There is a need for model uniform core criteria for mass casualty triage because disasters frequently cross jurisdictional lines and involve responders from multiple agencies who may be using different triage tools. These criteria (Tables 1-4) reflect the available science, but it is acknowledged that there are significant research gaps. When no science was available, decisions were formed by expert consensus derived from the available triage systems. The intent is to ensure that providers at a mass-casualty incident use triage methodologies that incorporate these core principles in an effort to promote interoperability and standardization. At a minimum, each triage system must incorporate the criteria that are listed below. Mass casualty triage systems in use can be modified using these criteria to ensure interoperability. The criteria include general considerations, global sorting, lifesaving interventions, and assignment of triage categories. The criteria apply only to providers who are organizing multiple victims in a discrete geographic location or locations, regardless of the size of the incident. They are classified by whether they were derived through available direct scientific evidence, indirect scientific evidence, expert consensus, and/or are used in multiple existing triage systems. These criteria address only primary triage and do not consider secondary triage. For the purposes of this document the term triage refers to mass-casualty triage and provider refers to any person who assigns primary triage categories to victims of a mass-casualty incident.

(Disaster Med Public Health Preparedness. 2011;5:125–128)

Objective: The paucity of evidence and wide variation among communities creates challenges for developing congressionally mandated national performance standards for public health preparedness. Using countermeasure dispensing as an example, we present an approach for developing standards that balances national uniformity and local flexibility, consistent with the quality of evidence available.

Methods: We used multiple methods, including a survey of community practices, mathematical modeling, and expert panel discussion.

Results: The article presents recommended dispensing standards, along with a general framework that can be used to analyze tradeoffs involved in developing other preparedness standards.

Conclusions: Standards can be developed using existing evidence, but would be helped immensely by a stronger evidence base.

(Disaster Med Public Health Preparedness. 2010;4:285-290)

Mass casualty triage is the process of prioritizing multiple victims when resources are not sufficient to treat everyone immediately. No national guideline for mass casualty triage exists in the United States. The lack of a national guideline has resulted in variability in triage processes, tags, and nomenclature. This variability has the potential to inject confusion and miscommunication into the disaster incident, particularly when multiple jurisdictions are involved. The Model Uniform Core Criteria for Mass Casualty Triage were developed to be a national guideline for mass casualty triage to ensure interoperability and standardization when responding to a mass casualty incident. The Core Criteria consist of 4 categories: general considerations, global sorting, lifesaving interventions, and individual assessment of triage category. The criteria within each of these categories were developed by a workgroup of experts representing national stakeholder organizations who used the best available science and, when necessary, consensus opinion. This article describes how the Model Uniform Core Criteria for Mass Casualty Triage were developed.

(Disaster Med Public Health Preparedness. 2011;5:129-137)

The ability to appraise one's own ability has been found to have an important role in the recovery and quality of life of clinical populations. Examinee and task variables have been found to influence metacognition in healthy students; however the effect of these variables on the metacognitive accuracy of adults with neurological insult, such as traumatic brain injury (TBI), remains unknown. Twenty-two adults with moderate and severe TBI and a matched sample of healthy adults participated in this study examining the influence of item sequencing on metacognitive functioning. Retrospective confidence judgments were collected while participants completed a modified version of the Matrix Reasoning subtest. Significant influence of item sequence order was found, revealing better metacognitive abilities and performance when participants completed tasks where item difficulty progressed in order from easy to difficult. We interpret these findings to suggest that the sequencing of item difficulty offers “anchors” for gauging and adjusting to task demands. (JINS, 2012, 18, 379–383)

Huntington's disease (HD) is a neurodegenerative disorder diagnosed clinically with the development of choreiform movements. However, neuropsychological studies have demonstrated cognitive and psychiatric changes during the preclinical phase (pre-HD) prior to formal diagnosis. Previous studies have demonstrated the sensitivity of time reproduction tasks to basal ganglia pathology, as seen in clinical HD and Parkinson's disease. In this study, 29 pre-HD participants, ranging from 3 to 39 years from estimated onset (YEO) of HD based on genetic testing and chronological age, were administered the paced finger-tapping task using target intervals of 600 and 1200 ms. Mean inter-response interval, a measure of timing accuracy, did not systematically deviate from the target interval as a function of YEO. In contrast, timing variability increased curvilinearly as a function of YEO, but not with chronological age alone. Motor timing variability, but not accuracy, may serve as a marker to define the earliest behavioral changes in HD. The present study is among the first to examine the relationship between behavioral measures and YEO in pre-HD. (JINS, 2007, 13, 539–543.)

