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Objective: To study outcome from severe head injury (SHI: GCS < or = 8) and to investigate impact of prehospital factors and clinical intensive care parameters on outcome. To compare with former study results (1980-88) of our clinical setting., Methods: Retrospectively, the history of 228 patients with SHI treated between 1988 and 1995 was looked into. The outcome was measured with the Glasgow Outcome Scale (GOS) post intensive care (median 9, min-max 2-77 days) and 6 months after trauma by a questionnaire. The GOS was related to age, Glasgow Coma Scale (GCS on the scene), prehospital hypotension and hypoxia (HH), intracranial pressure (ICP), cerebral perfusion pressure (CPP), intensive therapy including Tromethamine and/or Thiopentone. The rate of infections was determined., Results: Increasing age influences outcome negatively. Prehospital GCS and HH were significantly correlated with outcome. GOS of 30 patients with HH: GOS 1: 53%, GOS 2 + 3: 27%, GOS 4 + 5: 20%. GOS of 40 patients without HH: GOS 1: 25%, GOS 2 + 3: 10%, GOS 4 + 5: 65%. During intensive care the level of CPP (not ICP) as well as tromethamine and/or thiopentone treatment for control of elevated ICP were significantly correlated with outcome. Mortality rate in 32 patients with CPP < 50 mmHq was 69%, in 29 patients with CPP > 50 mmHg only 20%. Patients treated additionally with Tromethamine and Thiopentone because of uncontrollable intracranial hypertension showed a significantly worse outcome: GOS 1: 66%, GOS 2 + 3: 6%, GOS 4 + 5: 28%, compared to those who needed neither Tromethamine nor Thiopentone: GOS 1: 27%, GOS 2 + 3: 18%, GOS 4 + 5: 55%. Thiopentone treatment was not associated with an increased rate of pulmonary and other infections. In comparison to our former outcome study, covering the years 1980-88, we have not seen any improvements in outcome, despite modifications in intensive care protocols., Conclusions: Prehospital hypotension and hypoxia have a significant negative impact on outcome by causing secondary brain damage. Despite various modifications in intensive care therapy an unchanged portion of secondary brain damage will not prove treatable. Therefore, prevention or early aggressive treatment of hypotension and hypoxia is the most promising way of improving outcome after severe head injury at the moment.

Introduction: The prehospitaly initiated endotracheal intubation and controlled ventilation, is especially in multi-system-trauma cases, recognized to be the "gold standard". Thus especially in view of the increasing demands being placed upon the quality of prehospital emergency treatment in general, the quality of such prehospital induced ventilation, is becoming of increasing importance. Thereby we must take into consideration the limited possabilities, which are afflicted with a high degree of uncertainess, which we have at our disposal to effectively evaluate the efficiency of emergency ventilation. The purpose of our study within a collective of severely traumatized patients, was to determine the quality of prehospitaly induced ventilation with regards to the adequacy of oxygenation and ventilation and as a result of our findings, to identify areas for procedural optimization., Results: The prospective study over an one year period involved n = 104 trauma cases (male: 79; female: 25/age: 39.8 +/- 20.8 years/ISS: 28.1 +/- 15.3) whose prehospital emergency treatment required and included endotracheal intubation and controlled ventilation. All patients were subject to a prehospital pulse oxymetric monitoring, whereas none were subject to an objectivating apparatus monitoring of ventilation: 94.2% of the patients were upon admission adequately oxygenated (paO2 > 80 mmHg); only one patient was hypoxemic (paO2 < 60 mmHg). 46.2% were adequately ventilated (paCO2: 35-45 mmHg), 43.2% however were hyperventilated (paCO2 < 35 mmHg), and 10.6% hypoventilated (paCO2 > 45 mmHg). A statistical significant relation between hyper-/hypoventilation and the degree of severity of trauma as well as to the individual injury pattern was not evident. However with reference to age: The group of > 60 years of age were significantly more frequently hyperventilated (paCO2 < 30 mmHg: 31.2%; p < 0.05). A noteworthy accumulation of hypoventilation was experienced amongst the group of patients, who during the prehospital treatment phase were hemodynamic instable (shock index > 1)., Conclusion: In summary it is evident, that as a rule, even very severe traumatized patients can prehospitaly be adequately oxygenated and that such oxygenation can with the assistance of pulse oxymetric monitoring be effectively controlled. Remaining problem is the emergency physicians ability to evaluate and control ventilation. The prehospital determination of minute volume (MV) in accordance with the presently valid recommendation: MV = 100-150 ml/kg body weight, in the majority of trauma cases results in inadequate ventilation. The introduction of an objectifying monitoring method is therefore urgently required.

