Learning from terrorist mass casualty incidents: a global survey

BACKGROUND

Reports published directly after terrorist mass casualty incidents frequently fail to capture difficulties that may have been encountered. An anonymised consensus-based platform may enable discussion and collaboration on the challenges faced. Our aim was to identify where to focus improvement for future responses.

METHODS

We conducted a mixed methods study by email of clinicians' experiences of leading during terrorist mass casualty incidents. An initial survey identified features that worked well, or failed to, during terrorist mass casualty incidents plus ongoing challenges and changes that were implemented as a result. A follow-up, quantitative survey measured agreement between responses within each of the themes using a Likert scale.

RESULTS

Thirty-three participants responded from 22 hospitals that had received casualties from a terrorist incident, representing 17 cities in low-middle, middle and high income countries. The first survey identified themes of sufficient (sometimes abundant) human resource, although coordination of staff was a challenge. Difficulties highlighted were communication, security, and management of blast injuries. The most frequently implemented changes were education on specific injuries, revising future plans and preparatory exercises. Persisting challenges were lack of time allocated to training and psychological well-being. The follow-up survey recorded highest agreement amongst correspondents on the need for re-triage at hospital (90% agreement), coordination roles (85% agreement), flexibility (100% agreement), and large-scale exercises (95% agreement).

CONCLUSION

This survey collates international experience gained from clinicians managing terrorist mass casualty incidents. The organisation of human response, rather than consumption of physical supplies, emerged as the main finding. NHSH Clinical Effectiveness Unit project registration number: 2020/21-036.

Difficult Intubation Factors in Prehospital Rapid Sequence Intubation by an Australian Helicopter Emergency Medical Service

OBJECTIVE

Prehospital rapid sequence intubation (RSI) of critically ill trauma patients is a high-risk procedure that may be associated with an increased rate of severe complications such as failed intubation, failure of oxygenation, hypoxia, hypotension, or need for surgical airway. The objective of this study was to describe the factors associated with difficult intubation in prehospital RSI as defined by more than a single look at laryngoscopy to achieve tracheal intubation.

METHODS

This is an observational study using prospectively collected data.

RESULTS

Four hundred forty-three RSIs were performed. Paramedics were the initial laryngoscopist in 290 (65.5%). First-look laryngoscopy resulted in successful tracheal intubation (TI) in 372 (84.0%) (95% confidence interval, 80.3%-87.1%). Intubation was achieved on second look at laryngoscopy in 58 (13.1%). "First-pass" TI was achieved in 394 (88.9%). Overall, successful TI was achieved in 438 (98.9%) (95% confidence interval, 97.4%-99.5%). Complications occurred in 116 (26.2%), with desaturation the commonest in 77 (17.4%).

CONCLUSION

Factors associated with more than 1 look at laryngoscopy before TI included paramedic laryngoscopist and the presence of at least 1 of the following indicators: blood/vomitus in the airway, limited mouth opening, and limited neck movement. Trauma to face/neck, obese body habitus, C-spine precautions, cricoid pressure, midline stabilization, and intubation on the ground did not influence the level of difficulty encountered.

RAPD-PCR typing of Acinetobacter isolates from activated sludge systems designed to remove phosphorus microbiologically

AIMS

This study investigated whether there were differences in RAPD fingerprints between already described genomic species of Acinetobacter and those from activated sludge systems. Whether plant-specific populations of acinetobacters exist was also examined.

METHODS AND RESULTS

Fifty-two isolates of Acinetobacter from four biological phosphorus removal (EBPR) systems of different configurations, and the known genomic species, were characterized using RAPD-PCR, and fragments separated on agarose gels. Patterns were analysed using Gel Pro software and data analysed numerically. RAPD-PCR produced patterns suggesting that many environmental isolates differ from known genomic species. In two cases, strains from individual plants clustered closely enough together to imply that there may be plant-specific populations of acinetobacters.

CONCLUSION

The data suggest that current understanding of the taxonomic status of Acinetobacter may need modifying to accommodate non-clinical isolates, as many of the clusters emerging after numerical analysis of RAPD-PCR fragments from activated sludge isolates were quite separate from the clusters containing the already described genomic species. Some evidence was also obtained from the clusters generated to support a view that particular populations of Acinetobacter may occur in individual activated sludge plants.

SIGNIFICANCE AND IMPACT OF THE STUDY

These data suggest that the current understanding of the systematics of Acinetobacter, based as it is almost exclusively on clinical isolates, may need drastic revision to accommodate environmental strains. They also suggest that a re-examination of the importance and role of Acinetobacter in the activated sludge process may be appropriate.

Fine structure of hippocampal dendrites in the dentate fascia of LS/SS-mice after chronic ethanol treatment

1. The effect of ethanol and its withdrawal on the dendritic microtubules in the dentate fascia of male mice was studied in the ethanol-sensitive, long-sleep (LS) line and the ethanol-insensitive, short-sleep (SS) line. 2. Both mouse lines were treated with a liquid ethanol diet. Dendrites in the dentate molecular layer (DML) of the right hippocampus were examined. 3. They revealed marked changes in microtubule density as compared with the controls. While the microtubule density in LS mice was significantly reduced by 15% and 18% in the middle and distal third of the DML, respectively, in SS mice the reduction (by 12%) took place in the distal third only. During withdrawal a recovery of the microtubule density has been observed in both lines.

Changes in GABAergic and non-GABAergic synapses during chronic ethanol exposure and withdrawal in the dentate fascia of LS and SS mice

Ethanol-sensitive LSIBG and ethanol-insensitive SSIBG mice were exposed to ethanol (23.5% ethanol-derived calories) for 4 months. Half of the animals was sacrificed at this time and the other half was withdrawn from the ethanol diet for 1 month. GABA immunoelectron microscopy was used to study the impact of the treatments on synaptic contacts in the dentate molecular layer. In the LS mice a significant loss of non-GABAergic axospinous synapses (26.7%; p < 0.05) was observed during ethanol exposure which was followed by a loss of GABAergic synapses on dendritic shafts (54.7%; p < 0.01) during withdrawal. In the SS mice there was a significant decrease in the non-GABAergic axospinous synapses (23.5%; p < 0.05) and a significant increase in axodendritic synapses (63.3%; p < 0.05) during ethanol exposure. The observed changes in the GABAergic and non-GABAergic innervation of the dentate fascia induced by ethanol were observed in the projection zone of the perforant path. They could adversely affect the hippocampal physiology with a consequent impairment of mnemonic functions.

Inhibitory contacts on dendritic spines of the dentate fascia

GABA-containing axon terminals were observed in the distal two-thirds of the dentate molecular layer to contact spines and dendrites of the granule cells. These contacts have the morphological characteristics of inhibitory synapses: they contain pleomorphic vesicles and have symmetrical junctional specializations. Convergence of an asymmetrical, non-GABAergic and a symmetrical, GABAergic synapse on one spine was often observed.