Summary

Background and objective: To measure ‘depth of anaesthesia’, anaesthesiologists use a combination of observable end-points such as immobility and autonomic stability. Unconsciousness and amnesia are not reliably observable end-points, but correlate with parameters derived from the electroencephalogram. We investigated the association of subjective assessment and electroencephalographic measures of anaesthetic depth in a group of experienced (>4 yr of experience) and a group of inexperienced (<2 yr of experience) anaesthesiologists. Methods: One hundred ASA I or II patients were assigned to either group. Anaesthesiologists assessed ‘anaesthetic depth’ using an 11-point numeric and a 5-point verbal scale. Bispectral index and spectral entropy were recorded as electroencephalogram parameters. The association between the subjective assessment and the electroencephalogram parameters was calculated using the prediction probability, PK. Results: Association between subjective assessment and electroencephalographic parameters showed a tendency to a better prediction probability in the experienced group. The difference was significant (P < 0.05) for the bispectral index (PK 0.76 ± 0.01 for experienced and 0.71 ± 0.01 for inexperienced anaesthesiologists). In both groups, a large percentage of the data points recorded during surgery showed bispectral index values above the recommended value of 60 (13.2% in the experienced and 34.3% in the inexperienced group) despite a subjective assessment of ‘deep’ or ‘very deep’ anaesthetic depth. Conclusion: The study demonstrates that the association between subjectively assigned values of anaesthetic depth and electroencephalographic parameters of anaesthetic depth is better for anaesthesiologists with more clinical experience. However, in the ‘inexperienced’ as well as ‘experienced’ group a high percentage of bispectral index and entropy values above 60 occurred despite a subjective assessment of adequate anaesthetic depth. Although there was no evidence for explicit memory, this may indicate a risk for memory formation.

Background and objective: Cognitive dysfunction has been reported after general anaesthesia, but its assessment is time consuming and difficult to evaluate. This pilot study assessed the feasibility of using the Sustained Attention to Response Test to assess 35 ASA I-II adults (mean age 31.6 yr) undergoing day case surgery under general anaesthesia, and 25 ASA I-II adults (mean age 47.8 yr) undergoing day case surgery under local anaesthesia.

Methods: The Sustained Attention to Response Test was performed before surgery and repeated 2 h after surgery.

Results: When patients repeated the test after surgery under local anaesthesia, the number of incorrect responses increased, but reaction times decreased (P < 0.05). Following general anaesthesia, the number of incorrect responses increased (P < 0.05), but reaction times remained unchanged.

Conclusions: The Sustained Attention to Response Test is simple to administer and may be a useful tool when comparing different anaesthetic techniques and their effects on postoperative deficits in sustained attention.

Background and objective The use of tension-free tape in the vagina is a relatively new surgical procedure for the treatment of urinary incontinence. Traditionally, the procedure is carried out using local anaesthesia and sedation. We aimed to assess the quality of anaesthesia obtained during insertion of tension-free vaginal tape using local anaesthetic infiltration and intravenous conscious sedation.

Methods Twenty-four patients were studied using intravenous midazolam, fentanyl and infiltration with 0.5% prilocaine and epinephrine. Visual analogue scores before operation were used to assess anxiety. The digit symbol substitution test was used before and after surgery to assess psychomotor recovery, and amnesia for the procedure was assessed by means of picture recall. A nurse, anaesthetist and surgeon independently assessed quality of anaesthesia based on vocalization, facial expression, movement and co-operation with incontinence testing.

Results The nurse, anaesthetist and surgeon reported good or excellent conditions in 18, 14 and 22 cases, respectively. There was no significant psychomotor impairment using the digit symbol substitution test, with mean (standard deviation) preoperative and postoperative scores of 22 (8) and 21 (7) correctly matched symbol digit pairs. There was a significant correlation between preoperative anxiety and intraoperative fentanyl requirement (r=0.48, P < 0.05).

Conclusion Satisfactory anaesthetic conditions can be achieved for the insertion of tension-free vaginal tape using local anaesthesia with sedation.