Airway , Breathing And Circulation Research Articles

A global perspective on gun violence injuries

Introduction and definitionsCivilian gunshot violence is a growing public health issue on a global scale. Treatment of patients with gunshot injuries is based on algorithms derived from military studies, but the distinct differences in weaponry, energy of injury, timing and type of care, and environment translate to a gap in knowledge. With a focus on non-accidental gunshot trauma and excluding suicide etiologies, we propose to build a collaborative research group to address important questions focused on best practices for gunshot injury patients. Pre-hospital careThere are important differences in the care of gunshot victims across the globe; some countries provide advanced interventions in the field and others deliver basic support until transport to a higher level of care in hospital. Some simple interventions include the use of extremity tourniquets and intravenous fluid support; others to consider are tranexamic acid, whole blood, and hemostatic agents. Acute treatmentControl of exsanguinating hemorrhage is a key priority for gunshot injuries. Military doctrine has evolved to prioritize exsanguination over airway or breathing as the critical first step. The X-ABC protocol focuses on exsanguinating hemorrhage, then standard evaluation of Airway, Breathing and Circulation (ABCs) to enhance survival in trauma patients. The timing of bony stabilization, in terms of damage-control vs definitive care, needs further study in this population, as does use of antibiotics for bony extremity injuries. Finally, recognition of the mental health effects of gun trauma, including post-traumatic stress disorder (PTSD), anxiety disorders, substance abuse and depression is important in advocating for prevention such as implementation of social support and specific interventions. Definitive careThe need for abdominal closure after exploratory laparotomy, definitive fracture treatment, and other treatment all contribute to length of stay for gunshot injured patients. Optimizing stabilization allows earlier mobilization and decreases nosocomial complications. Nerve injuries are often a source of long-term disability and their evaluation and treatment require further investigation. Resources and ethicsThere are growing numbers of mass-casualty gunshot events, which require consideration of how to organize and use resources for treatment, including staff, operating room access, blood products, and order of treatment. Drills and planning for incident command hierarchy and communication are key to optimizing resource utilization. The ethics of choosing treatment priorities and resources are important considerations as well.

Hypothermia and Cold Injury in Children.

Hypothermia and Cold Injury in Children.

Bypassing nearest hospital for more distant neuroscience care in head-injured adults with suspected traumatic brain injury: findings of the head injury transportation straight to neurosurgery (HITS-NS) pilot cluster randomised trial

ObjectiveReconfiguration of trauma services, with direct transport of patients with traumatic brain injury (TBI) to specialist neuroscience centres (SNCs)—bypassing non-specialist acute hospitals (NSAHs), could improve outcomes. However, delays in stabilisation...

THE IMPACT OF BYPASS OF NON-SPECIALIST ACUTE HOSPITALS IN FAVOUR OF SPECIALIST NEUROSCIENCE CENTRES AS THE PRIMARY HOSPITAL DESTINATION FOR TRAUMATIC BRAIN INJURY PATIENTS

Objectives & BackgroundSince the introduction of the regional trauma networks in the UK, the practice of transporting traumatic brain injury (TBI) patients past the nearest non-specialist acute hospital (NSAH) in...

The Head Injury Transportation Straight to Neurosurgery (HITS-NS) randomised trial: a feasibility study.

