The use of anesthesia in patients in shock is associated with many problems and considerable risk. This is particularly true when only little time is available for adequate pretreatment because surgical intervention is urgent. In choosing a method of anesthesia for patients in shock, knowledge of the pathophysiology and treatment is of utmost importance.

Le Dran first introduced the term “Shock” (French translation: “commotion”) to the medical nomenclature. The term has undergone alteration in later usage. In 1795, Latta defined shock as the condition arising from serious war injuries resulting from bullet wounds. He was the first to describe shock as “a short sojourn along the way to death.” During the First World War and the postwar period, the role of intra vascular volume deficiency in shock was clarified. Experience gained during the 1939-45 World War and the Korean War, together with the increased civilian accident rate, and research in the field of anesthesiology have led in recent years to considerble clarification of both pathogenetic and the therapeutic aspects. Today, shock can be defined as an acute reduction in tissue perfusion with consequent tissue hypoxia and metabolic acidosis, regardless of the causative factor.

The organs are first functionally and then morphologically damaged. Four mechanisms can be involved in shock; 1) reduction of the volume of blood in circulation (hypovolemic shock); 2) disturbances of the vascular system (vascular shock, anaphylactic and toxic shock); 3) reduction in the functional capacity of the heart (cardiogenic shock); and 4) intrathoracic circulation impediment (shock emboli).

Emergency Medical Services (EMS) have taken great strides toward the development of city and statewide programs. However, once a person embarks on a plane or on a ship for any extended period of time, the EMS are at times meager and at other times not coordinated well with ground EMS. The American Heart Association has developed a protocol for basic and advanced cardiac life support to exist in all major air terminals, and especially within aircraft of all types. Particularly important are those aircrafts carrying large numbers of people for extended periods of time.

Of the 110 million people in Brazil, only 4% to 6% read regularly; nevertheless, 50% have access to a television set. Instructors, audio-visual training aids, and manikins are virtually non-existent. The objective of this study is to test the feasibility of teaching cardiopulmonary resuscitation (CPR) through television (TV). Two representative groups were taught in this study: 1) high school students; and 2) regular army recruits. The first group because 50% of the population is under age 18; the second group of 18 to 19 years because they better represent the general population.

On June 2, 1862, William A. Hammond, Surgeon General of the United States Army, announced the intention of his office to collect material for the publication of a “Medical and Surgical History of the War of the Rebellion (1861–1865)” (1), usually called the Civil War of the United States of America, or the War Between the Union (the North; the Federal Government) and the Confederacy of the Southern States. Forms for the monthly “Returns of Sick and Wounded” were reviewed, corrected and useful data compiled from these “Returns” and from statistics of the offices of the Adjutant General (payroll) and Quartermaster General (burial of decreased soldiers).

Major disasters, during which large numbers of injured must be hospitalized, require specific medical measures. To obtain the most efficient results, the simplest means must be used at the site of the disaster to provide: the prevention of pain and shock; the maintenance of vital metabolic functions; the administration of local and general anesthesia; and the medical supervision of the transport of critically injured and the post-operative care of the patients. It must be taken into account that the use of non-physicians to help anesthesiologists may be necessary. These individuals work under the direction of the physician.

Pain relief must be provided by sedatives and analgesics which cause minimal central respiratory depression, no increased stimulation to cardiac patients, and no increase in intracranial pressure in head injuries. An additional requirement is that no unwieldly apparatus is required. These criteria are met with the narcotic, sodium-4-hydroxybutyrate (SomsanitR).

In 1950, Roberts and Frankel (1) investigated the effects of gamma-aminobutyric acid (GABA) on the regulating system for the sleep rhythm of the mammalian cerebrum. Two years later, Roberts and his co-workers (2-4) showed that GABA is reduced in the brain by a specific transaminase to a semial-dehyde of succinic acid (succinylsemialdehyde) and this, in turn, is reduced to a dehydrogenase, which is probably identical with lactate dehydrogenase, to gamma- or 4-hydroxybutyric acid. Since parenterally administered amino butyric acid is unable to pass through the blood-brain barrier, Laborit and his team (5,6) searched for derivatives which could reach the central nervous system via the cardiovascular system and found that 4-hydroxy-butyric acid has this property.

