Emergency Tracheal Intubation: Techniques and Outcomes
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Tracheal Intubation Following Traumatic Injury)
CLINICAL MANAGEMENT UPDATE The Journal of TRAUMA Injury, Infection, and Critical Care Guidelines for Emergency Tracheal Intubation Immediately after Traumatic Injury C. Michael Dunham, MD, Robert D. Barraco, MD, David E. Clark, MD, Brian J. Daley, MD, Frank E. Davis III, MD, Michael A. Gibbs, MD, Thomas Knuth, MD, Peter B. Letarte, MD, Fred A. Luchette, MD, Laurel Omert, MD, Leonard J. Weireter, MD, and Charles E. Wiles III, MD for the EAST Practice Management Guidelines Work Group J Trauma. 2003;55:162–179. REFERRALS TO THE EAST WEB SITE and impaired laryngeal reflexes are nonhypercarbic hypox- Because of the large size of the guidelines, specific emia and aspiration, respectively. Airway obstruction can sections have been deleted from this article, but are available occur with cervical spine injury, severe cognitive impairment on the Eastern Association for the Surgery of Trauma (EAST) (Glasgow Coma Scale [GCS] score Յ 8), severe neck injury, Web site (www.east.org/trauma practice guidelines/Emergency severe maxillofacial injury, or smoke inhalation. Hypoventi- Tracheal Intubation Following Traumatic Injury). lation can be found with airway obstruction, cardiac arrest, severe cognitive impairment, or cervical spinal cord injury. I. STATEMENT OF THE PROBLEM Aspiration is likely to occur with cardiac arrest, severe cog- ypoxia and obstruction of the airway are linked to nitive impairment, or severe maxillofacial injury. A major preventable and potentially preventable acute trauma clinical concern with thoracic injury is the development of Hdeaths.1–4 There is substantial documentation that hyp- nonhypercarbic hypoxemia. Lung injury and nonhypercarbic oxia is common in severe brain injury and worsens neuro- hypoxemia are also potential sequelae of aspiration. -
Prehospital Airway Management Using the Laryngeal Tube an Emergency Department Point of View
Notfallmedizin Anaesthesist 2014 · 63:589–596 M. Bernhard1 · W. Beres2 · A. Timmermann3 · R. Stepan4 · C.-A. Greim5 · U.X. Kaisers6 · DOI 10.1007/s00101-014-2348-1 A. Gries1 Published online: 2. Juli 2014 1 Emergency Department, University Hospital of Leipzig, Leipzig © Springer-Verlag Berlin Heidelberg 2014 2 Department of Anaesthesiology and Intensive Care Medicine, Main Klinik Ochsenfurt, Ochsenfurt 3 Department of Anaesthesiology, Pain Therapy, Intensive Care Medicine and Emergency Medicine, DRK Kliniken Berlin Westend und Mitte, Berlin Redaktion 4 Department of Public Health, Fulda County, Fulda A. Gries, Leipzig 5 Department of Anesthesiology, Intensive Care Medicine and Emergency Medicine, Hospital of Fulda, Fulda V. Wenzel, Innsbruck 6 Department of Anesthesiology and Intensive Care Medicine, University Leipzig, Medical Faculty, Leipzig Prehospital airway management using the laryngeal tube An emergency department point of view Securing the airway and maintaining ox- Studies describing the successful use of mittee of the Medical Faculty of Leipzig, ygenation and ventilation represent es- the laryngeal tube in the prehospital setting Germany. Single cases were documented sential life-saving strategies in emergen- sound promising [9, 10, 22]. However, the initially after ED admission. The case se- cy medicine [1, 2, 3, 40]. Depending on results of these studies and of case reports ries was evaluated retrospectively, was not the experience of the person performing were not reported by an independent ob- preregistered, and written informed con- the procedure and on the individual in- server and, therefore, reporting bias could tent could not be obtained. tubation conditions, endotracheal intuba- be possible [11, 22]. Only one prospective, tion (ETI) is still considered to be the gold randomized study has confirmed that the Results standard [4, 5, 40]. -
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. -
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. -
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. -
A Randomized Prospective Controlled Trial Comparing the Laryngeal Tube
Somri et al. BMC Anesthesiology (2016) 16:87 DOI 10.1186/s12871-016-0237-7 RESEARCH ARTICLE Open Access A randomized prospective controlled trial comparing the laryngeal tube suction disposable and the supreme laryngeal mask airway: the influence of head and neck position on oropharyngeal seal pressure Mostafa Somri1, Sonia Vaida3, Gustavo Garcia Fornari4,6, Gabriela Renee Mendoza4,6, Pedro Charco-Mora5,6, Naser Hawash1, Ibrahim Matter2, Forat Swaid2 and Luis Gaitini1,6* Abstract Background: The Laryngeal Tube Suction Disposable (LTS-D) and the Supreme Laryngeal Mask Airway (SLMA) are second generation supraglottic airway devices (SADs) with an added channel to allow gastric drainage. We studied the efficacy of these devices when using pressure