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Trauma and penetrating injury, mostly in the form of assault and self-inflicted gunshot and stab wounds, is a major contributor to mortality and morbidity in the modern world, specifically among younger populations. While the prevalence of this form of injury is drastically lower in the UK and Europe in comparison with the USA, it is still common enough to necessitate practising anaesthetists to have a good understanding and working knowledge of the principles in treating victims with penetrating injury. This review article aims to cover basic principles of attending to penetrating trauma victims starting at the pre-hospital level and continuing into the emergency department (ED) and the operating theatre. We will highlight major issues with regard to airway control, severe bleeding treatment, and emergency scene and ED procedures. We also suggest a work flow for treating life-threatening penetrating injury and review the major controversies in this field. Our perspective is based on the experience and procedures used at the University of Washington's Harborview Medical Center, the only level 1 trauma centre covering the states of Washington, Alaska, Montana, Idaho, and Wyoming in the USA. This region contains almost 11 000 000 persons over a surface area of more than 2 700 000 km(2).

IntroductionStep climbing is a potentially useful modality for testing exercise capacity. However, there are significant variations between test protocols and lack of consistent validation against gold standard cycle ergometry cardiopulmonary exercise testing (CPET). The purpose of the study was to validate a novel technique of exercise testing using a dedicated device.MethodsWe built a step oximetry device from an adapted aerobics step and pulse oximeter connected to a computer. Subjects performed lung function tests, a standard incremental cycle CPET and also a CPET while stepping on and off the step oximetry device to maximal exertion. Data from the step oximetry device were processed and correlated with standard measurements of pulmonary function and cycle CPET.ResultsWe recruited 89 subjects (57 years, 50 men). Oxygen uptake (VO2) was 0.9 mL/kg/min (95% CI −3.6 to 5.4) higher in the step test compared with the gold standard cycle CPET, p<0.001. VO2 in the two techniques was highly correlated (R=0.87, p<0.001). Work rate during stair climbing showed the best correlation with VO2 (R=0.69, p<0.0001). Desaturation during step climbing correlated negatively with diffusion capacity for carbon monoxide (r=−0.43, p<0.005). No adverse events occurred.ConclusionsThe step oximetry test was a maximal test of exertion in the subjects studied, achieving slightly higher VO2 than during the standard test. The test was safe to perform and well tolerated by the patients. Parameters derived from the step oximetry device correlated well with gold standard measurements. The step oximetry test could become a useful and standardisable exercise test for clinical settings where advanced testing is not available or appropriate.

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