Triage is the process of classifying injured patients according to a predetermined hierarchy. Triage typically involves the urgency prioritization of trauma patients in mass casualty circumstances. The triage process is also used daily in Emergency Medical Systems that incorporate trauma care systems to identify how severely a patient is injured and to channel the patient into the appropriate treatment echelon, i.e., to determine a threshold level of severity that merits a specific level of care.

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.

Many disaster plans are based on the presence of a physician at the scene to perform triage. This requirement originated when there were no trained paramedical personnel in the field and may actually delay care in rural areas where a physician may not be readily available or may be the only physician at the hospital.

It is our hypothesis that properly trained Advanced Emergency Medical Technicians (AEMT's) may serve as triage officers for rural disasters with little difference, and perhaps improvement, in the outcomes of medical care. AEMT's are among the first responders to arrive at scenes of accidents and often triage from three to five trauma patients in multiple victim accidents on the highway. They are on duty, available and strategically located both day and night. The AEMT's are familiar with working under field conditions, i.e. at night by headlight, in rain, snow, and darkness, and know extrication procedures. They are aware of environmental hazards. They have radio and telemetry communication with a physician when needed.

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.

Although road accidents account for about 17% of hospital emergencies, they are the third commonest cause of death. Polytrauma is the main cause of death below the age of 40 years. Legislative action and safety measures (i.e. speed restriction, safety belts, safety helmets) and improvement in the hospital emergency care system in Germany resulted in a continuous reduction in road accident victims from about 19,000 in 1979 to about 12,000 in 1983. Additionally, the fall in personal injury resulted in savings of about 7,900 DM (US $3,000) in cases of minor injury, 79,000 DM (30,000 US$) in cases of severe injury and about 685,000 DM (280,000 US$) in cases where lives were saved.

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.

Head injury has been demonstrated to be one of the most important lesions in polytrauma patients and of very decisive relevance to the posttraumatic prognosis. Moreover, other lesions and their sequelae (e.g. shock, thorax trauma) are known to worsen the primary cerebral injury by causing secondary brain damage due to hypotension and hypoxemia. This study considers the influence of prehospital emergency care to the posttraumatic prognosis in severe head injuries.

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.

Controlled mechanical ventilation using positive and expiratory pressure (PEEP) is a well-established therapeutic measure in intensive care. Its early application has been shown to markedly decrease morbidity and mortality, especially in polytraumatized patients with an acute respiratory distresss syndrome. It therefore seems reasonable to use positive end expiratory pressure as early as possible in the clinical treatment of emergency patients before extensive pulmonary changes have had time to develop completely.

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.

The various disorders resulting from heat stress can be understood and treated from an understanding of the underlying pathophysiology. Broadly speaking, they can arise as a result of excessive heat production from the body, or impairment of heat loss to the environment. The normal responses of the body to attempt to lose heat, peripheral vasodilation and sweating, are the root causes of the main disorders. In the tropics, the high environmental heat load leads to a spectrum of illnesses ranging from chronic exhaustion to acute and lethal heat stroke. Cooling and correction of fluid and electrolyte disturbances are the key to their treatment. In temperate climates, variants seen commonly occur in those imposing a metabolic heat load by endurance exercise. In these cases, there is some evidence that hyperventilation plays a role in their development, and this merits paper-bag rebreathing in addition to cooling and rehydration, during treatment. Those assisting at sporting events should attempt to stop competitors as soon as they show signs of heat exhaustion, and must be aware that almost all competitors will be hyperthermic towards the finish, and should be cooled and rehydrated as soon as possible.

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.

Nineteen clinical cases of accidental hypothermia were treated with airway warming (AW) and the results compared with 18 cases which were allowed to rewarm spontaneously. AW accelerated the rate of rewarming and had beneficial effects on cardiac and cerebral function. In patients with chronic hypothermia, i.e. the elderly and those suffering from malnutrition, the accelerated rewarming increased the risk of developing pulmonary and/or cerebral edema which could prove fatal. The patients with acute hypothermia all rewarmed successfully but the mortality for the chronic hypothermic patients was higher in the AW group.

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.

The increasing popularity of scuba diving as a sport necessitates that emergency personnel become familiar with medical diving problems. It is important to understand that pulmonary barotrauma can be sustained with an uncontrolled ascent of little more than 1 meter. This can occur under any circumstance in which compressed air is breathed under water. The most common is scuba diving or submarine escape training, but it may also be encountered when a person escapes from a submerged car or a child surfaces after breathing from an inverted bucket in a swimming pool. Two cases of pulmonary barotrauma are reported and the spectrum of presentation of this condition is discussed.

Knowledge of this condition increases clinical awareness resulting in early diagnosis and effective treatment. It will be shown that it is better to over treat this condition, as the side effects of treatment are minimal and the results of failure to treat can be disastrous.

Scuba diving has become a popular sport resulting in an increased incidence of diving accidents. A survey done by the United States Navy from 1955 to 1960 revealed that decompression sickness (D.C.S.) is the most common serious complication experienced by scuba divers and the third most likely cause of death. The major cause is drowning and the second is arterial gas embolism from pulmonary barotrauma.

D.C.S. has been classified into two groups. Type I includes the less severe forms with bubbles in the skin (“itches”), joints and other tissues. Type II includes the serious conditions with neurological involvement “staggers.” A detailed knowledge of D.C.S., commonly known as “the bends,” is essential to both divers and emergency personnel in order to minimize the morbidity and mortality associated with this condition.

A case of Type II bends with spinal cord damage is presented and the condition discussed.

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.

Fluorocarbons, which strictly speaking should perhaps be termed perfluorocarbons or perfluorochemicals (PFCs), are organic compounds produced by extensive fluorination of relatively simple alphatic and aromatic chemicals. They have, over the last thirty or forty years, been used for a wide variety of purposes in both industrial and domestic fields. As a consequence of one of their physical properties, namely their high solubility for respiratory gases, they are being developed as constituents of oxygen transporting plasma substitutes. Preliminary trials are being carried out in Japan and the United States and PFCs may well be on the verge of entering routine clinical medicine.

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.