Lay persons can learn cardiopulmonary resuscitation (CPR) with the instructors' method, and by self-training with the use of manikins. LSFA includes airway control (head-tilt, jaw thrust), mouth-to-mouth ventilation, control of external bleeding by direct compression and elevation, positioning for coma (stable side position) and shock (horizontal, legs up), and extrication from a wreck (rescue pull). LSFA so far has not included chest compressions for cardiac arrest. LSFA capability by bystanders who would treat injured victims in mass disasters might be the most important component to consider for disaster response. A LSFA self-training system, including a manual which coaches skill practice on one another, and an attractive first aid kit (A. Laerdal) was found effective in a study carried out in Norway. The present controlled study was to compare two self-training systems (designed by A. Laerdal et al), one with and one without the use of manikins, with the presently prevalent instructors' method and an untrained control group. The trainees were high school students in a typical community in Indiana PA, USA. The study was carried out in 1978–1979.

Traffic, industrial or natural disasters and wars frequently threaten the lives of a large number of victims. Often the patients suffer a combination of injuries to the head, extremities, thorax, lung and abdomen. Immediate anesthetic measures at the site of the accident are required and essential to the survival of the patients with multiple injuries. During transport, further surgical and anesthetic treatment may also be needed. Occasionally, the number of people involved in a disaster exceeds the treatment capacity of the nearby medical institutions. Urgent and improvised decisions are required with a clear picture of the treatment resources at the site of the accident or during transport.

Special attention must be focused on necessary surgical measures and intensive care, as well as resuscitation and advanced anesthetic expertise — essential pillars of support. In many cases, the anesthetic treatment of patients with multiple injuries is the decisive therapeutic measure. The anesthetic technique must be guided by the pathophysiological requirements. The medications used should have a controllable and pronounced hypnotic-sedative and analgesic effect, without having a depressant influence on respiration or circulation, and they should improve organ perfusion. Furthermore, they should provide a means for cerebral protection. The anesthetic apparatus should be simple and compact and it should be possible to apply the technique over several hours, using room air, with or without the addition of oxygen. The agents and apparatus should be compatible with the use of every type of muscle relaxant and narcotic. New intravenous anesthetic agents meet these criteria.

Cardiopulmonary Resuscitation (CPR) lessens mortality and morbidity following cardiac arrest and has gained widespread acceptance. However, the cognitive and psychomotor skills achieved at the initial training sessions tend to deteriorate fairly quickly. Experience or retraining can help to preserve these skills. The authors felt that repetitive exposure to the principal facts might achieve the same purpose. Furthermore they viewed the time spent in the bathroom (lavatory) as an untapped educational resource for instructing a group of individuals; a suitable poster taped on a bathroom wall would repeatedly present the key information to a captive audience. Judging by the graffiti already present, the audience is presumably accustomed to reading in this environment. This paper reports two trials: in the first, posters were displayed in an undergraduate dormitory followed by a test of theoretical knowledge; in the second, the posters were displayed in hospital bathrooms used by nurses followed by a test of theoretical and practical ability.

The use of oxygen in emergency situations outside hospitals is limited by difficulties in supply. Low capacity cylinders (100-120 1) weigh 3-4 kg, and have cumbersome mechanisms for pressure and flow reduction. Disposable cylinders of oxygen from a chemical source create the possibility of the contents running out, and are fragile. Particularly when exposed to high pressures or temperature.