Unlabelled: There is compelling data from several clinical studies on the impact of various anti- and proinflammatory mediators on traumatized patients. Immediate trauma-related results, however, are only available from animal experiments so far. Therefore, in this prospective clinical study the following questions were addressed: (I) Is there any marker in the preclinical phase that give information independent of and better than conventional studies conducted so far, (II) does this possible factor prove to be a (significant) predictor of late complications and/or poor overall outcome, and (III) does this mediator provide information that can alter treatment decisions?, Methods: Upon approval of the local IRB/IEC, 85 patients (pts) were enrolled who suffered from multiple injuries. The pts were rescued by the helicopter-based service of the German Army Hospital in Ulm. The first blood samples were drawn at the site of accident and at admission, then in hourly to daily intervals. The plasma concentrations of following mediators were analyzed: Prostanoids, products of O2-radicals, soluble adhesion molecules, various cytokines, C-reactive protein, creatinine kinase, and neopterin. All values were calculated in relation to the actual plasma protein content to eliminate fluid-induced dilution effects. Subsets of patients were performed according to the severity of trauma (ISS < 9; 9-17; 18-31; > 32), based on the different injury pattern, and survivors versus nonsurvivors as well., Results: As early as at the scene of accident, all patients revealed a severity-dependent increase in most mediators' plasma levels. There was, however, also a pattern-related inflammatory response that was most pronounced in pts who had suffered from thoracic trauma irrespective of whether it was associated with multiple trauma. In a total, 15 pts died within 72 h after the accident. In those casualties, the plasma concentrations of prostaglandin E2 (P < 0.03), glutathione (P < 0.01) as well as creatinine kinase (P < 0.05) were more markedly elevated when compared with survivors., Conclusion: Although there were severity-dependent as well as pattern-related releases of various mediators, which in part were more apparent in nonsurviving patients, we failed in proving any predictive marker to specifically discriminate outcome.

Membrane-fixed CD14 acts as a receptor for the protein-bound endotoxin (LPS) complex and mediates the cellular effects of endotoxin. Soluble CD14 (sCD14) is suggested to neutralize circulating LPS, i.e., acting as an endotoxin antagonist. The aim of this study was to elucidate the release of both sCD14 and endotoxin in traumatized patients, starting from the earliest phase after trauma. A total of 15 patients (O ISS = 19, 9-75) suffering major trauma were enrolled in this prospective study. Blood samples were collected as early as immediately at the site of accident, on hospital admission, and thereafter hourly, then daily. For patients (O ISS = 47) died within 24 h because of their severe injuries. Immediately after the accident as well as during the first 2 h after hospital admission, the mean sCD14 levels of surviving patients did not differ from those of healthy volunteers (n = 53). Thereafter, however, sCD14 increased continuously in the trauma group. The concentrations remained elevated throughout the entire observation period. There was, however, no relation between the sCD14 release and the pattern or the severity of injury. In contrast, endotoxin levels revealed a pattern-specific release. The highest plasma concentrations of LPS were observed in patients suffering from (additional) thoracic injury. On the basis of these results we conclude that the release of sCD14 after trauma does not reflect a strict principle such as action/reaction caused by the appearance of endotoxin immediately after the injury. Soluble CD14 is more likely release by an endotoxin-independent mechanism.

