Tracheal Intubation Following Traumatic Injury)
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Patient; but by the Use of X-Rays, Bronchoscopy, and Exploratory Thoracotomy, We Are Beginning to Get a Conception of the Pathology in the Living, Which Is An
Postgrad Med J: first published as 10.1136/pgmj.11.111.25 on 1 January 1935. Downloaded from January, 1935 INTRATHORACIC NEOPLASMS 25 INTRATHORACIC NEOPLASMS By H. P. NELSON, M.A., M.D., F.R.C.S. (Assistant Surgeon, Brompton Hospital.) Primary neoplasms within the thorax fall into two main groups; those arising in the broncho-pulmonary system, which express themselves by the typical respira- tory symptoms of cough, sputum and haemoptysis; and mediastinal neoplasms, a heterogeneous group, which sooner or later draw attention to themselves by pressure on nerves or obstruction of veins, trachea or oesophagus. Broncho-Pulmonary Neoplasms. The growth usually starts in one of the larger bronchi. The outstanding symptoms are cough and hamoptysis and the physical signs are due to bronchial obstruction. Practically speaking, all this group are carcinomas, but recently bronchial adenomas have been recognized as a group which were previously often classified as malignant. Other innocent tumours such as fibromas, chondromas and papillomas have been reported. Bronchial Carcinomas are definitely on the increase; although some authorities still believe that this is only apparent owing to improved diagnostic methods, it by copyright. is difficult to maintain this view when the post-mortem records also indicate an increase. Our understanding of the gross pathology of these tumours is derived from the study of post-mortem material, when the condition has advanced to kill the patient; but by the use of X-rays, bronchoscopy, and exploratory thoracotomy, we are beginning to get a conception of the pathology in the living, which is an essential preliminary to treatment. -
Emergency Department Resuscitation of the Critically Ill Review by Stephen C
BOOK AND MEDIA REVIEW Emergency Department Resuscitation of the Critically Ill Review by Stephen C. Morris, MD, MPH 0196-0644/$-see front matter Copyright © 2018 by the American College of Emergency Physicians. Emergency Department Resuscitation of the crashing morbidly obese patient reviews some of the nuanced Critically Ill management we should be striving for as more of our patients become obese, such as specific airway and ventilation Winters ME, Bond MC, Marcolini EG, et al management and use of ideal versus total body weight American College of Emergency Physicians calculations for critical-care-specific medications. Consider It was with great pleasure that I agreed to review the another example from the chapter on left ventricular assist second edition of Emergency Department Resuscitation of the devices. Although these patients have long been the domain Critically Ill, by Michael E. Winters. I had read and relied of specialty centers, with complex physiology and on the first edition posttraining. Like most who work in complications, the longevity now offered by the devices will emergency medicine, I practice a great deal of critical care; ultimately make them the domain of the community however, I have not completed a fellowship in critical care, emergency department. Additionally, at the cutting edge of nor do I review critical care literature with the level of our practice, the text contains a chapter on extracorporeal scrutiny that I would like. For those of us who want to membrane oxygenation, with a discussion of the practical ensure that we are up to date to guarantee clinical and clinical aspects of implementation. -
Airway Management for COVID 19
Airway Management in Critically Ill COVID-19 Patients KATHERINE HELLER, MD ASSISTANT PROFESSOR UNIVERSITY OF WASHINGTON SCHOOL OF MEDICINE DEPARTMENT OF ANESTHESIOLOGY MEDICAL DIRECTOR: UWMC SICU Disclosures (none) Outline Staff safety PPE Patient factors/ timing Adjuncts for oxygenation Intubation procedure Preparation Equipment/technique Unusual situations Difficult airways Tracheostomy Emergencies Opening Questions Please navigate to pollev.com/katherinehel603 Priorities Priority #1: Staff Safety Considerations for Staff Procedural planning Appropriate PPE takes time Avoid emergencies when able Consider rounding (remotely?) on known COVID patients PPE Any airway management is an Aerosol Generating Procedure (AGP) Need respirator level protections airborne + contact/droplet N95 vs PAPR N95 PAPR Pro Pro Easy to don Comfortable Fast Protect face, neck, head Allow use of stethoscope Reusable More readily available Con Con Allows contamination of Require power source face and neck Need assistance to don Less comfortable and doff May not fit everyone Noisy Fit can change Infection Control Choose what work for you and your institution More important to have clear protocols and expectations Minimize in room staff Have equipment easily available Filter in line on circuit Infection control Barrier Devices Not recommended Additional encumbrance to intubation without proven benefit Not a replacement for PPE May actually increase risk [11] Failed airway Breach of PPE FDA revoked EUA for barrier devices in -
