Respiratory Failure and ARDS
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ABCDE Approach
The ABCDE and SAMPLE History Approach Basic Emergency Care Course Objectives • List the hazards that must be considered when approaching an ill or injured person • List the elements to approaching an ill or injured person safely • List the components of the systematic ABCDE approach to emergency patients • Assess an airway • Explain when to use airway devices • Explain when advanced airway management is needed • Assess breathing • Explain when to assist breathing • Assess fluid status (circulation) • Provide appropriate fluid resuscitation • Describe the critical ABCDE actions • List the elements of a SAMPLE history • Perform a relevant SAMPLE history. Essential skills • Assessing ABCDE • Needle-decompression for tension • Cervical spine immobilization pneumothorax • • Full spine immobilization Three-sided dressing for chest wound • • Head-tilt and chin-life/jaw thrust Intravenous (IV) line placement • • Airway suctioning IV fluid resuscitation • • Management of choking Direct pressure/ deep wound packing for haemorrhage control • Recovery position • Tourniquet for haemorrhage control • Nasopharyngeal (NPA) and oropharyngeal • airway (OPA) placement Pelvic binding • • Bag-valve-mask ventilation Wound management • • Skin pinch test Fracture immobilization • • AVPU (alert, voice, pain, unresponsive) Snake bite management assessment • Glucose administration Why the ABCDE approach? • Approach every patient in a systematic way • Recognize life-threatening conditions early • DO most critical interventions first - fix problems before moving on -
Emergency Nursing Program Foreword
RESOURCE MANUAL NSW HEALTH 2011 Transition to Practice Emergency Nursing Program Foreword The role of emergency nurses requires a broad level of skill and ability to meet the care needs of patients and their families. The Transition to Emergency Nursing Program is designed to support registered nurses new to the practice of emergency nursing. The Emergency Department is a fast-moving environment within which nurses can find themselves faced with a variety of challenges across a day. This program will assist them as they develop their knowledge and skills to meet these often changing care needs within the emergency setting. The program also supports a more consistent approach to transition to emergency nursing and it is anticipated will become the standard for initial entry to practice as an emergency nurse across NSW. This Resource Manual is the core document for the program and is complemented by both the Participant Workbook and the Facilitator’s Manual. Within the Emergency Department participants will be supported by staff to meet the relevant learning objectives during the 3-6 months over which this program extends. The development of the Transition to Emergency Nursing Program has been a lengthy process which reflects the commitment of emergency nurses to their area of practice and I acknowledge and thank them for their enthusiasm and work in enabling the Program to be developed. I am sure that it will have a positive impact for those nurses new to emergency nursing and to the care of patients. 1 Adjunct Professor Debra Thoms Chief Nursing and Midwifery Officer NSW Health NSW Department of Health 73 Miller Street NORTH SYDNEY NSW 2060 Tel. -
Airway Pressures and Volutrauma
Airway Pressures and Volutrauma Airway Pressures and Volutrauma: Is Measuring Tracheal Pressure Worth the Hassle? Monitoring airway pressures during mechanical ventilation is a standard of care.1 Sequential recording of airway pressures not only provides information regarding changes in pulmonary impedance but also allows safety parameters to be set. Safety parameters include high- and low-pressure alarms during positive pressure breaths and disconnect alarms. These standards are, of course, based on our experience with volume control ventilation in adults. During pressure control ventilation, monitoring airway pressures remains important, but volume monitoring and alarms are also required. Airway pressures and work of breathing are also important components of derived variables, including airway resistance, static compliance, dynamic compliance, and intrinsic positive end-expiratory pressure (auto-PEEP), measured at the bedside.2 The requisite