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Background: Emergency oral tracheal intubations in the pre-hospital setting can be more difficult because the rescuer's position with respect to a patient lying on the ground may not provide optimal conditions for intubation. Since optimal visualisation of the larynx often depends on the force generated during laryngoscopy, we measured the pressure required for intubation (P(i)) as well as the maximum pressure (P(max)) that can be generated with the laryngoscopy blade in seven intubator positions., Methods: Nineteen hospital personnel with intubation experience participated in this study. A modified #3 Macintosh laryngoscope blade was used to measure the pressure exerted on the tongue of a manikin placed on the ground during intubation. The following positions were studied: standard, sitting, prone, kneeling, left and right lateral decubitus and straddling., Results: Intubating in the straddling position required the lowest P(i), as a percent of P(max) (68+/-14%). This was significantly less than the prone, right lateral decubitus and sitting positions. (Tukey's W procedure, P<0.05), Conclusion: The straddling position affords the intubator significantly more reserve force than the prone, right lateral decubitus or sitting position. We suggest that the straddling position may be an advantageous position for pre-hospital intubations especially when visualisation of the glottis is difficult.

Objective: A recent thrombelastography study indicated a compromised in vitro blood coagulation after 10:10 (equal parts of blood and infusion) and 10:4 (10 parts blood to four parts infusion) hemodilution with several plasma substitutes. Oncovertin N (Oncovertin) (a 10% dextran 40 solution) had the strongest anticoagulant effect of all solutions tested, and HAES-sterile 10% (HAES) (a 10% hydroxyethyl starch 200/0.5 solution) showed the strongest effect of five different hydroxyethyl starch preparations. The aim of this study was to determine how in vitro hemodilution with HAES and Oncovertin affects the activity of coagulation factors., Design: HAES and Oncovertin were tested to determine the intrinsic effect of colloid molecules, as opposed to hemodilution. Normal saline (NaCl) and nonlactated Ringer solution were used as noncolloidal controls., Setting: University research institute., Patients: Six healthy volunteers., Interventions: Twenty milliliters of blood was obtained from each subject., Measurements and Main Results: Prothrombin index, activated partial prothrombin time, soluble fibrin monomers, and the activity of coagulation factors I, II, V, VII, VIII, IX, X, XI, and XII were measured with the Behring Chromotimer according to the manufacturer's instructions. Two dilution ratios of citrated blood to infusion were used: 10:10 (equal parts of blood and infusion) and 10:4 (10 parts blood to four parts infusion). Baseline was undiluted. Hemodilution with NaCl at both 10:4 and 10:10 influenced the coagulation variables measured. The activities of factors I, VII, and soluble fibrin monomers were less influenced than expected by hemodilution alone. The activities of factors II, V, IX, and XI were significantly (p <.04) lower with both 10:4 and 10:10 dilution with NaCl. In the assays for factors IX, XI, and XII, clots formed immediately after adding the appropriate reagents in the presence of Ringer solution at 10:10 hemodilution, so that the activities of those factors could not be measured. For the other factors and for 10:4 dilution, the outcome after Ringer solution was similar to that of NaCl. The activities were less influenced after 10:4 hemodilution with both HAES and Oncovertin than after dilution with NaCl and Ringer solution, with no significant differences from baseline. At 10:10 hemodilution with both HAES and Oncovertin, several factor activities were significantly (p <.04) lower than baseline., Conclusions: Both NaCl and Ringer solution cause measurable effects on coagulation factors at 10:4 hemodilution that can be explained by hemodilution alone. The effects on clotting factors of 10:4 hemodilution with HAES and Oncovertin were not significant. Even at 10:10 hemodilution with HAES or Oncovertin, the reduction in factor activities, although significantly (p <.04) different from baseline, was less than what was expected by dilution alone.