The Nebraska Office of Emergency Health Systems Trauma Program Is Pleased That You Wish to Participate in the Statewide Trauma System
Revised July 2019 INSTRUCTIONS FOR FILLING OUT PRE-REVIEW QUESTIONNAIRE (PRQ) The Nebraska Office of Emergency Health Systems Trauma Program is pleased that you wish to participate in the statewide trauma system. The Nebraska Statewide Trauma System is comprised of hospitals and clinics striving to improve trauma patient care. Through this system all facilities offering trauma care may become centers of excellence. Thank you for participating in this process. In order to prepare for your on-site review, please complete this questionnaire. All answers should directly follow the questions. The entire questionnaire is available on the web in a downloadable format @ http://dhhs.ne.gov/Pages/EHS-Statewide-Trauma-System-of-Care.aspx. The PRQ should be completed electronically if possible otherwise, you may submit a hard copy. Note: If a hard copy is printed a color printer should be used so that information and questions printed in blue appear on the page to the applicant. Return the completed questionnaire to: Sherri Wren EHS Trauma Program Manager Office of Emergency Health Systems P.O. Box 95026 Lincoln, NE 68509-5026 Phone: (402) 471-0539 E-mail: [email protected] If you have questions or concerns while filling out the PRQ, please contact: State of Nebraska Trauma Nurse Specialist OR your Regional Trauma Program Manager (please reference website list of Designated Trauma Centers on the website cited above for names and contact information). I. PURPOSE: A. The purpose of this questionnaire for Consultation Visits is: 1. To provide your institution with an outline of what site visitors will be discussing with you. -
A Clinical Prediction Rule for Pulmonary Complications After Thoracic Surgery for Primary Lung Cancer
A Clinical Prediction Rule for Pulmonary Complications After Thoracic Surgery for Primary Lung Cancer David Amar, MD,* Daisy Munoz, MD,* Weiji Shi, MS,† Hao Zhang, MD,* and Howard T. Thaler, PhD† BACKGROUND: There is controversy surrounding the value of the predicted postoperative diffusing capacity of lung for carbon monoxide (DLCOppo) in comparison to the forced expired volume in 1 s for prediction of pulmonary complications (PCs) after thoracic surgery. METHODS: Using a prospective database, we performed an analysis of 956 patients who had resection for lung cancer at a single institution. PC was defined as the occurrence of any of the following: atelectasis, pneumonia, pulmonary embolism, respiratory failure, and need for supplemental oxygen at hospital discharge. RESULTS: PCs occurred in 121 of 956 patients (12.7%). Preoperative chemotherapy (odds ratio 1.64, 95% confidence interval 1.06–2.55, P ϭ 0.02, point score 2) and a lower DLCOppo (odds ratio per each 5% decrement 1.13, 95% confidence interval 1.06–1.19, P Ͻ 0.0001, point score 1 per each 5% decrement of DLCOppo less than 100%) were independent risk factors for PCs. We defined 3 overall risk categories for PCs: low Յ10 points, 39 of 448 patients (9%); intermediate 11–13 points, 37 of 256 patients (14%); and high Ն14 points, 42 of 159 patients (26%). The median (range) length of hospital stay was significantly greater for patients who developed PCs than for those who did not: 12 (3–113) days vs 6 (2–39) days, P Ͻ 0.0001, respectively. Similarly, 30-day mortality was significantly more frequent for patients who developed PCs than for those who did not: 16 of 121 (13.2%) vs 6 of 835 (0.7%), P Ͻ 0.0001. -
Developing an Airway Management Bundle to Standardize Emergent
It Takes A Village: Developing an Airway Management Bundle to Standardize Emergent Intubation Processes in the Emergency Department James Sacca, MD, Daniel Casey Kim, MD, Dimitri Papanagnou, MD, MPH, EdD(c) Department of Emergency Medicine, Thomas Jefferson University Hospital 1. Crash Airway Pre-medicate: Glycopyrrolate: 0.2 mg RSI TIME OUT If patient arrives without airway device present Ondansetron: 4 mg Pre-oxygenate and prepare for immediate intubation Nebulized or atomized Lidocaine: Patient Name__________________________________ If patient arrives with supraglottic device present 4 ml of 4% or 8 ml of 2% Needs Assessment Strategy #2 TJUH AIRWAY BUNDLE Problem Definition If able to oxygenate and ventilate, delay intubation Sedation: Code status permits intubation: Y or N or Unknown If patient arrives with ETT present Ketamine: 1 mg/kg bolus NPO since__________________ Confirm ETT placement (see 5.) Consider paralytic once successful Unconscious, Consider visualization with laryngoscopy Allergies______________________________ or NKDA Unreactive, D. Delayed sequence intubation 2. RSI Patient delirious/agitated so can’t pre-oxygenate We performed a FMEA to uncover latent threats through in situ Height___________________ Near death? Pre-medicate: Mallampati score_____________ Pretreatment: Glycopyrrolate: 0.2 mg Yes No For reactive airway disease: Lidocaine 1.5 mg/kg IV Ondansetron: 4 mg [ ] dentures removed Yes Airway management is at the core of emergent patient care. Emergent 1 For cardiovascular disease: Fentanyl 3 mcg/kg Sedation: simulation, as well as real patient intubations. A in situ simulation of Crash airway Difficult airway? For elevated ICP: both of the above meds/doses Ketamine: 1.5 mg/kg IBW bolus Personnel Pre-oxygenate No Induction: Paralyze intubations in the Emergency Department (ED) at Thomas Jefferson 1. -