pressures for these variables include peak inspiratory pressure, inspiratory plateau pressure, expiratory plateau pressure, and change in airway pressure within a breath. Plateau pressures should be measured at periods of zero flow during both volume control and pressure control ventilation. Change in airway pressure should be measured relative to change in volume delivery to the lung (pressure-volume loop) to elucidate work of breathing. See the related study on Page 1179. Evidence that mechanical ventilation can cause and exacerbate acute lung injury has been steadily mounting.3-5 While most of this evidence has originated from laboratory animal studies, recent clinical reports appear to support this concept.6,7 Traditionally, ventilator-induced lung injury brings to mind the clinical picture of tension pneumothorax. Barotrauma (from the root word baro, which means pressure) is typically associated with excessive airway pressures. -
Spontaneous Pneumothorax in COVID-19 Patients Treated with High-Flow Nasal Cannula Outside the ICU: a Case Series
International Journal of Environmental Research and Public Health Case Report Spontaneous Pneumothorax in COVID-19 Patients Treated with High-Flow Nasal Cannula outside the ICU: A Case Series Magdalena Nalewajska 1, Wiktoria Feret 1 , Łukasz Wojczy ´nski 1, Wojciech Witkiewicz 2 , Magda Wi´sniewska 1 and Katarzyna Kotfis 3,* 1 Department of Nephrology, Transplantology and Internal Medicine, Pomeranian Medical University, 70–111 Szczecin, Poland; [email protected] (M.N.); [email protected] (W.F.); [email protected] (Ł.W.); [email protected] (M.W.) 2 Department of Cardiology, Pomeranian Medical University, 70–111 Szczecin, Poland; [email protected] 3 Department of Anesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University in Szczecin, 70–111 Szczecin, Poland * Correspondence: katarzyna.kotfi[email protected] Abstract: The coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has become a global pandemic and a burden to global health at the turn of 2019 and 2020. No targeted treatment for COVID-19 infection has been identified so far, thus supportive treatment, invasive and non-invasive oxygen support, and corticosteroids remain a common therapy. High-flow nasal cannula (HFNC), a non-invasive oxygen support method, has become a prominent treatment option for respiratory failure during the SARS-CoV-2 pandemic. Citation: Nalewajska, M.; Feret, W.; HFNC reduces the anatomic dead space and increases positive end-expiratory pressure (PEEP), Wojczy´nski,Ł.; Witkiewicz, W.; allowing higher concentrations and higher flow of oxygen. Some studies suggest positive effects of Wi´sniewska,M.; Kotfis, K. HFNC on mortality and avoidance of intubation. -
The Child with Altered Respiratory Status
Path: K:/LWW-BOWDEN-09-0101/Application/LWW-BOWDEN-09-0101-016.3d Date: 3rd July 2009 Time: 16:31 User ID: muralir 1BlackLining Disabled CHAPTER 16 The Child With Altered Respiratory Status Do you remember the Diaz fam- Case History leave Lela, the baby sister, ily from Chapter 9, in which with Claudia’s mother, Selma, Jose has trouble taking his asthma medication, and head to the hospital. and in Chapter 4, in which Jose’s little sister, At the hospital the emergency department Lela, expresses her personality even as a new- nurse observes Jose sitting cross-legged and born? Jose is 4 years old and was diagnosed leaning forward on his hands. His mouth is with asthma this past fall, about 6 months ago. open and he is breathing hard with an easily Since that time Claudia, his mother, has audible inspiratory wheeze. He is using his noticed several factors that trigger his asthma subclavicular accessory muscles with each including getting sick, pollen, and cold air. breath. His respiratory rate is 32 breaths per One evening following a warm early-spring minute, his pulse is 112 beats per minutes, day, Jose is outside playing as the sun sets and and he is afebrile. Claudia explains that he the air cools. When he comes inside he was fine; he was outside running and playing, begins to cough. Claudia sets up his nebulizer and then came in and began coughing and and gives him a treatment of albuterol, which wheezing, and she gave him an albuterol lessens his coughing. Within an hour, Jose is treatment. -
Approach to Cyanosis in a Neonate.Pdf