Chest trauma cases benefit to a great degree from adequate, timely initiated and consistent prehospital treatment. However, prehospital determination and evaluation of blunt chest trauma is associated with a high degree of uncertainty. The purpose of our study was to examine and determine, in a collective of 255 trauma patients, the value of additional prehospital pulse oximetric monitoring regarding the optimization of the emergency physician's diagnosis and treatment of blunt chest trauma. We conclude from our findings that, in addition to the physical examination, with the application of pulse oximetry the prehospital diagnosis of lung contusion as well as the early detection of tension pneumothorax are more accurate. Therefore, the combination of physical examination and pulse oximetric monitoring is a requirement for the optimization of prehospital diagnosis and therapy in blunt chest trauma.

Unlabelled: In prehospital emergency treatment, the timely establishment of a secure vascular access, especially in infants and small children, can be difficult or even impossible. An alternative to the puncture of peripheral or central veins is intraosseous (IO) puncture However, experience with this method in prehospital emergency medicine within the Federal Republic of Germany is extremely limited at present. After intensive theoretical and practical training of our trauma anaesthesiologists, IO puncture was introduced in our rescue helicopter program "Christoph 22" as an alternative to peripheral or central venous puncture in the prehospital treatment of patients up to 6 years of age. IO puncture is indicated after a maximum of three failed peripheral venous puncture attempts. The purpose of this study was to collect data and summarise first-hand experience on the prehospital use of the IO method as well as the practicability of our prescribed IO puncture algorithm in order to subject them to critical review and evaluation., Materials and Methods: A restrospective study by the rescue helicopter service "Christoph 22" was carried out for the period 1 June 1993-31 August 1995., Results: In a total of 1,455 primary rescue missions flown, the proportion of patients < and = 6 years of age, was 6.2% (n = 90). Ten patients in this partial collective (11.1%) were subjected to IO puncture (Fig. 3). In all of these cases (10/10), the first IO puncture attempt was successful. A standardized puncture technique was performed using the proximal tibia. The time required to successful placement of the IO infusion line was < and = 60 s in all cases. Complications, especially incorrect needle position, did not occur during the study period. Materials infused by IO infusion before hospitalisation included crystalloids (Lactated Ringer's, Päd OP) as well as colloids (hydroxyethylstarch, human albumin), adrenaline, atropine, ketamine, thiopentone, diazepam, fentanyl, succinylcholine, and vecuronium (Table 3). Prehospital induction of general anaesthesia using the IO infusion line was required by 2/10 children; dosage and onset of administered drugs was described by the trauma anaesthesiologists as being similar to that using an i.v. infusion line. Seven of the patients had been treated prior to the arrival of the rescue helicopter team by other emergency medical personnel; in all of these cases multiple peripheral and in 3 additional central venous puncture attempts had failed (duration of attempts: 10-50 min). Upon arrival of the rescue helicopter, 5 of these patients had been pulseless and non-breathing (Table 2)., Conclusion: The IO infusion technique has proven to be a simple, fast, and safe alternative method of emergent access to the vascular system.

