Emergency Protocols Research Articles

A tale of two communities: B-race-ing disaster responses in the media following the Canterbury and Kaikōura earthquakes

New Zealand media reports have shaped public discourses on the role of community stakeholders in responding to the devastation caused by the 2010–2011 Canterbury earthquakes and the Kaikōura Earthquake in 2016. Anecdotal evidence has also suggested that Māori disaster management responses to both contexts received differing levels of media attention and thus inconsistent recognition within the public domain. Iwi (Māori tribes) have historically enacted kaitiakitanga (cultural guardianship) for their respective regions. Contemporary iwi remain obligated to ensure the wellbeing of local Māori as well as the broader community and environment during adversity, and act accordingly. Media stories pertaining to Māori responders' actions in the aftermath of 2016 Kaikōura earthquakes, have highlighted the effectiveness of such community-led responses as well as the importance of maintaining a unified and well integrated approach to recovery management. In contrast, very few media reports provide comment on the Māori earthquake recovery response to the 2010–2011 Christchurch earthquakes. In this article, the ways in which Māori responses were represented by the media following both natural hazard events, are examined. Media conceptualisations of Māori disaster management leadership are explored through drawing on content and thematic analyses while constructions of Māori cultural identity are considered in the context of disaster management practices. Tensions pertaining to public recognition and legitimatisation of Māori response capabilities are also documented and will inform refinement of media approaches to disaster communication as well as national emergency management policy and protocols.

Spontaneous rupture of the ascending aorta.

Nontraumatic, spontaneous rupture of the ascending aorta is rare and the etiology is largely unknown. We reviewed seven patients from our institution, with no known aortic disease or hereditary connective tissue disorder that presented with spontaneous ascending aortic rupture from 2012 to 2017. Most patients presented with non-radiating chest pain along with hypertension (71.4%). The mean ascending aortic diameter at rupture was 4.60 ± 0.62 cm. The median door-to-operating room time was 2.58 h, resulting from effective implementation of an aortic emergency protocol. There were no operative mortalities. In patients with ascending aortic rupture, aortic diameter may not always correlate with the risk of rupture. Rapid diagnosis combined with a multidisciplinary approach is vital for the successful management of these high-risk patients.

Assessment of severe dyspnea in critically ill patients by transthoracic sonography: Fayoum experience of the Bedside Lung Ultrasonography in Emergency protocol

BackgroundManagement of critically ill patients requires imaging tools, which are important for optimizing diagnostic and therapeutic actions. Both bedside chest radiography and thoracic computed tomography have limitations that constrain their utility. The aim of our work is to explore the value of transthoracic ultrasound (TUS) using the Bedside Lung Ultrasonography in Emergency (BLUE) protocol in critical ill patients with severe dyspnea.Patients and methodsThis study included 109 ICU patients with acute dyspnea at Fayoum University Hospital. The judgments of chest ultrasound using the BLUE protocol were compared with the final diagnoses; rare diagnoses and uncertain diagnoses were excluded.ResultsBy application of the BLUE protocol, TUS was absolutely sensitive, specific, and accurate for the diagnosis of pneumothorax. For pneumonia, the sensitivity, specificity, and diagnostic accuracy were 93.8, 95.7, and 95.8%, respectively, whereas these parameters for pulmonary edema were 100, 96.8, and 99%, respectively. TUS was absolutely sensitive in the diagnosis of chronic obstructive pulmonary disease, asthma, or diffuse parenchymal lung disease, whereas the specificity and diagnostic accuracy were 88.9 and 88.9%, respectively, for chronic obstructive pulmonary disease and asthma and 96.8 and 100%, respectively, for diffuse parenchymal lung disease.

Bedside Lung Ultrasound in Emergency Protocol as a Diagnostic Tool in Patients of Acute Respiratory Distress Presenting to Emergency Department.