THE BUSINESS of EMERGENCY MEDICINE … MADE EASY! Sponsored by AAEM Services, the Management Education Division of AAEM
THE BUSINESS OF EMERGENCY MEDICINE … MADE EASY! Sponsored by AAEM Services, the management education division of AAEM UDisclaimer The views presented in this course and syllabus represent those of the lecturers. The information is presented in a generalized manner and may not be applicable to your specific situation. Also, in many cases, one method of tackling a problem is demonstrated when many others (perhaps better alternatives for your situation) exist. Thus, it is important to consult your attorney, accountant or practice management service before implementing the concepts relayed in this course. UGoal This course is designed to introduce emergency physicians with no formal business education to running the business of emergency medicine. The title “The Business of Emergency Medicine Made Easy” is not meant to be demeaning. Instead, the course will convince anyone with the aptitude to become an emergency physician that, by comparison, running the business of emergency medicine is relatively simple. With off- the-shelf software and a little help from key business associates, we can run an emergency medicine business and create a win-win-win situation for the hospital, patients, and EPs. By eliminating an unnecessary profit stream as exists with CMGs, we can attract and retain better, brighter EPs. AAEM’s Certificate of Compliance on “Fairness in the Workplace” defines the boundaries within which independent groups should practice in order to be considered truly fair. Attesting to the following eight principles allows a group the privilege -
Tracheal Intubation
//Tracheal Intubation http://www.expertconsultbook.com/expertconsult/b/book.do?m... Tracheal Intubation Technique As previously discussed, because of differences in anatomy, there are differences in techniques for intubating the trachea of infants and children compared with adults.[1–4,17–19,99,114,115] Because of the smaller dimensions of the pediatric airway there is increased risk of obstruction with trauma to the airway structures. A technique to be avoided is that in which the blade is advanced into the esophagus and then laryngeal visualization is achieved during withdrawal of the blade. This maneuver may result in laryngeal trauma when the tip of the blade scrapes the arytenoids and aryepiglottic folds. There are several approaches to exposing the glottis in infants with a Miller blade. One philosophy consists of advancing the laryngoscope blade under constant vision along the surface of the tongue, placing the tip of the blade directly in the vallecula and then using this location to pivot or rotate the blade to the right to sweep the tongue to the left and adequately lift the tongue to expose the glottic opening. This avoids trauma to the arytenoid cartilages. One can thus lift the base of the tongue, which in turn lifts the epiglottis, exposing the glottic opening. If this technique is unsuccessful, one may then directly lift the epiglottis with the tip of the blade (see Video Clip 12-1, Coming Soon). Another approach is to insert the Miller blade into the mouth at the right commissure over the lateral bicuspids/incisors (paraglossal approach). The blade is advanced down the right gutter of the mouth aiming the blade tip toward the midline while sweeping the tongue to the left. -
Tracheotomy in Ventilated Patients with COVID19
Tracheotomy in ventilated patients with COVID-19 Guidelines from the COVID-19 Tracheotomy Task Force, a Working Group of the Airway Safety Committee of the University of Pennsylvania Health System Tiffany N. Chao, MD1; Benjamin M. Braslow, MD2; Niels D. Martin, MD2; Ara A. Chalian, MD1; Joshua H. Atkins, MD PhD3; Andrew R. Haas, MD PhD4; Christopher H. Rassekh, MD1 1. Department of Otorhinolaryngology – Head and Neck Surgery, University of Pennsylvania, Philadelphia 2. Department of Surgery, University of Pennsylvania, Philadelphia 3. Department of Anesthesiology, University of Pennsylvania, Philadelphia 4. Division of Pulmonary, Allergy, and Critical Care, University of Pennsylvania, Philadelphia Background The novel coronavirus (COVID-19) global pandemic is characterized by rapid respiratory decompensation and subsequent need for endotracheal intubation and mechanical ventilation in severe cases1,2. Approximately 3-17% of hospitalized patients require invasive mechanical ventilation3-6. Current recommendations advocate for early intubation, with many also advocating the avoidance of non-invasive positive pressure ventilation such as high-flow nasal cannula, BiPAP, and bag-masking as they increase the risk of transmission through generation of aerosols7-9. Purpose Here we seek to determine whether there is a subset of ventilated COVID-19 patients for which tracheotomy may be indicated, while considering patient prognosis and the risks of transmission. Recommendations may not be appropriate for every institution and may change as the current situation evolves. The goal of these guidelines is to highlight specific considerations for patients with COVID-19 on an individual and population level. Any airway procedure increases the risk of exposure and transmission from patient to provider. -