PedsCases Podcast Scripts This podcast can be accessed at www.pedscases.com, Apple Podcasting, Spotify, or your favourite podcasting app. Approach to Cyanosis in a Neonate Developed by Michelle Fric and Dr. Georgeta Apostol for PedsCases.com. June 29, 2020 Introduction Hello, and welcome to this pedscases podcast on an approach to cyanosis in a neonate. My name is Michelle Fric and I am a fourth-year medical student at the University of Alberta. This podcast was made in collaboration with Dr. Georgeta Apostol, a general pediatrician at the Royal Alexandra Hospital Pediatrics Clinic in Edmonton, Alberta. Cyanosis refers to a bluish discoloration of the skin or mucous membranes and is a common finding in newborns. It is a clinical manifestation of the desaturation of arterial or capillary blood and may indicate serious hemodynamic instability. It is important to have an approach to cyanosis, as it can be your only sign of a life-threatening illness. The goal of this podcast is to develop this approach to a cyanotic newborn with a focus on these can’t miss diagnoses. After listening to this podcast, the learner should be able to: 1. Define cyanosis 2. Assess and recognize a cyanotic infant 3. Develop a differential diagnosis 4. Identify immediate investigations and management for a cyanotic infant Background Cyanosis can be further broken down into peripheral and central cyanosis. It is important to distinguish these as it can help you to formulate a differential diagnosis and identify cases that are life-threatening. Peripheral cyanosis affects the distal extremities resulting in blue color of the hands and feet, while the rest of the body remains pinkish and well perfused. -
Apnea and Control of Breathing Christa Matrone, M.D., M.Ed
APNEA AND CONTROL OF BREATHING CHRISTA MATRONE, M.D., M.ED. DIOMEL DE LA CRUZ, M.D. OBJECTIVES ¢ Define Apnea ¢ Review Causes and Appropriate Evaluation of Apnea in Neonates ¢ Review the Pathophysiology of Breathing Control and Apnea of Prematurity ¢ Review Management Options for Apnea of Prematurity ¢ The Clinical Evidence for Caffeine ¢ The Role of Gastroesophageal Reflux DEFINITION OF APNEA ¢ Cessation of breathing for greater than 15 (or 20) seconds ¢ Or if accompanied by desaturations or bradycardia ¢ Differentiate from periodic breathing ¢ Regular cycles of respirations with intermittent pauses of >3 S ¢ Not associated with other physiologic derangements ¢ Benign and self-limiting TYPES OF APNEA CENTRAL ¢ Total cessation of inspiratory effort ¢ Absence of central respiratory drive OBSTRUCTIVE ¢ Breathing against an obstructed airway ¢ Chest wall motion without nasal airflow MIXED ¢ Obstructed respiratory effort after a central pause ¢ Accounts for majority of apnea in premature infants APNEA IS A SYMPTOM, NOT A DIAGNOSIS Martin RJ et al. Pathogenesis of apnea in preterm infants. J Pediatr. 1986; 109:733. APNEA IN THE NEONATE: DIFFERENTIAL Central Nervous System Respiratory • Intraventricular Hemorrhage • Airway Obstruction • Seizure • Inadequate Ventilation / Fatigue • Cerebral Infarct • Hypoxia Infection Gastrointestinal • Sepsis • Necrotizing Enterocolitis • Meningitis • Gastroesophageal Reflux Hematologic Drug Exposure • Anemia • Perinatal (Ex: Magnesium, Opioids) • Polycythemia • Postnatal (Ex: Sedatives, PGE) Cardiovascular Other • Patent Ductus Arteriosus • Temperature instability • Metabolic derangements APNEA IN THE NEONATE: EVALUATION ¢ Detailed History and Physical Examination ¢ Gestational age, post-natal age, and birth history ¢ Other new signs or symptoms ¢ Careful attention to neurologic, cardiorespiratory, and abdominal exam APNEA IN THE NEONATE: EVALUATION ¢ Laboratory Studies ¢ CBC/diff and CRP ¢ Cultures, consideration of LP ¢ Electrolytes including magnesium ¢ Blood gas and lactate ¢ Radiologic Studies ¢ Head ultrasound vs. -
Asphyxia Neonatorum