Mouth-to-mouth remains most rational and effective. Problems include aesthetic concern and exhaustion in rescuer. It is possible, however, to adapt a Brooke or a Safar airway for use with oxygen, by attaching a tube with tape near the proximal outlet of the airway. This apparatus has been tried on 4 patients during general anesthesia with thiopentone-succinylcholine-neuroleptics—for appendectomies using controlled ventilation with expired air with oxygen added. Tidal volumes of 350-500 ml of air/oxygen were delivered at a frequency of 6-8 breaths per minute. The nose was closed by a clip. Sellik's maneuver could prevent gastric inflation. The color of blood was normal, arterial pressure and pulse did not change, and skin was dry. No fatigue or other effects were reported by the anesthesiologist-“rescuer”. In outdoor use, where oxygen from a chemical source is used, the problems associated with the exothermic reaction can be limited by cylinder lagging with openings to disperse heat. A flow of O2 6-7 1/min is sufficient to support a critical situation. It allows O2 enrichment for mouth-to-mouth, mouth-to-mask, mouth-to-airway, or bag valve ventilation. Modest cost, and low weight allow large numbers to be stored for airport disasters, when resuscitation is performed on a large scale for many victims.

The objective of this study was to evaluate a school Trauma Awareness (TA) program conducted by the Health Education Center (HEC) of Pittsburgh, Pennsylvania under contract with the Emergency Medical Services (EMS) Institutes. A total of 44 presentations were made before 3545 persons dealing with school children in seven counties of western Pennsylvania. The TA program was undertaken because: l) the leading cause of death among school-age children in the USA during the 1970s was accidents, 60% of which occurred on school premises or going to and from school; and 2) there was a need for improvement of EMS in the local schools.

Resuscitation and acute respiratory care must be taught to all personnel involved in the management of everyday emergencies and mass casualties. Personnel range from the lay public to physician specialists. In deciding who should be taught what and how one must consider the limitations of learning ability of trainees and of resources. Mouth-to-mouth ventilation can be learned by laymen merely from viewing pictures, but better with manikin practice to perfection. CPR steps A-B-C can be effectively taught to non-physicians including laymen with instructor-coached manikin practice to perfection. but also with self-practice coached by audiotape, and to some extent even by frequent film viewing only without manikin practice. In 1972, A. Laerdal invented a CPR steps A-B-C self-training system consisting of a recording manikin, flipcharts and the coaching audiotape. We added a demonstration film to be shown before manikin practice.

The protective effect of an artificial tanning scab seems to be greater than that of the physiologic eschar, in controlling the invasion by micro-organisms and the loss of water, electrolytes and plasma. Allgöwer, et al. confirmed a reduced toxicity in burns, using experimental tanning procedures. Applying mercurochrome 2%, tannic acid 5% and silver nitrate 10% is a simple and most effective local treatment, especially when large numbers of patients are involved. No further topical agents are necessary for days, and infusion therapy may consist simply of water and electrolytes for the first 2k h, and the patients are stabilized for transport. A most important advantage of this procedure, which was obvious in all our patients, is the reduction of pain. Resorption of the applied substances must be considered. Toxic side-effects have not been seen with the use of tannic acid 5% nor with silver nitrate 10%. Increased blood levels of mercury have been found, however, but they have not caused toxic complications in more than 200 monitored patients. Betadine may be used instead of mercurochrome as a local antiseptic. The antiseptic effect of betadine was found to be greatly prolonged after tanning, as compared to 100 patients with comparable burns without tanning—with septic complications having been reduced in the tannic acid group.

Although decisive changes have been made in the past ten years by re-organizing and improving pre-hospital care, emergency measures at the scene of the accident still require special emphasis in accident victims with head injuries concerning the recognition and treatment of vital complications. The success of these measures depends on the time interval for their initiation, on the practical skill and expertise of the person administering life support, and the availability of equipment.

An emergency examination at the scene of the accident is absolutely essential for correct assessment and should reveal imminent failure of arrest of vital functions. This can be achieved by using the rescuer's five senses and does not require special diagnostic equipment. An initial sign that cerebral trauma has occurred can often be recognized by a superficial injury to the skull during an initial orientation examination, although some of the most severe closed craniocerebral injuries can occur without the slightest superficial sign of trauma.