Severely injured patients, in particular, benefit from initiation of endotracheal intubation and controlled ventilation before hospital admission. The most frequent and most serious mishap of this emergency procedure is inadvertent esophageal tube placement. A reliable and simple determination of proper tube placement involves capnometry, the measurement of carbon dioxide concentration during the respiratory cycle. The purpose of this study was to evaluate the dependability of semi-quantitative capnometry in verifying proper tube placement in the prehospital treatment of trauma patients. First, we determined and tested the suitability of the equipment used in this study (STAT CAP) in 40 patients under controlled hospital conditions; subsequently, we tested it under prehospital conditions on 40 trauma patients. Within the two study groups, the STAT CAP proved to be of high sensitivity (1.0) and specificity (1.0) in identifying tracheal tube position immediately after intubation manoeuvre, even in patients with a shock index > 1 (n = 14) and patients with cardiac arrest (n = 3). In cases of tracheal tube position, a CO2 signal was noted after two ventilations, on average, in both study groups. The average initial CO2 value recorded amongst the hospital study group was 30-50 mmHg, against 20-30 mmHg in the prehospital trauma group. The traditional signs used to verify endotracheal tube placement (direct visualization of the vocal cords and auscultation of breath sounds upon the chest) failed in three cases amongst the prehospital trauma group; in all of these cases the STAT CAP detected the (tracheal) tube placement correctly. We conclude that the STAT CAP reliably detects tracheal placement of endotracheal tube in non-arrested patients. In the arrested patient, interpretation of CO2 nonappearance requires caution. In addition to the traditional clinical signs, semi-quantitative capnometry is a meaningful supplement to verify tracheal tube placement in the prehospital management of trauma patients.

Trauma patients are at great risk of accidental hypothermia (body temperature [BT] < 36 degrees C). Hypothermia influences the functioning of all organ systems and can lead to pathological changes, which in turn additionally complicate the trauma. Furthermore, hypothermia can, e.g., by influencing blood coagulation (reduction of thrombocyte aggregation, increased fibrinolysis) have a markedly unfavourable impact upon the in-hospital surgical treatment of the trauma patient. In a prospective study involving 302 trauma patients treated during primary helicopter rescue missions over a 1-year period, we studied the following factors: (1) incidence and degree of severity of hypothermia; (2) seasonal influence; (3) possibility of individual risk groups within the study group; (4) changes in BT during the prehospital treatment phase; and (5) their consequences for emergency treatment. METHOD. BT was taken upon commencement of emergency treatment and upon release of the patient to the receiving hospital. To avoid possible damage to the patient's tympanic membrane by the thermometer probe, we excluded all patients under 16 years of age and those with an indication of an ear or temporal-bone injury. In all cases standardized patient positioning was applied. The statistical evaluation was performed utilizing descriptive presentations and the Mann-Whitney U test and chi-square test. RESULTS. During study period, a total of 302 trauma patients were treated. On 228 of these, prehospital temperature monitoring was performed (151 males and 77 females, average age 41.8 years). Because of the established criteria for exceptions and equipment malfunction, no monitoring was performed on 74 patients. Traffic accidents (69%) were the major cause of injury (Table 2), predominantly the group with NACA III (32%), followed by NACA IV (22%) and NACA V (18%) (Table 3); 27% had multi-system trauma. BT monitoring disclosed that 49.6% or almost every second trauma patient, had hypothermia. The proportion of hypothermia II degrees (BT 34 degrees-30 degrees C) versus hypothermia III degrees (BT < 30 degrees C) was 6.6% to 0.5%. Our statistical evaluation did not disclose any significant connection between season of the year and frequency of accidental hypothermia. Special risk factors in regard to frequency and degree of severity turned out to be "entrapment" (98.1% of patients with an entrapment trauma [ET] versus 34.5% without such; P < 0.001) and age (56.8% of patients > 65 years of age without ET and 100% with ET; P < 0.001) (Figs. 2, 3). No significant changes in BT were noted during the prehospital treatment phase. Clinical symptoms pointing to hypothermia or other indicators, i.e., shivering, were only noted in 4.4% of the cases where the patients BT was below normal. CONCLUSION. Based upon our findings, accidental hypothermia poses a relevant problem in the prehospital treatment of trauma patients. It is not limited to a special season of the year. The variability or total absence of definite diagnostic symptoms underlines the necessity for prehospital BT monitoring, whereby tympanic-membrane thermometry has proven to be a worthwhile method.