Objective:The objective of this study is to determine the accuracy of the bedside lung ultrasound in emergency (BLUE) protocol in giving a correct diagnosis in patients presenting with acute respiratory distress in emergency department.Materials and Methods:Patients with acute respiratory distress were evaluated. Ultrasound findings such as artifacts (A line, B line), lung sliding, alveolar consolidation or pleural effusion, and venous analysis were recorded. Ultrasonography findings were correlated with final diagnosis made by the treating unit. Sensitivity and specificity were calculated.Results:A total 50 patients were evaluated. The A profile (predominant A line with lung sliding) indicated chronic obstructive pulmonary disease/asthma (n = 14) with 85.17% sensitivity and 88.88% specificity. B profile (predominant B + lines with lung sliding) indicated pulmonary edema (n = 13) with 92.30% sensitivity and 100% specificity. The A/B profile (A line on one side and B + line on other side) and the C profile (anterior consolidation) and the A profile plus posterolateral alveolar and/or pleural syndrome indicated pneumonia (n = 17) with 94.11 sensitivity and 93.93% specificity. The A profile plus venous thrombosis indicated pulmonary embolism (n = 1) with 100% sensitivity and specificity. A’ profile (predominant A line without lung sliding) with lung point indicated pneumothorax (n = 5) with 80% sensitivity and 100% specificity.Conclusion:BLUE protocol was successful in average 90.316% cases. BLUE performed in emergency department is equivalent to computed tomography scan. BLUE protocol aids in making diagnosis and saves time and cost; avoids the side effects related to radiation.

Ultrazvuk pluća - drugi deo (Ultrazvuk pluća deo 2)

Clinical use of lung ultrasound (LUS) in emergency and critical care is studied extensively. LUS is a non-invasive, real-time method, easily available at bedside, economical, free of radiation hazard and free of complications. All these features make LUS useful in reducing need for bedside chest radiography and computed tomography. The First International Conference on Lung Ultrasound (ICC-LUS) recommended approach to six major areas of LUS. The BLUE protocol (Bedside Lung Ultrasound and Emergency Protocol) is the first LUS-based systematic approach in diagnosing pleural and lung pathology. This protocol helps to differentiate features of acute dyspnea (pulmonary edema, pneumonia, acute respiratory distress syndrome, pulmonary embolism, pleural effusion or pneumothorax). LUS for pneumothorax diagnosis has become the standard part of the Extended Focused Assessment by Sonography for Trauma (E-FAST). Interpretation of lung ultrasound findings is based on the identification of the main pathological substrates of pulmonary parenchyma: interstitial syndrome, interstitial-alveolar syndrome, alveolar syndrome / consolidation, pleural effusion and pneumothorax.

Community Pharmacy Response in the Aftermath of Natural Disasters: Time-Sensitive Opportunity for Research and Evaluation.

One year ago, Hurricane Maria passed over the archipelago of Puerto Rico, leaving widespread disruption of nearly all human services, including the health care sector. In the aftermath of the hurricane, limited access to medical care and prescription medications presented a serious challenge to maintaining control of preexisting chronic diseases. Many patients did not have access to refrigeration for heat-sensitive medications. Significant dietary changes due to the limited availability of shelf-stable foods further exacerbated chronic conditions such as heart failure and diabetes. The role of community pharmacists following a natural disaster has previously been documented, and may include the triage of evacuees, assessment of immunization needs, and provision of prescription medications under a collaborative practice agreement. However, our experience in Puerto Rico demonstrated a variety of barriers limited pharmacists’ ability to adequately respond to the magnitude of this disaster. These included medication shortages, extended loss of power, and limited telecommunications for contacting prescribers, disaster relief agencies, and third-party payers. Ultimately, the lack of preexisting emergency protocols made overcoming such barriers difficult. As the first and sometimes only accessible health care provider to many patients following a natural disaster, we must build a solid evidence base and better understanding of the individual, interpersonal, and environmental factors that contribute to the community pharmacist response. To date, however, a paucity of data exists on both the pharmacist and patient factors, which may contribute to an effective immediate response to patient needs at the community pharmacy following a natural disaster. Future research must focus on these multi-level factors to better inform public policy and effective disaster planning. Ultimately, such research and planning will lead to increased resiliency in our primary health care systems in the face of future disasters.