Reconfiguration of trauma services, with direct transport of traumatic brain injury (TBI) patients to neuroscience centres (NCs), bypassing non-specialist acute hospitals (NSAHs), could potentially improve outcomes. However, delays in stabilisation of airway, breathing and circulation (ABC) and the difficulties in reliably identifying TBI at scene may make this practice deleterious compared with selective secondary transfer from nearest NSAH to NC. National Institute for Health and Care Excellence guidance and systematic reviews suggested equipoise and poor-quality evidence - with regard to 'early neurosurgery' in this cohort - which we sought to address. Pilot cluster randomised controlled trial of bypass to NC conducted in two ambulance services with the ambulance station (n = 74) as unit of cluster [Lancashire/Cumbria in the North West Ambulance Service (NWAS) and the North East Ambulance Service (NEAS)]. Adult patients with signs of isolated TBI [Glasgow Coma Scale (GCS) score of < 13 in NWAS, GCS score of < 14 in NEAS] and stable ABC, injured nearest to a NSAH were transported either to that hospital (control clusters) or bypassed to the nearest NC (intervention clusters). recruitment rate, protocol compliance, selection bias as a result of non-compliance, accuracy of paramedic TBI identification (overtriage of study inclusion criteria) and pathway acceptability to patients, families and staff. 'Open-label' secondary outcomes: 30-day mortality, 6-month Extended Glasgow Outcome Scale (GOSE) and European Quality of Life-5 Dimensions. Overall, 56 clusters recruited 293 (169 intervention, 124 control) patients in 12 months, demonstrating cluster randomised pre-hospital trials as viable for heath service evaluations. Overall compliance was 62%, but 90% was achieved in the control arm and when face-to-face paramedic training was possible. Non-compliance appeared to be driven by proximity of the nearest hospital and perceptions of injury severity and so occurred more frequently in the intervention arm, in which the perceived time to the NC was greater and severity of injury was lower. Fewer than 25% of recruited patients had TBI on computed tomography scan (n = 70), with 7% (n = 20) requiring neurosurgery (craniotomy, craniectomy or intracranial pressure monitoring) but a further 18 requiring admission to an intensive care unit. An intention-to-treat analysis revealed the two trial arms to be equivalent in terms of age, GCS and severity of injury. No significant 30-day mortality differences were found (8.8% vs. 9.1/%; p > 0.05) in the 273 (159/113) patients with data available. There were no apparent differences in staff and patient preferences for either pathway, with satisfaction high with both. Very low responses to invitations to consent for follow-up in the large number of mild head injury-enrolled patients meant that only 20% of patients had 6-month outcomes. The trial-based economic evaluation could not focus on early neurosurgery because of these low numbers but instead investigated the comparative cost-effectiveness of bypass compared with selective secondary transfer for eligible patients at the scene of injury. Current NHS England practice of bypassing patients with suspected TBI to neuroscience centres gives overtriage ratios of 13 : 1 for neurosurgery and 4 : 1 for TBI. This important finding makes studying the impact of bypass to facilitate early neurosurgery not plausible using this study design. Future research should explore an efficient comparative effectiveness design for evaluating 'early neurosurgery through bypass' and address the challenge of reliable TBI diagnosis at the scene of injury. Current Controlled Trials ISRCTN68087745. This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 1. See the NIHR Journals Library website for further project information.

Management of maxillofacial trauma in emergency: An update of challenges and controversies.

Trauma management has evolved significantly in the past few decades thereby reducing mortality in the golden hour. However, challenges remain, and one such area is maxillofacial injuries in a polytrauma patient. Severe injuries to the maxillofacial region can complicate the early management of a trauma patient owing to the regions proximity to the brain, cervical spine, and airway. The usual techniques of airway breathing and circulation (ABC) management are often modified or supplemented with other methods in case of maxillofacial injuries. Such modifications have their own challenges and pitfalls in an already difficult situation.

Intoxicaciones agudas por alcohol, otras drogas y fármacos psicoactivos

Initial management begins with the conventional system ABC (airway, breathing and circulation) and neurological assessment and management of complications (seizures, arrhythmias and electrolyte disorders). Subsequently, more specific to reduce the absorption, promote disposal and use of antidotes (if any) measures. The clinical manifestations of acute ethanol intoxication, relate directly with blood alcohol levels. Clinical management is based on general measures, thiamine must be used as prophylaxis for Wernicke encephalopathy. Several studies have shown that Metadoxine may be useful in treating acute alcohol intoxication. The clinical manifestations related to drug abuse are a common target, the condition of the central nervous system and hemodynamic instability. The handling is very similar, despite the variety of illicit substances: hydration, use of naloxone / flumazenil, checking vital signs. Psychotropic drugs are a very heterogeneous group, have a wide margin of safety (with exceptions). The use of activated charcoal should be performed at multiple doses, due to the long half life of this group, being ineffective measures to accelerate the elimination of the drug. Lithium is the drug within the group, sequels and organ damage can cause poisoning last once. The handling is related in case of serious poisoning, existing as only specific antidote flumazenil for benzodiazepine poisoning.

Crash Cart Drug Drawer Layout and Design

A two-phase study of crash cart medications in the Emergency Department (ED) is reported. The purpose of the phased study was to determine a standardized layout for emergency medications that would promote safety and efficiency during a code blue event. During Phase I, a comprehensive list of ED medications and crash cart configurations was compiled and compared across three acute care hospitals. Three emergency departments were consulted to catalogue medications and to understand the workflow processes surrounding the crash cart such as medication stocking and inventory control. A number of similarities and differences were found for drug usage and crash cart drug drawer layout across hospitals. Phase II examined how ED nurses accessed and used medications from the crash cart. ED nurses individually designed the primary crash cart drawer by placing pictures of each medication into a ‘jigsaw puzzle’ while thinking aloud. Alphabetization of medications and grouping by ABC (airway, breathing and circulation) emerged as primary access strategies proposed by ED nurses. Implications for these and other design insights are discussed with respect to crash cart safety and efficiency.

Clear the fog: the challenges of altered mental status in children.

EMS is dispatched to a residence for an "unresponsive child." On arrival, a frantic mother is waiting at the door and directs the crew to the living room. EMS providers find an 8-year-old male who's only responsive to deep pain. While one paramedic assesses the patient, their partner obtains a history from the mother. The mother states her child was complaining of a headache for the past week, and says it worsened earlier today. He's an otherwise healthy child. A full primary survey reveals that airway breathing and circulation (ABCs) are intact. The patient's vital signs are a heart rate of 60, respiratory rate of 8, blood pressure of 160/120 and oxygen saturation of 90%. An IV is established, and a glucose check is administered, revealing a blood sugar of 95. The patient will only respond to deep, sternal rub.

