesia in the management of limb fractures. The purpose of this paper is to outline the history and development of the technique and emphasize important guidelines designed to increase the safety of the method.

In spite of the current interest in intraoperative reinfusion and the acknowledged benefits of the autologous versus homologous transfusions, this approach towards blood conservation and minimizing the risks inherent to blood transfusions (Table I) has not received the recognition which it properly deserves. Reluctance by surgeons to use this technique is undoubtedly due to the confusion which still exists in the literature regarding the possibility of complications in using this procedure. Widely divergent hematological abnormalities in the form of various coagulopathies and hypofibrinogenemia still appear in medical communications.

There is a great clinical need for readily available volume replacement fluids with the property of oxygen transport. From the fluorocarbone emulsions only stromafree hemoglobin solutions seem to meet the essential requirements of oxygen transport and delivery at the tissue level. However, the high oxygen affinity and the short intravascular persistence have been preventing, up until now, the application of hemoglobin solutions for blood replacement.

Recently, a modified hemoglobin solution with a decreased oxygen affinity and a long intravascular persistence, has been produced by binding pyridoxalphosphate to the hemoglobin and its subsequent crosslinking. The hemodynamics and oxygen unloading capacity of this pyridoxalated polyhemoglobin have been investigated in a model of total blood exchange.

The mortality rate for penetrating trauma of the abdomen has declined to a present rate of approximately 10%. However, blunt abdominal trauma still carries a high mortality, in some reports up to 30%. This is due mainly to major trauma with a resulting slow onset of symptoms sometimes resulting in a delay in diagnosis and treatment. One possible cause of delayed symptomatology after abdominal trauma could be delayed perforation of intestinal wall hemorrhages. A survey of the literature on this type of intestinal lesion was done in 1977 by Hughes et al, who found 260 clinical reports of intestinal wall hematomas.

Within the Stockholm region there are eleven emergency hospitals, six of which can send medical teams to the site of a disaster within fifteen minutes after an alarm. This ensures qualified first aid to the injured at the disaster site. Each team consists of the surgeon and anesthetist on duty and three nurses with special training in emergency medicine, anesthesia or intensive care. The personnel leaving the hospital are replaced by other personnel in the hospital. All members of the team are equipped with special clothing: an overall with dressings and other equipment in the pockets, a helmet and boots and warm underwear, allowing outdoor work at the low temperatures not infrequently met in the Swedish winter (Figures 1,2). Doctors and nurses have special markings, so that they are easily recognized.

An increasing amount of medical equipment is brought to the scene of a medical emergency. Most of these apparatus seem to be only slightly modified versions of equipment originally designed to be used inside the hospital. This equipment has to function in various extreme environmental conditions.

In acute respiratory failure, an immediate restoration of respiratory functions is imperative. Depending upon the available equipment and the qualifications of the physician and nursing staff, the most suitable ventilation procedure should be selected. In every case, accurate ventilation is accomplished by Intermittent Positive Pressure Ventilation (IPPV). If emergency equipment is not available, the simplest method of achieving this is mouth-to-mouth or mouth-to-nose breathing. The efficacy of this method is limited by the low FiO2 (about 17%) and by the physical condition of the first aider; after 30 minutes of resuscitation, even an experienced and well conditioned emergency rescuer will be exhausted.

Triage and rescue of casualties from accidents involving hazardous materials is a challenge for many emergency medical services (EMS) personnel. With very toxic materials, the untrained and unprepared rescuer may become a victim. In addition, few hospitals in the United States have decontamination units attached to their emergency departments and emergency department personnel may become exposed if the casualty is not decontaminated. Many environmental cleanup teams, including the U.S. Environmental Protection Agency (EPA) team, are well trained in materials handling but are not immediately available when a hazardous materials spill with personal injuries occurs.