Small children prioritised under emergency protocol to tackle 'critical' EpiPen shortage

Small children prioritised under emergency protocol to tackle 'critical' EpiPen shortage

Improved group key management region based cluster protocol in cloud

Group key management protocol (GKMP) is an emergent protocol for secured group communication services like videoconferencing, video on demand, etc. GKMP provides the creation and distribution of keys within groups. The intervention of a centralized key manager is avoided with this technique. To improve the security in multicast environments, GKMP effectively combines region-clustering approach based on the theory of hyper sphere and re-encryption using projective geometry. This forms a region based cluster protocol. Security is handled in an effective way through digital signature technique namely EdDSA and projective geometry. This paper concentrates on applying the intelligent security algorithm over the group controller in a distributed environment. The comparison with conventional techniques prove that the proposed algorithm outperforms well in terms of improved security and reduced overhead in multicast environments. The region based cluster protocol scheme increases the scalability of GKMP scheme in cloud environments.

Perspectives on Long-Distance Air Travel with Type 1 Diabetes.

We sought to determine the real-life experiences of individuals traveling long distance (across five or more time-zones) with type 1 diabetes (T1D). Five hundred three members of the T1D Exchange online community ( www.myglu.org ) completed a 45-question survey about their travel experiences flying long distance. The cohort was stratified by duration of T1D and whether or not participants used continuous subcutaneous insulin infusion (CSII) therapy and/or a continuous glucose monitor (CGM). In the last 5 years, 71% of participants had flown long distance. When asked about their perceived "fear of flying," CSII users (with and without a CGM) reported their primary anxiety was "losing supplies," while non-CSII users described concerns over "unstable blood glucose (highs and lows)" (P < 0.05). In addition, 74% of participants reported more hypoglycemia and/or hyperglycemia while traveling overseas and 9% had avoided international travel altogether because of problems related to diabetes management. Furthermore, 22% of participants had run out of insulin at some point during a trip and 37% reported inadequate attention in current sources of information to the unpredictability of self-management needs while traveling. Especially problematic for individuals traveling with T1D are a lack of resources adequately addressing (1) protocols for emergencies while abroad, (2) how to navigate airport security, and (3) managing basal insulin rates when crossing time zones. A strong need exists for easily accessible, free resources for traveling with T1D that is tailored to both device use and duration of the disease.

Laboratory markers of cardiac and metabolic complications after generalized tonic-clonic seizures

BackgroundGeneralized tonic-clonic seizures (GTCS) frequently lead to emergency inpatient referrals. Laboratory blood values are routinely performed on admission to detect underlying causes and metabolic or cardiac complications. Our goal was to assess the nature and frequency of complications occurring in association with GTCS.MethodsWe retrospectively extracted data from emergency protocols and discharge letters of adult patients admitted to the Department of Epileptology between 01/2010 and 06/2015. Inclusion criteria were diagnosis of GTCS and admission via emergency services. Exclusion criteria were status epilepticus prior to admission to hospital and non-generalized seizures.ResultsA total of 223 patients (of 986 screened cases) were included. Overall, 1.8% required intubation while 1.3% had less severe respiratory problems. In 5.6% of patients, a transient hypoxemia was measured. Hypertensive urgencies affected 7.8% of the patients, sinus tachycardia occurred in 41.2%. Troponin I (cTNI) was determined in 75 patients and was increased in 12% of these cases. Occurrence of elevated cTNI levels was significantly correlated with patient’s age. Four patients were diagnosed with NSTEMI and one patient with STEMI. Creatine kinase (CK) was increased in 59.4% of the patients, with <5-fold increases in 47%, <10-fold in 5.8% and >10-fold increases in 4.3%. Rhabdomyolysis with an >50 fold increase in CK was detected in 1.9% of patients. Prolonged disturbances of consciousness affected 5% of cases while agitation, delirium, and psychotic episodes occurred in 6.3%. Minor traumatic injuries affected 45.7% of patients.ConclusionsTroponin elevations in association with GTCS are one of the more common complications after emergency admissions especially in older patients. In our selected patient population, serious complications such as intracranial hemorrhage, myocardial infarction and acute renal failure occurred in <1% of GTCS only.