controlled mechanical ventilation during general anesthesia for short and medium duration surgical procedures and compared the oropharyngeal seal pressure in different head and-neck positions. Methods: Eighty patients in each group had either LTS-D or SLMA for airway management. The patients were recruited in two different institutions. Primary outcome variables were the oropharyngeal seal pressures in neutral, flexion, extension, right and left head-neck position. Secondary outcome variables were time to achieve an effective airway, ease of insertion, number of attempts, maneuvers necessary during insertion, ventilatory parameters, success of gastric tube insertion and incidence of complications. Results: The oropharyngeal seal pressure achieved with the LTS-D was higher than the SLMA in, (extension (p=0.0150) and right position (p=0.0268 at 60 cm H2O intracuff pressures and nearly significant in neutral position (p = 0.0571). The oropharyngeal seal pressure was significantly higher with the LTS-D during neck extension as compared to SLMA (p= 0.015). -
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. -
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. -
A Uniform Triage Scale in Emergency Medicine Information Paper
A Uniform Triage Scale in Emergency Medicine Information Paper Triage: sorting, sifting (Webster’s New Collegiate Dictionary) from the French verb trier- “to sort.” Triage has long been considered a simple frontline sorting mechanism in hospital-based emergency departments (EDs). However, evolution in the practice of emergency medicine during the past two decades necessitates a change in how this entry point process is performed and utilized. Many triage systems are in use in the US, but there is no uniform triage scale that would facilitate the development of operational standards in EDs. A nationally standardized triage scale would provide an analytic basis for determining whether the health care system provides safe access to emergency care based on design, resources, and utilization. The performance of EDs could be compared based on case mix and acuity, and expected standards for facilities could be defined. Planners and policy makers would have the tools and the data needed to make rational improvements in the health care delivery system. This paper on triage will acquaint the reader with the history of triage, and provide an overview of the Australian and Canadian systems which are already in use on a national level. The reliability of triage is addressed, and the Canadian and Australian scales are compared. Future implications for a national triage scale are described, along with the goals and benefits of triage development. While there is some controversy about potential liability issues, the many advantages of a national triage scale appear to outweigh any potential disadvantages. History of triage The first medical application of triage occurred on the French battlefield where sorting the victims determined who would be left behind. -
Tracheal Intubation in Critically Ill Patients
Cabrini et al. Critical Care (2018) 22:6 https://doi.org/10.1186/s13054-017-1927-3 RESEARCH Open Access Tracheal intubation in critically ill patients: a comprehensive systematic review of randomized trials Luca Cabrini1,2, Giovanni Landoni1,2, Martina Baiardo Redaelli1, Omar Saleh1, Carmine D. Votta1, Evgeny Fominskiy1,3, Alessandro Putzu4, Cézar Daniel Snak de Souza5, Massimo Antonelli6, Rinaldo Bellomo7,8, Paolo Pelosi9* and Alberto Zangrillo1,2 Abstract Background: We performed a systematic review of randomized controlled studies evaluating any drug, technique or device aimed at improving the success rate or safety of tracheal intubation in the critically ill. Methods: We searched PubMed, BioMed Central, Embase and the Cochrane Central Register of Clinical Trials and references of retrieved articles. Finally, pertinent reviews were also scanned to detect further studies until May 2017. The following inclusion criteria were considered: tracheal intubation in adult critically ill patients; randomized controlled trial; study performed in Intensive Care Unit, Emergency Department or ordinary ward; and work published in the last 20 years. Exclusion criteria were pre-hospital or operating theatre settings and simulation- based studies. Two investigators selected studies for the final analysis. Extracted data included first author, publication year, characteristics of patients and clinical settings, intervention details, comparators and relevant outcomes. The risk of bias was assessed with the Cochrane Collaboration’s Risk of Bias tool. Results: We identified 22 trials on use of a pre-procedure check-list (1 study), pre-oxygenation or apneic oxygenation (6 studies), sedatives (3 studies), neuromuscular blocking agents (1 study), patient positioning (1 study), video laryngoscopy (9 studies), and post-intubation lung recruitment (1 study).