The Macintosh laryngoscope blade was compared with three modified blades--the Bizzarri-Giuffrida, the 'Improved Vision' Macintosh, and the Wiemers blade. Before and after a training session 24 participants intubated a Laerdal Airway Management Trainer with the four blades in random order. Intubation time was measured, oesophageal malpositions and 'clicks' indicating possible teeth damage, were counted. Each participant scored the handling of each blade on a 6-point scale (1 = very good, 6 = very poor). Intubation times before training were 10.6 +/- 5.3 s for the Macintosh, 16.7 +/- 9.2 s for the Bizzarri-Giuffrida, 13.3 +/- 9.0 s for the 'Improved Vision' Macintosh and 11.7 +/- 6.1 s for the Wiemers. Intubation times after training were 7.1 +/- 2.5 s for the Macintosh, 10.6 +/- 5.4 s for the Bizzarri-Giuffrida, 8.1 +/- 3.4 s for the 'Improved Vision' Macintosh and 7.6 +/- 2.5 s for the Wiemers. The handling scores were: 2.0 +/- 0.8 for the Macintosh, 3.9 +/- 1.2 for the Bizzarri-Giuffrida, 2.1 +/- 0.8 for the 'Improved Vision' and 2.3 +/- 0.8 for the Wiemers. In regard to the intubation time before training (P < 0.02), the intubation time after training (P < 0.003), and handling (P < 0.0005), the Bizzarri-Giuffrida was significantly inferior to the Macintosh. The 'Improved Vision' Macintosh and the Wiemers were not significantly different to the Macintosh. No significant difference was seen for oesophageal malpositioning and 'clicks' between any of the blades.

Unlabelled: Using a MEDLINE-based analysis, we studied the national origin of articles published in important anesthesia, pain, critical care, and emergency medicine journals. All journals in English listed in the Science Citation Index (SCI) of Journal Citation Reports under the subheadings Anesthesiology (n = 17) and Emergency Medicine & Critical Care (n = 13) were analyzed with the help of MEDLINE. Issues from 1996 and 1997 were included and summarized. Letters, abstracts, editorials, meeting reports, and news were not included. MEDLINE printouts were studied, and we classified the country of origin of the first author. The following subsets were defined: Anesthesia, Regional Anesthesia and Pain, Clinical Monitoring and Computing, Intensive Care Medicine and Resuscitation, and Emergency Medicine and Trauma. A total of 10,643 publications in 30 journals were published during 1996 and 1997. Of the 30 journals, 17 originate in the United States (US) and 8 from United Kingdom (UK). In 14 of the 17 US journals, >50% of the publications came from the US. The US was the most active nation, with a total of 4,283 articles (40.2% of all contributions), followed by the UK with 1,418 articles (13.3%). When looking at the number of publications with regard to inhabitants or impact factor per million inhabitants, small highly industrialized nations (Finland 35.41 and Sweden 33.9 articles/million inhabitants) were significantly more active than large highly industrialized countries (US 16.2, Germany 6.1, Japan 4.5 articles/million inhabitants). It is presumed that indicators of productivity in medical research are the number of articles published and the cumulative impact factor. During 1996 and 1997, the US was the most active nation with regard to publications in important journals in the areas of anesthesia, pain, critical care, and emergency medicine. Small highly industrialized nations, however, had a higher activity rate than larger countries., Implications: In a MEDLINE-based analysis, we examined the number of publications in important anesthesia, pain, critical care, and emergency medicine journals (n = 30) for the years 1996 and 1997 and analyzed these with regard to national origin. The United States was by far the most active nation in this medical area (4283 articles [40.2%]), followed by the United Kingdom (13.3%). With regard to publications per million inhabitants, small highly industrialized nations contributed overproportionally to publications in this area.

Critical illness polyneuropathy (CIP), a neurologic complication which may occur secondary to surgery, trauma and coma, is associated with sepsis or multiple organ failure (MOF). CIP is characterized by an axonal distal degeneration of sensory and motor fibres. The patients will often become neurologically conspicuous when weaning from mechanical ventilation is unexpectedly difficult. In such cases electrophysiologic examinations must be performed. CIP following cardiac surgery is widely unrecognized. The most important aspect of CIP therapy is treatment of the underlying disease, because no specific treatment for CIP exists. We report on a 64-year old patient who developed sepsis and CIP following cardiovascular surgery. The neurological complication was initially misinterpreted as hypoxic brain damage.