Nonintubated uniportal VATS pulmonary anatomical resections.

Nonintubated procedures have widely developed during the last years, thus nowadays major anatomical resections are performed in spontaneously breathing patients in some centers. In an attempt for combining less invasive surgical approaches with less aggressive anesthesia, nonintubated uniportal video-assisted thoracic surgery (VATS) lobectomies and segmentectomies have been proved feasible and safe, but there are no comparative trials and the evidence is still poor. A program in nonintubated uniportal major surgery should be started in highly experienced units, overcoming first a learning period performing minor procedures and a training program for the management of potential crisis situations when operating on these patients. A multidisciplinary approach including all the professionals in the operating room (OR), emergency protocols and a comprehensive knowledge of the special physiology of nonintubated surgery are mandatory. Some concerns about regional analgesia, vagal block for cough reflex control and oxygenation techniques, combined with some specific surgical tips can make safer these procedures. Specialists must remember an essential global concept: all the efforts are aimed at decreasing the invasiveness of the whole procedure in order to benefit patients' intraoperative status and postoperative recovery.

Development of Pediatric Emergency Protocols and Communication Plans in Pediatric Radiation Oncology: Multidisciplinary Core Competencies.

Radiation therapy is an essential component of treatment for many pediatric cancers, yet the cost of maintaining a radiation facility at a dedicated pediatric center is often prohibitive. As a result, adult facilities treat pediatric patients where preparation for a pediatric emergency may be inadequate. The purpose of this quality improvement project was to develop a multidisciplinary emergency preparedness plan for a collaborative pediatric radiation oncology program at an adult community hospital with its partnering academic children's hospital. Using a cyclical process involving multidisciplinary collaboration that combines policy development, preparation, and team-building, the authors created the protocols and processes that would support the stabilization of a pediatric emergency and facilitate transfer to the partnering children's hospital. Further development of a communication plan outlines the flow of patient information through the multidisciplinary team during these transitions of care. Areas for future work include quantitative outcome measures to determine the effectiveness of the policies and procedures developed to prepare staff for pediatric emergencies.

Wanted and Unwanted Care: The Double-Edged Sword of Partial Do-Not-Resuscitate Orders.

The interpretation of do-not-resuscitate orders (DNRs) may vary in nonarrest situations. To reduce ambiguity, many hospitals allow patients to elect partial DNRs. To investigate the effect of partial DNRs on physicians' willingness to perform cardiopulmonary resuscitation (CPR) and nonarrest procedures. Cross-sectional study using scenario-based questionnaires between October 2015 and March 2016. A partial DNR was identified as a DNR with Adult Emergency Protocols (AEP) order. Each survey presented 3 patient scenarios followed by 10 interventions. Preclerkship and clerkship medical students, and internal medicine residents at a single medical school, and hospitalists at a tertiary-care academic medical center. Responses from 275 of 366 (75.1%) eligible subjects were collected. Compared to the case with a full DNR, the presence of a partial DNR was positively associated with subjects' willingness to provide both nonarrest procedures and CPR (p < 0.05). The number of training or practice years was positively associated with a decision not to perform CPR: case 1 (odds ratio [OR], 1.09; confidence interval [CI], 1.04-1.16; p = 0.003); case 2 (OR, 1.07; CI, 1.01-1.14; p = 0.03); and case 3 (OR, 1.09; CI, 1.04-1.16; p < 0.001). A partial DNR made our respondents more willing to provide nonarrest procedures, but also CPR. These findings suggest an ongoing need to develop better means of incorporating patients' goals of care into orders that more faithfully guide care for both nonarrest and arrest situations.