Damage Control Surgery in the Era of Damage Control Resuscitation

Damage Control Surgery (DCS) is an operative strategy that sacrifices the completeness of the immediate surgical repair in order to address the physiological consequences of the combined trauma (double hit)...

Respiratory assessment in critically ill Patients: airway and breathing

In this series of articles, the authors outline what they consider to be essential/core critical care skills that all nurses should possess in order to timely and appropriately assess critically ill patients. It is anticipated that the possession of these core skills will enable nurses to appropriately assess and identify those patients who are at risk of deterioration. By comprehensively assessing individual patients and identifying problems early, nurses can initiate specific interventions that may stabilise and/or improve patient outcomes and help prevent unnecessary intensive care unit admission. Having covered respiratory assessment here, in subsequent articles the authors will outline and discuss the following key critical care skills that all nurses should possess: cardiac and circulatory assessment, neurological assessment, hydration status assessment, fluid management and intravenous therapy. In this article the authors discuss the airway, breathing and circulation (ABC) approach to patient assessment and then focus on respiratory assessment and management.

Part 6: Advanced Cardiovascular Life Support

Part 6: Advanced Cardiovascular Life Support

Pre-registration house officers: What do they know about pain management?

Abstract Sixty-three new pre-registration house officers (PRHO) in two university teaching hospitals in the West of Scotland answered a two-part questionnaire developed by the investigators. This attempted to study how well they would manage specific acute pain situations and pain management related complications. A non-clinical section assessed their experiences with undergraduate teaching of acute pain management, their prescribing habits and interest in continuing education in pain related topics. Many of the doctors surveyed felt that their undergraduate training in acute pain was inadequate and turned to seniors, nurses and drug formularies for help. Most expressed an interest in learning a wider range of pain-related topics. The acute pain service (APS) and anaesthetists were underutilised. Less than 50% were aware of the availability of protocols for opioid administration, epidurals and patient controlled analgesia (PCA). There was a tendency to underestimate pain and hence to prescribe inadequate analgesia. In unambiguous scenarios, most doctors fared well, whilst responses to more complex scenarios were only satisfactory. In a scenario relating to opioid overdose, 36% were unsure how much naloxone to use. Too few considered getting senior help or attending to Airway, Breathing and Circulation (ABC). Many could not manage PCA. Undergraduate teaching in acute pain is receiving more emphasis. On the job seminars and continuing education in acute pain topics are beneficial. The results of our survey will be considered when planning training for future PRHOs in this region.

PERIOPERATIVE ANESTHETIC MANAGEMENT OF PEDIATRIC TRAUMA

PERIOPERATIVE MANAGEMENT OF PEDIATRIC TRAUMA Pediatric trauma is the leading cause of death in children between the ages of 1 and 15 years? A significant percentage of traumatic injuries occur in the pediatric age range, and, therefore, anesthesiologists must have a thorough understanding of the physiologic derangements of these patients and the anesthetic challenges of this population. Although pediatric trauma remains the primary cause of childhood morbidity and mortality, the cause of such trauma is rapidly evolving. Blunt-force injuries from falls and motor vehicle accidents are quickly being outnumbered by the penetrating wounds of guns and knives in the urban setting. The latter form of trauma accounts for the highest percentage of fatal injuries. Unlike adults, children with head injuries combined with major trauma have a 50% mortality rate. The pediatric population presents unique challenges to anesthesiologists. With respect to the ABCs (airway, breathing, and circulation), the pediatric airway is distinct from that of the adult in that the redundancy of soft tissues and relatively large head size place children at a higher risk for airway obstruction. These factors, coupled with a small aperture and relatively large tongue, make the pediatric airway potentially difficult even in the most experienced hands.14 The fact that the apnea-to-hypoxia interval is so short in children makes immediate airway assessment and intervention crucial in ensuring the successful resuscitation of pediatric trauma patients. A high percentage of pediatric trauma deaths are related to improper or inadequate airway management, and, thus,

NEAR-DROWNING VICTIMS—THE ABCS OF CARE

With the development of more supervised swimming facilities and especially the growing sophistication of the general population in the ABCs (Airway, Breathing and Circulation) of resuscitation, a large number of neardrowning victims are reaching hospital emergency rooms. In the emergency room, physicians and nurses may suddenly be confronted, perhaps for the first time, with a drowning victim. The treatment provided in the hospital can determine the living or dying of these victims. A large number of near-drowning victims have been studied in the past several years. These studies have shifted the emphasis in treatment from fluid and electrolyte disturbances and focused on ventilation, hypoxemia, circulation, and acidosis. Clinical management of these four derangements is, in essence, an extension of the ABCs of emergency resuscitation. The new emphasis in clinical management