CLINICAL REVIEW Asphyxia Neonatorum Raul C. Banagale, MD, and Steven M. Donn, MD Ann Arbor, Michigan Various biochemical and structural changes affecting the newborn’s well being develop as a result of perinatal asphyxia. Central nervous system ab normalities are frequent complications with high mortality and morbidity. Cardiac compromise may lead to dysrhythmias and cardiogenic shock. Coagulopathy in the form of disseminated intravascular coagulation or mas sive pulmonary hemorrhage are potentially lethal complications. Necrotizing enterocolitis, acute renal failure, and endocrine problems affecting fluid elec trolyte balance are likely to occur. Even the adrenal glands and pancreas are vulnerable to perinatal oxygen deprivation. The best form of management appears to be anticipation, early identification, and prevention of potential obstetrical-neonatal problems. Every effort should be made to carry out ef fective resuscitation measures on the depressed infant at the time of delivery. erinatal asphyxia produces a wide diversity of in molecules brought into the alveoli inadequately com Pjury in the newborn. Severe birth asphyxia, evi pensate for the uptake by the blood, causing decreases denced by Apgar scores of three or less at one minute, in alveolar oxygen pressure (P02), arterial P02 (Pa02) develops not only in the preterm but also in the term and arterial oxygen saturation. Correspondingly, arte and post-term infant. The knowledge encompassing rial carbon dioxide pressure (PaC02) rises because the the causes, detection, diagnosis, and management of insufficient ventilation cannot expel the volume of the clinical entities resulting from perinatal oxygen carbon dioxide that is added to the alveoli by the pul deprivation has been further enriched by investigators monary capillary blood. -
Sleep Apnea Sleep Apnea
Health and Safety Guidelines 1 Sleep Apnea Sleep Apnea Normally while sleeping, air is moved at a regular rhythm through the throat and in and out the lungs. When someone has sleep apnea, air movement becomes decreased or stops altogether. Sleep apnea can affect long term health. Types of sleep apnea: 1. Obstructive sleep apnea (narrowing or closure of the throat during sleep) which is seen most commonly, and, 2. Central sleep apnea (the brain is causing a change in breathing control and rhythm) Obstructive sleep apnea (OSA) About 25% of all adults are at risk for sleep apnea of some degree. Men are more commonly affected than women. Other risk factors include: 1. Middle and older age 2. Being overweight 3. Having a small mouth and throat Down syndrome Because of soft tissue and skeletal alterations that lead to upper airway obstruction, people with Down syndrome have an increased risk of obstructive sleep apnea. Statistics show that obstructive sleep apnea occurs in at least 30 to 75% of people with Down syndrome, including those who are not obese. In over half of person’s with Down syndrome whose parents reported no sleep problems, sleep studies showed abnormal results. Sleep apnea causing lowered oxygen levels often contributes to mental impairment. How does obstructive sleep apnea occur? The throat is surrounded by muscles that are active controlling the airway during talking, swallowing and breathing. During sleep, these muscles are much less active. They can fall back into the throat, causing narrowing. In most people this doesn’t affect breathing. However in some the narrowing can cause snoring. -
Clinical Management of Severe Acute Respiratory Infections When Novel Coronavirus Is Suspected: What to Do and What Not to Do
INTERIM GUIDANCE DOCUMENT Clinical management of severe acute respiratory infections when novel coronavirus is suspected: What to do and what not to do Introduction 2 Section 1. Early recognition and management 3 Section 2. Management of severe respiratory distress, hypoxemia and ARDS 6 Section 3. Management of septic shock 8 Section 4. Prevention of complications 9 References 10 Acknowledgements 12 Introduction The emergence of novel coronavirus in 2012 (see http://www.who.int/csr/disease/coronavirus_infections/en/index. html for the latest updates) has presented challenges for clinical management. Pneumonia has been the most common clinical presentation; five patients developed Acute Respira- tory Distress Syndrome (ARDS). Renal failure, pericarditis and disseminated intravascular coagulation (DIC) have also occurred. Our knowledge of the clinical features of coronavirus infection is limited and no virus-specific preven- tion or treatment (e.g. vaccine or antiviral drugs) is available. Thus, this interim guidance document aims to help clinicians with supportive management of patients who have acute respiratory failure and septic shock as a consequence of severe infection. Because other complications have been seen (renal failure, pericarditis, DIC, as above) clinicians should monitor for the development of these and other complications of severe infection and treat them according to local management guidelines. As all confirmed cases reported to date have occurred in adults, this document focuses on the care of adolescents and adults. Paediatric considerations will be added later. This document will be updated as more information becomes available and after the revised Surviving Sepsis Campaign Guidelines are published later this year (1). This document is for clinicians taking care of critically ill patients with severe acute respiratory infec- tion (SARI). -