There exists strong sentiment, among emergency medical personnel and physicians alike, that the pneumatic anti-shock garment (PASG) “saves lives.” As a result, controlled studies have been criticized as the “withholding of important therapy.” The purpose of this presentation is to confirm the need for controlled clinical trials of the PASG. Despite an early report that the PASG offered no advantage in terms of the presenting emergency center Trauma Score (TS), similar disparagements have continued, particularly because survival data were not discussed. The present report is a pilot analysis of the effect of the PASG on the prehospital survival of patients arriving at an urban trauma center in the United States. In the study, sixty-eight patients were assigned randomly to control and PASG groups in a prospective investigation involving injured patients with systemic hypotension. The 32 control patients, whose mean initial systolic blood pressure (BP) was 59 ± 32 mm Hg, and the 36 PASG-treated patients, whose mean initial BP was 55 ± 31 mm Hg, were found to be well matched for age, sex, type and location of injuries, initial field TS; response, field management, and transport times; and the total amount of intravenous crystalloid infused. The results demonstrated no significant difference between the control and PASG-treated groups in terms of those pronounced dead on arrival at the trauma center (9/32 vs. 10/36). Further studies are therefore justified to determine how the PASG affects the long-term morbidity and mortality of injury victims, particularly those within certain sub-groups such as penetrating abdominal versus those with penetrating thoracic injuries. This report reaffirms the need for early responsible, scientific scrutiny of prehospital interventions.

In 1981 we described the introduction and development of a coma scale for use in Head Injured patients. The scale has become adopted for routine use in the Accident and Emergency Unit at Pinderfields General Hospital, Wakefield, and at other centers, for example the Emergency Department at the Glasgow Royal Infirmary finds the scale more sensitive than its own Glasgow Coma Scale in monitoring the course of accident victims.

This brief examination of casualty patterns suggests that differences may exist in the numbers of immediately dead and critical patients, depending on the nature of the disaster. More data must be collected from future disasters to more accurately define relationships between critical patients and total numbers injured. Such characterization is essential for hospital disaster planning because critical patients require great resources and optimal hospital functioning.

Knowledge of casualty patterns can make disaster planning more practical, disaster drills more realistic, and disasters less disastrous.

The Emergency Medical Service System in Tokyo has been developed through the cooperative efforts and achievements of many. EMS in Tokyo consists of three parts: 1) the network system of emergency hospitals; 2) the transportation system of emergency patients (Ambulance System); and 3) the communications system (Emergency Medical Information System). Emergency services are controlled by the Japanese Ministry of Home Affairs and the Ministry of Health and Welfare. The former is in charge of ambulance and rescue services located in the fire department, the latter has to do with medical affairs.

The traditional hospital disaster plan is complex and inefficient. Implementation during an actual or perceived crisis usually results in the mobilization of the entire hospital staff and multiple medical resources. This “all or none” phenomenon is costly in terms of manpower and supplies. Furthermore, there is protracted disruption of normal hospital services during disaster plan activation for training or real emergencies.

The arrangements for dealing with Major Accidents in the United Kingdom are set out in the Health Circular (HC(77)1) which places the onus for planning on Health Districts—each district serving a population of no greater than 200,000. The Metropolitan Area of West Yorkshire, served by the West Yorkshire Metropolitan Ambulance Service, the West Yorkshire Metropolitan Police and the West Yorkshire Fire Service, takes in nine such districts and covers an area of 794,000 square miles and a population of just over two million. West Yorkshire is traversed by two motorways and a major trunk road.

In recent years, medical care in Sweden as in other small countries, has become increasingly dependent upon the availability of imported goods. The consequences of even limited import restrictions of drugs and supplies has necessitated special planning for such a contingency. Special difficulties in this respect would arise in the field of anesthesia and intensive care, as all drugs for general anesthesia, and almost all disposable items used in anesthesia and intensive care in Sweden, are imported. To solve this problem, it would be necessary to ration drugs and materials, increase domestic production, introduce resterilization of disposable equipment and again use nondisposable supplies. In addition, stores of drugs and supplies are being built up to be used as a reserve in case of blockade or war. The nursing standards would have to be changed, by delegation to other personnel so that nurses take a larger responsibility, and by using methods which are unusual or even unknown to the staff in service today, i.e. ether anesthesia.

For some time emergency ambulances have been in operation in Italy. In spite of their modern equipment, these ambulances often turn out to be unsuitable for a comfortable journey and do not have satisfactory working conditions. This is due to the lack of up-to-date standards for vehicles and equipment.