In a retrospective study conducted from 1.1. 1988-31.12.1991, we at our rescue helicopter station "Christoph 22" identified the special circumstances, which arise for the trauma anaesthesiologist during prehospital treatment of entrapped trauma patients. During the time frame of our study, we observed a continuous increase of patients suffering an entrapment trauma (from 8.3% to 15.9%). Motor vehicle accidents were the primary cause of entrapment (78.4%). Patients with an entrapment trauma in comparison to those without, to a much higher degree suffered more severe injuries (proportion of multi-system trauma: 49.4% versus 26%). Upon arrival of the trauma anaesthesiologist at the scene, the vital functions in the majority of the cases were already disturbed and unstable. The emergency medical measures required at the emergency scene therefore had to be timely and to the point and taken in close coordination with the technical rescue team. The proven procedures which we apply in such cases will be illustrated. Hospital of preference should, if possible, always be a trauma center.

Introduction: Polytraumatized patients develop complex changes in blood coagulation and fibrinolysis even before their arrival at the emergency room (ER). Hemostaseological parameters (i.e. antithrombine 3, alpha-2-antiplasmine, D-dimers) obtained upon admission however, permit advance differentiation of later mortality vs. survival and of possible future secondary organ failure with varying specification., Objectives: Which clinical findings enable to identify such patients early in the ER even when no specialized hemostaseological laboratory is available?, Material and Methods: a) Prospective study of 40 polytraumatized adults upon arrival at the hospital; b) Blood sampling at the earliest possible time during takeover in the ER; c) Injury Severity Score (ISS) for descriptive purposes; d) Evaluation of the prehospital emergency physician's records in regard to respiratory therapy, fluid resuscitation, and arterial blood pressure; e) Statistics; Wilcoxon test, Spearman correlation coefficient., Results: All 40 patients (m:f = 28:12; mean age: 36 (SD: 16.6) years; mean ISS: 34.7 (SD: 11.4)) displayed advanced disseminated intravascular coagulation with secondary hyperfibrinolysis upon arrival in the ER. The amount of deviation from the hemostaseological norm could not be derived from either the correlation of the typical activated parameters of coagulation of fibrinolysis with the ISS or the analysis of the separate injuries. On the other hand the subgroup of patients displaying a systolic blood pressure of less than 100 mmHg at the site of the accident or upon arrival at the ER all had significantly lower antithrombine 3, protein C, and alpha-2-antiplasmine activities as well as increased concentrations of specific reaction products resulting from activated coagulation (thrombine-antithrombine 3-complex) and of fibrinolysis (D-dimers)., Conclusion: In our study patients with multiple injuries displaying a systolic blood pressure of less than 100 mmHg either at the scene of the accident or upon arrival in the ER showed coagulation values which by other investigators were regarded as a sign of potential secondary organ failure or death.

Pulse oximetric monitoring in air rescue service (rescue helicopter) is primarily influenced by motion artifacts (especially those of a passive nature), by low perfusion and by the problem of probe dislocation. In a prospective study involving 162 unselected emergency patients treated by the medical team of the emergency helicopter service "Christoph 22" (Ulm), we studied the possibility of reducing these adverse factors by applying available state-of-the-art technology, such as ECG-synchronization and adhesive probes. By applying the thus modified methods of monitoring, the interference factor was reduced to S = 0.056, that is only 5.6% of measurement time was adversely effected. The increase in measurement stability resulted from the reduction in number of described artifacts (motion artifacts and low perfusion), as well as from the reduction in duration of interfered measurement time. ECG-synchronization very effectively influenced the passive motion artifacts. Their frequency was reduced by the factor 8.2, respectively 42. An effective reduction in number of probe dislocations can be achieved by applying adhesive probes. The high costs of such probes presently limits their application. Radiation can be eliminated by redesigning the probe. ECG-synchronization of pulse oximetric signal has proved to be a method to reduce the artifacts frequently experienced in air rescue and has considerably contributed to the increase of emergency patient safety.