Emergency Medical Services at the Crossroads
Future of Emergency Care Series Emergency Medical Services At the Crossroads Committee on the Future of Emergency Care in the United States Health System Board on Health Care Services PREPUBLICATION COPY: UNCORRECTED PROOFS THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This study was supported by Contract No. 282-99-0045 between the National Academy of Sciences and the U.S. Department of Health and Human Services’ Agency for Healthcare Research and Quality (AHRQ); Contract No. B03-06 between the National Academy of Sciences and the Josiah Macy, Jr. Foundation; and Contract No. HHSH25056047 between the National Academy of Sciences and the U.S. Department of Health and Human Services’ Health Resources and Services Administration (HRSA) and Centers for Disease Control and Prevention (CDC), and the U.S. Department of Transportation’s National Highway Traffic Safety Administration (NHTSA). Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project. International Standard Book Number 0-309-XXXXX-X (Book) International Standard Book Number 0-309- XXXXX -X (PDF) Library of Congress Control Number: 00 XXXXXX Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. -
Recent Advances in Video-Assisted Transthoracic Tracheal Resection Followed by Reconstruction Under Non-Intubated Anesthesia with Spontaneous Breathing
2894 Editorial Recent advances in video-assisted transthoracic tracheal resection followed by reconstruction under non-intubated anesthesia with spontaneous breathing Katsuhiro Okuda, Satoru Moriyama, Hiroshi Haneda, Osamu Kawano, Tadashi Sakane, Risa Oda, Takuya Watanabe, Ryoichi Nakanishi Department of Oncology, Immunology and Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya 467-8601, Japan Correspondence to: Katsuhiro Okuda, MD, PhD. Department of Oncology, Immunology and Surgery, Nagoya City University Graduate School of Medical Science, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya 467-8601, Japan. Email: [email protected]. Provenance: This is an invited Editorial commissioned by Section Editor Jianfei Shen, MD (Department of Cardiothoracic Surgery, Taizhou Hospital of Zhejiang Province, Wenzhou Medical University, Taizhou, China). Comment on: Li S, Liu J, He J, et al. Video-assisted transthoracic surgery resection of a tracheal mass and reconstruction of trachea under non- intubated anesthesia with spontaneous breathing. J Thorac Dis 2016;8:575-85. Submitted Jul 27, 2017. Accepted for publication Aug 02, 2017. doi: 10.21037/jtd.2017.08.58 View this article at: http://dx.doi.org/10.21037/jtd.2017.08.58 Tracheal resection followed by reconstruction is one of the associated with some problems that remain to be improved. most difficult procedures in the field of thoracic surgery. There is a possibility of tracheal injury due to endotracheal Right thoracotomy performed via a posterolateral incision intubation, and lung parenchymal injury (including is selected for middle and lower tracheal resection under pneumonia) can occur in the perioperative period as a general anesthesia. In order to develop a novel less invasive result of mechanical ventilation (5,6). -
Anytown Trauma Center Trauma Protocols
ANYTOWN TRAUMA CENTER TRAUMA PROTOCOLS TITLE: TRAUMA TEAM ACTIVATION PROTOCOL PURPOSE: The purpose of the protocol is to establish guidelines for trauma team activation and define the members of the responding trauma team to facilitate the resuscitation and management of critical or seriously injured patients who require rapid, organized resuscitation, evaluation and stabilization to promote optimal outcomes. It also serves to provide triage guidelines for adult and pediatric patients. PROCESS: 1. TRAUMA TEAM ACTIVATION PROTCOL A. The criteria for activation of the trauma team is clearly defined and posted at the Emergency Department triage desk, by the EMS communication station and in the resuscitation rooms. B. The trauma team may be activated prior to arrival based on the EMS communication and their assessment. C. The trauma surgeon, emergency medicine physician, emergency department charge nurse/ house supervisor, emergency department nurses and the Trauma Program Manager may activate the trauma team. D. The person calling the trauma activation will initiate the trauma page to group page the trauma team and will specify the MOI, BP, HR, ETA and level of activation required and age if available. E. If the trauma team members are present in the emergency department and alert is still communicated to ensure everyone is notified. F. Trauma team member notification and arrival times will be documented on the trauma flow sheet (paper or electronic). G. Trauma team members will sign-in when they arrive. H. Trauma team members will be activated for all patients who meet the following criteria: 1. Level 1 trauma activation (major): life threatening injuries and/or unstable vital signs, limb-threating or disability threatening injury 2.