Experience After Implementation of an Acute Cardiovascular Emergency Protocol (ACEP)

Experience After Implementation of an Acute Cardiovascular Emergency Protocol (ACEP)

Prothrombin complex concentrate for emergent reversal of warfarin: an international survey of hospital protocols.

For emergent warfarin reversal, four-factor prothrombin complex concentrates (4FPCCs) are recommended by many international guidelines. We surveyed international clinical sites including members of the Biomedical Excellence for Safer Transfusion (BEST) Collaborative. Most sites have emergent warfarin reversal protocols (53% use PCC, 25% use PCC+ plasma and 2% use plasma alone); however, variation between adjusted dosing and fixed dosing was observed.

The impact of the BLUE protocol ultrasonography on the time taken to treat acute respiratory distress in the ED

Respiratory distress is one of the most common complaints in the emergency department (ED) [1]. In extreme scenarios, during which respiratory distress becomes respiratory failure, the survival of the patients will significantly drop [2]. For instance, a recent cohort study showed that the mortality rate among hospitalized patients with respiratory distress was as much as 10% [3]. Hence, in the management of a patient with respiratory distress, using a timely approach to differentiate the underlying causes and initiating specific therapies (decompression of the pneumothorax, intubation and ventilation support, bronchodilators or corticosteroid nebulization, anticoagulation and fibrinolytic therapy in pulmonary thromboembolisms, etc.) is of undisputed importance. In 2008, the Bedside Lung Ultrasound in Emergency (BLUE) protocol was developed to guide the diagnosis of respiratory distress [4]. Lichtenstein and his colleagues who proposed the BLUE protocol, showed that the diagnostic accuracy of lung ultrasound (LUS) in the Intensive Care Unit (ICU) was 90.5%. Similarly, Silva et al. demonstrated that LUS was more accurate in cases of acute respiratory failure than routine approaches (patient history and physical examination, radiologic and laboratory evidence) [5]. The BLUE protocol enables physicians to differentiate the underlying causes of respiratory failure. More to the point, LUS was proved to be effective in the monitoring of therapeutic responses in acute respiratory distress syndrome (ARDS) [6]. The BLUE protocol can be applied using a simple ultrasound machine equipped with a micro-convex array transducer [7]. Nevertheless, performing an accurate LUS requires specific training [8]. Although current evidence encourages the use of LUS in treating respiratory distress in critical care, it is not widely accepted in EDs [9]. We hypothesized that utilizing a bedside testing protocol such as the BLUE protocol in the ED may shorten the time interval between patient admission and the delivery of any definitive treatment [10]. We have therefore conducted a randomized clinical trial to assess whether or not the application of the BLUE protocol by a trained emergency physician has an impact on the timely diagnosis and treatment of respiratory distress in the ED.

Emergency Departments need Psychiatric Emergency Protocols!

Emergency Departments need Psychiatric Emergency Protocols!

Methods of controlled ovarian stimulation for embryo/oocyte cryopreservation in breast cancer patients

ABSTRACTIntroduction: Controlled ovarian stimulation (COS) is a crucial step before oocyte collection and subsequent embryo/oocyte cryopreservation. However, in young breast cancer patients, the need for COS raises specific issues that should be taken into account during oncofertility counseling.Areas covered: We aim to perform an overview of COS protocols with a specific focus on the current knowledge and clinical challenges related to their use in young breast cancer patients.Expert commentary: Many protocols for COS are currently available to induce multiple follicular recruitment and maximize oocyte retrieval in women undergoing in vitro fertilization treatment. In cancer patients, to avoid the need to wait for a spontaneous menstruation, emergency protocols are also available so that COS can be started at any time during the menstrual cycle. COS protocols with the addition of tamoxifen or letrozole have been specifically designed for breast cancer patients to limit the potential negative impact of th...