The introduction of pulse oximetric monitoring in prehospital emergency medicine considerably contributed to emergency patients' safety, stability and protection. As inherent in any method of measurement, certain factors can interfere with it and limit its practical application. The emergency helicopter service at Ulm, in a prospective study involving 400 patients, systematically collected data on these limiting factors and evaluated them. The index "S" was established to quantify the time lost due to malfunctioning. Within the study group, the index average was S = 0.269, that is 26.9% of measurement time was subject to interference. The major cause was motion artifacts (68%) sensor probe dislocation (15%), low perfusion (14%) and radiation (3%). Regarding the volume of time lost due to specific interfering factors, motion artifacts (61.8%) and low perfusion (25.5%) were dominant, followed by sensor probe dislocation (10.3%) and radiation (2.4%). Interference therefore, both in time and frequency was primarily due to motion artifacts and low perfusion. The conclusions from this study led to the evaluation of two methods by which the interfering factors could be reduced: 1. ECG-synchronisation of the pulse oximetric signal; 2. The use of adhesive sensors.--The degree of increase in pulse oximetric measurement stability achieved by these two methods will be investigated in part 2 of this study.

Coagulation disorders are of utmost importance in emergency surgery as well as for secondary organ failure of polytraumatized patients. In order to get hold of the early onset of these disorders, blood samples were harvested from 20 randomly selected patients (Injury Severity Score mean = 36.7 +/- 10.5) on the scene of emergency (mean = 18 [10-29] min after trauma) and at the time of hospital admission (mean = 78 [58-98] min after trauma). In addition to the activation of intravascular coagulation and the consumption of physiological inhibitors, high amounts (10- to 50-fold above normal) of degradation products (FgDP, FbDP, TDP, D-dimers) are present on the scene, already. The influence of hemodilution due to high-volume resuscitation is discussed.

Coagulation changes due to polytrauma are considered to be an important determinant for the outcome. In this context, physiological inhibitors of activated coagulation are highlighted with special reference to antithrombin-III (AT-III). Blood samples of 20 randomly selected adults with polytrauma (Injury Severity Score mean = 36.7 +/- 8.6) were investigated. To investigate the very early onset of coagulation changes, samples were taken as early as possible at the site of emergency (mean = 18.3 +/- 5.5 min. after trauma) as well as at hospital admission (mean = 78.0 +/- 10.4 min.). By means of a specially designed "mini-lab", basic processing of the samples harvested (centrifugation, pipetting, freezing) was done on the spot to obtain haemostaseological results that agree as closely as possible with the subsequent analyses. Due to the activation of intravascular coagulation as well as the consumption of physiological inhibitors, comprehensive coagulation disturbances become obvious at the time of hospital admission. These are intensified by haemodilution as a consequence of high-dose fluid replacement. However, significantly elevated levels of specific coagulation reaction products (thrombin-antithrombin-III-complex) give evidence of the consumption of inhibitory potential exceeding haemodilution.

The early diagnosis and adequate treatment of respiratory complications in trauma cases has a decisive influence upon the patients' posttraumatic development. Pulse oximetry enables us to evaluate and monitor the prehospital respiratory situation objectively for the first time. Within a prospective study conducted from October 1988 to October 1989 in 336 unselected, primarily traumatized, emergency patients rescued by our "SAR Ulm 75" helicopter team, to determine the possibilities and limitations of this method, we maintained continuous pulse oximetric monitoring in all cases. The practical applicability and functional stability of the pulse oximeters used were adequate. On-the-spot intubation was necessary in 45% of the patients (or they were intubated prior to our taking over). Oxygen inhalation by nasal cannula was needed in 55%. While not being decisive for immediate intubation, monitoring with a pulse oximeter does play an essential role in controlling respiratory therapy. In 32% of our cases, pulse oximetric monitoring permitted early adjustment of the respiratory therapy to meet the patients requirements. This method is of special value in disclosing life-threatening respiratory complications (9.3%) i.e., valve pneumothorax. Within a group with a high percentage of multiple traumas (27%) and thorax traumas (39%), this was of enormous assistance in the differential diagnosis. Level and rate of increase of oxygen saturation can be an indication of the severity of a thorax trauma. The limitations of pulse oximetric monitoring, especially those resulting from low peripheral perfusion in trauma cases (7 patients), are fairly rare.