The Effects of Inhaled Albuterol in Transient Tachypnea of the Newborn Myo-Jing Kim,1 Jae-Ho Yoo,1 Jin-A Jung,1 Shin-Yun Byun2*
Original Article Allergy Asthma Immunol Res. 2014 March;6(2):126-130. http://dx.doi.org/10.4168/aair.2014.6.2.126 pISSN 2092-7355 • eISSN 2092-7363 The Effects of Inhaled Albuterol in Transient Tachypnea of the Newborn Myo-Jing Kim,1 Jae-Ho Yoo,1 Jin-A Jung,1 Shin-Yun Byun2* 1Department of Pediatrics, Dong-A University, College of Medicine, Busan, Korea 2Department of Pediatrics, Pusan National University School of Medicine, Yangsan, Korea This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Purpose: Transient tachypnea of the newborn (TTN) is a disorder caused by the delayed clearance of fetal alveolar fluid.ß -adrenergic agonists such as albuterol (salbutamol) are known to catalyze lung fluid absorption. This study examined whether inhalational salbutamol therapy could improve clinical symptoms in TTN. Additional endpoints included the diagnostic and therapeutic efficacy of salbutamol as well as its overall safety. Methods: From January 2010 through December 2010, we conducted a prospective study of 40 newborns hospitalized with TTN in the neonatal intensive care unit. Patients were given either inhalational salbutamol (28 patients) or placebo (12 patients), and clinical indices were compared. Results: The dura- tion of tachypnea was shorter in patients receiving inhalational salbutamol therapy, although this difference was not statistically significant. The dura- tion of supplemental oxygen therapy and the duration of empiric antibiotic treatment were significantly shorter in the salbutamol-treated group. -
Hypercapnia in Hemodialysis (HD)
ISSN: 2692-532X DOI: 10.33552/AUN.2020.01.000508 Annals of Urology & Nephrology Mini Review Copyright © All rights are reserved by David Tovbin Hypercapnia in Hemodialysis (HD) David Tovbin* Department of Nephrology, Emek Medical Center, Israel *Corresponding author: David Tovbin, Department of Nephrology, Emek Medical Received Date: February 04, 2019 Center, Afula, Israel. Published Date: February 14, 2019 Introduction 2 case reports and in our experience with similar patients, BiPAP Acute intra-dialytic exacerbation of hypercapnia in hemodialysis prevented intra-dialytic exacerbation of hypercapnia and possibly (HD) patient has been initially reported 18 years ago [1]. Subsequent respiratory arrest [1,2]. In recent years, new interest was raised similar case was reported few years later [2]. Common features of to HD dialysate bicarbonate concentration. After standardizing to both patients were morbid obesity, a previously stable HD sessions and an acute respiratory infection at time of hypercapnia [1,2]. HD pre-dialysis serum bicarbonate level was recommended as >22 patients with decreased ventilation reserve, due to morbid obesity inflammation malnutrition complex and comorbidities midweek mEq/L [11]. As higher dialysate bicarbonate concentration became with or without obstructive sleep apnea (OSA) and/or obesity more prevalent, a large observation cohort study demonstrated hypoventilation syndrome (OHS) as well as chronic obstructive that high dialysate bicarbonate concentration was associated pulmonary disease (COPD), are at increased risk. COPD is common with worse outcome especially in the more acidotic patients among HD patients but frequently under-diagnosed [3]. Most [12]. However, still not enough attention is paid to HD dialysate COPD patients do well during HD with only mild- moderate pCO2 bicarbonate in the increasing number of patients with impaired increases and slightly decreased pH as compared to non-COPD ventilation, and to their risk of intra-dialytic exacerbation of chronic HD patients [2,4].