INGV data lifecycle management system performances during Mw 6.0 2016 Amatrice earthquake sequence

At 01:36:32 UTC on August 24, 2016 an earthquake of magnitude 6.0 occurred in Central Italy, affecting many small towns and municipalities in the Lazio, Umbria, Marche and Abruzzo regions. The event caused severe damages, many victims and 299 fatalities. Only 21 seconds after the beginning of the earthquake, the first automatic location of this earthquake was available and stored in our earthquakes database. The first magnitude estimate followed 68 seconds after the origin time. Few seconds later the INGV seismologists on duty in accordance to the agreed protocols provided the first alert to the Italian Civil Protection Department (Dipartimento di Protezione Civile, DPC) and thereby triggered the seismic emergency protocol. Subsequently, they elaborated the data in order to produce the first manually reviewed hypocenter, which was published on the Institute’s website at 01:53:18 UTC. The sequence following this mainshock generated thousands of earthquakes in the epicentral area, which the INGV automated localization system processed and detected along with the usual seismic activity in the rest of the Italian territory. In this paper we analyze the behavior of the automated system and of the data lifecycle management procedures in such extraordinary conditions. In particular we want to measure the capability of the system to manage the huge data flow, in terms of frequency and size of seismic events and its ability to remain fairly responsive and accurate in accomplishing its duty in the expected time. This will help us to identify potential problems and to suggest necessary improvements to better serve the INGV mission for Civil Protection.&lt;br /&gt;&lt;br id="tinymce" class="mceContentBody " /&gt;

P1270Effects of blood pressure variability on layer-specific longitudinal strain in hypertensionP1271 Left atrial dynamics and diastolic function in hypertensive patientsP1272Echocardiographic evaluation of right ventricular function in patients with chronic obstructive pulmonary disease in comparison with healthy groupP1273The impact of preeclampsia on myocardial recovery in women with peripartum cardiomyopahty - speckle tracking studyP1274Diagnostic accuracy of bedside lung ultrasonography in emergency (BLUE)

Our previous study showed sub-epicardial longitudinal strain (EpiLS) was an independent prognostic factor for worse outcome in regular treated hypertension but not global longitudinal strain (GLS) and sub-endocardial longitudinal strain (EndLS). Increased blood pressure variability (BPV) has been found associated with target organ damage in hypertension. However, effects of BPV on layer-specific longitudinal strain have not been well studied. The aim of this study was to investigate the effects of different blood pressure parameters on layer-specific longitudinal strain in hypertension. This study included 95 patients (57 men, age 65 ± 12 years) with uncomplicated hypertension who have been regularly treated for more than 1 year. Speckle tracking echocardiography was used for measurement of longitudinal deformation from 3 apical views of left ventricle. GLS was measured by automated function imaging (AFI). We further divided into sub-endocardial and sub-epicardial myocardium and measured their longitudinal strain by manual click-and-draw method and averaged from 3 apical views. Blood pressure parameters included office systolic blood pressure (SBP), office diastolic blood pressure (DBP), central SBP and DBP by tonometry, average 24-hour SBP and DBP, and BPV parameters by ambulatory blood pressure monitor. BPV parameters included standard deviation of daytime SBP (DSSD), standard deviation of nighttime SBP (NSSD), standard deviation of daytime DBP (DDSD), and standard deviation of nighttime DBP (NDSD). We divided subjects into low and high group according to median level of each strain. No blood pressure parameters were different between low and high EndLS group except week difference in NDSD (9.0 ± 3.4 vs. 7.8 ± 2.0 mmHg, p = 0.051). NSSD (11.2 ± 4.6 vs. 9.3 ± 2.9 mmHg, p = 0.027) and NDSD (9.1 ± 3.4 vs. 7.7 ± 2.0 mmHg, p = 0.031) were significant increased in low GLS group but not other parameters. DDSD (10.3 ± 3.0 vs. 9.0 ± 2.5 mmHg, p = 0.034), NSSD (11.4 ± 4.4 vs. 9.1 ± 3.1 mmHg, p = 0.006), and NDSD (9.2 ± 3.2 vs. 7.6 ± 2.2 mmHg, p = 0.012) were significantly increased in low EpiLS group. Only BPV parameters were associated with decreased longitudinal strain in hypertension. Effects of BPV were majorly noted in EpiLS.