Between 50 to 60% of all polytraumatized patients have a thoracic injury with a mortality of 30 to 60%. The first diagnostic steps involving symptoms such as in- or expiratory pain, emphysema of the skin, flail chest or sipping noise lead via clinical examination to first and often definitive therapeutic procedures, i.e. intubation, artificial respiration and insertion of chest tube. X-ray of the chest, computed tomography as well as ultrasonic screening and monitoring of arterial blood gases are important in in-door technical diagnosis. The decision for emergency room thoracotomy or a regular or delayed operation has to be made at times. Complications (20%) to consider are pneumo- and haematothorax, pleural rind, pneumonia, broncho-pleural fistula and most of all pleural empyema.

Having seen the development of fatal pneumonias in ventilated patients, the cause of which was assumed to be the presence of residual traces of formaldehyde in the air in the respirator Kilian and Haug showed in 1973 initial formaldehyde concentrations up to 0.2 ppm in the ventilatory air of respirators correctly disinfected in the Aseptor. To study the effects of formaldehyde on lung function and lung structures, 23 young pigs were automatically ventilated with defined formaldehyde concentrations during 6 hours. The concentrations used were 0.02 ppm, 0.2 ppm and 2.0 ppm (double of the maximum permissible concentration). We found no differences in lung function, as shown by compliance measurements and arterial blood gas analysis. No radiological differences were in the thorax. Histologically, there were only slight alterations in lung structure in the group ventilated with double the maximum permissible concentration of formaldehyde. We conclude that the disinfection of respirators using formaldehyde in the Aseptor will remain the method of choice.

The technical equipment necessary for modern anaesthesia and intensive care medicine needs special and organized outfit control of the apparatus used and of their operation and proper function. Setting up of a centre for maintenance work on anaesthetic equipment is a possibility. Studies have shown that the necessary technical and hygienic maintenance work may be subdivided into 12 working phases each need special working sites and technical equipment corresonding to the requirements. The above systematic study is recommended to decrease risks assoicated which technique and hygiene.

The basics of the acute management of severe diving accidents are outlined by means of 25 patients (20 patients presented with decompression sickness, 5 suffered from a barotrauma of the lungs with consecutive air embolism) treated at our facilities. Contrary to widespread notion, disturbed vital functions have to be treated by intensive care measures, prior to the definite recompression therapy. These are: (1) Treatment of generalized or localized tissue hypoxia secondary to bubble-generation; (2) puncture of a (valvular-) pneumothorax after a pulmonary barotrauma; (3) haemodynamic stabilization when cardiac or spinal shock is present; (4) improvement of the rheological situation. When vital functions are unstable or endangered, these patients must not be transported in a monoplace chamber. This type of chamber does not leave any access to the patient in case of a deteriorating status. Since the severe diving accident mostly turns out to be a problem of intensive care medicine in close combination with the recompression therapy, the continuous integration of the recompression protocol with a comprehensive intensive care therapy is considered crucial.

The use of artificial ventilation in the treatment of seriously ill or severely injured patients demands extensive knowledge on the part of the physician of the physiological and pathological effects of ventilation. In addition, it is required that the manufacturers develop ventilators able to meet there special demands. During the last two years the Servo-Ventilator 900 has been in use in our intensive care unit. During this period we were very impressed by its versatile applicability. The use of this apparatus however more than ever before requires the knowledge of breathing mechanisms and their pathophysiological consequences. The various flow- and breathing-rate-patterns combined with the exact electronic control of the respiratory make possible subtle adjustments--to the required ventilation pattern.