Kamra, SK; Khandavilli, HK; Banerjee, P
Maxillofacial trauma patients present with airway problems. Submandibular intubation is an effective means of intubation to avoid tracheostomy for operative procedures. Airway is secured with oral endotracheal intubation in paralyzed patient and tube is then transplaced in sub mental or submandibular region. However there may be instances when paralyzing such trauma patients is not safe and short term tracheostomy is the only airway channel available for conduction of anesthesia. We report a case of submandibular intubation in awake patient of maxillofacial trauma with anticipated intubation problems. PMID:27833492
Harbrecht, Brian G; Franklin, Glen A; Smith, Jason W; Benns, Matthew V; Miller, Keith R; Nash, Nicholas A; Bozeman, Matthew C; Coleman, Royce; O'Brien, Dan; Richardson, J David
Full trauma team activation in evaluating injured patients is based on triage criteria and associated with significant costs and resources that should be focused on patients who truly need them. Overtriage leads to inefficient care, particularly when resources are finite, and it diverts care from other vital areas. Although shock and gunshot wounds to the abdomen are accepted indicators for full trauma activation, intubation as the sole criterion is controversial. We evaluated our experience to assess if intubation alone merited the highest level of trauma activation. All trauma patients from 2012 to 2013 were assessed for level of activation, injury characteristics, presence of intubation, and outcomes. Of 5,881 patients, 646 (11%) were level 1 (full) and 2,823 (48%) were level 2 (partial) activations. Level 1 patients were younger (40 ± 17 vs 45 ± 20 years), had more penetrating injuries (42% vs 9%), and had higher mortality (26% vs 8%)(p < 0.001). Intubated level 2 patients (n = 513), compared with intubated level 1 patients (n = 320), had higher systolic blood pressure (133 ± 44 vs 90 ± 58 mmHg), lower Injury Severity Score (21 ± 13 vs 25 ± 16), more falls (25% vs 3%), fewer penetrating injuries (11% vs 23%), and lower mortality (31% vs 48%)(p < 0.01). Fewer intubated level patients went directly to the operating room from the emergency department (ED)(16% vs 33%), and most who did had a craniotomy (63% vs 13%). Only 3% of intubated level 2 patients underwent laparotomy compared with 20% of intubated level 1 patients (p < 0.001). The ED lengths of stay before obtaining a head CT (47 ± 26 vs 48 ± 31 minutes) and craniotomy (109 ± 61 vs 102 ± 46 minutes) were similar. Deaths in intubated level 2 patients were primarily from fatal brain injuries. When appropriately triaged, selected intubated trauma patients do not require full trauma activation to receive timely, efficient care. Copyright © 2016 American College of Surgeons. Published by Elsevier Inc
Sut, Esra Yildiz; Gunal, Solmaz; Yazar, Mehmet Akif; Dikmen, Bayazit
In this study, we evaluated the effectiveness of intubations by way of "Gum Elastic Bougie" and "Intubating Laryngeal Mask Airway" in endotracheal intubation of patients with simulated cervical trauma. 134 patients were included in the study. All patients were placed cervical collar for a simulated cervical trauma. Patients were allocated randomly into three groups: Group NI (n=45) intubation with Macintosh laryngoscopy, Group GEB (n=45) intubation with Gum Elastic Bougie, and Group ILMA (n=44) intubation with Intubating Laryngeal Mask Airway. The number of intubation attempts, success of intubation, duration of complete visualization of the larynx, duration of intubation, user's performance score, hemodynamic changes and the observed complications were recorded. Success of intubation in the first attempt was highest in Group GEB while it was lowest in Group ILMA. Regarding the intubation success, rates of successful intubation were 95.6%, 84.4% and 65.9% in Groups GEB, NI, and ILMA, respectively. Durations of visualization of larynx and intubation were shorter in Groups NI and GEB than in Group ILMA. This difference was statistically significant (p<0.05) while there was no significant difference between Groups NI and GEB. The number of patients with "good" intubation performance was significantly higher in Group GEB while the number of patients with "poor" intubation performance was significantly higher in Group ILMA (p<0.05). We conclude that GEB, which is cheap and easily accessible, should be an advantageous choice in cervical trauma patients for both the easeness of intubation and patient morbidity and mortality. Copyright © 2016 Sociedade Brasileira de Anestesiologia. Publicado por Elsevier Editora Ltda. All rights reserved.
Kim, Dennis; Kobayashi, Leslie; Chang, David; Fortlage, Dale; Coimbra, Raul
The development of respiratory failure requiring an emergent unplanned intubation (UI) is a potentially preventable complication associated with increased morbidity and mortality. The objective of this study was to develop a clinical risk index for UI based on readily available clinical data to assist in the identification of trauma patients at risk for this complication. We also sought to determine the impact of UI on patient outcomes. This is a 3-year retrospective analysis of our Level 1 trauma center registry to identify all patients requiring a UI. Patients who required a UI were compared with patients who were never intubated. An additive risk index consisting of 10 clinical variables was created using the final significant variables from a stepwise logistic regression model. The sensitivity and specificity of every possible index score were calculated and added together to calculate the "gain in certainty" values. During the 3-year period, 7,552 patients were admitted, of whom 967 (12.8%) required intubation. Of these, 55 (5.7%) underwent a UI. The final risk index consisted of 10 variables as follows: age 55 years to 64 years, age 65 years or older, male sex, Glasgow Coma Scale (GCS) score of 9 to 13, seizures, chronic obstructive pulmonary disease, traumatic brain injury, four or more rib fractures, spine fractures, and long-bone fractures. Gain in certainty was maximized at an index score of 4, with the highest combined sensitivity and specificity of 86.0% and 74.9%, respectively. The probability of UI increased from 0.9% at a score of 1 to 2.9% at 4 and 43% at 9. UI was associated with increased overall complications, length of stay, and mortality (p < 0.001). UI is a potentially preventable adverse event associated with poor outcomes. Identification of patients at risk for this complication may be possible through the development of an additive risk index. Prospective validation of the risk index is potentially warranted. Diagnostic study, level III.
Loftus, Tyler J; Brakenridge, Scott C; Moore, Frederick A; Lemon, Stephen J; Nguyen, Linda L; Voils, Stacy A; Jordan, Janeen R; Croft, Chasen A; Smith, R Stephen; Efron, Phillip A; Mohr, Alicia M
Despite the excellent negative predictive value of sterile respiratory cultures, antibiotics often are continued after negative endotracheal aspirate (ETA) or bronchoalveolar lavage (BAL) for critically ill trauma patients. We hypothesized that persistent elevation of the Clinical Pulmonary Infection Score (CPIS) would predict continued antibiotic therapy after a negative respiratory culture for intubated trauma patients, and that prolonged antibiotics would provide no benefit. We performed a four-year retrospective cohort analysis (May 1, 2011-September 30, 2015), including patients from our trauma database with ETA or BAL, excluding patients with any infection other than pneumonia or bacteremia. Cultures with <2(+) organisms on gram stain and <2(+) or 10(4) organisms on culture were considered negative. The CPIS was assessed at the time of culture and five days later, when all cultures were final. Multiple logistic regression was used to identify predictors of long-term antibiotic therapy. A series of 106 patients with negative cultures were included, of whom 61 had ≤5 d of antibiotics and 45 had >5 d of antibiotics. There were no differences in injury severity, head or chest trauma, initial CPIS, or subsequent culture results between the groups. Long-term antibiotic therapy did not affect intensive care unit (ICU) length of stay (LOS), ventilator days, hospital LOS, or death. Factors predicting long-term antibiotic therapy included development of a localized chest radiograph infiltrate (odds ratio [OR] 6.8; 95% confidence interval [CI] 1.7-28), CPIS >5 five days after culture (OR 6.1; 95% CI 1.2-32), and a colonized culture (OR 3.3; 95% CI 1.3-8.3). Long-term antibiotic therapy for intubated trauma patients with negative respiratory cultures provided no benefit and was predicted by development of a localized chest radiograph infiltrate, persistently elevated CPIS, and a contaminated/colonized culture. Although long-term antibiotic use did not worsen
Upchurch, Cameron P; Grijalva, Carlos G; Russ, Stephan; Collins, Sean P; Semler, Matthew W; Rice, Todd W; Liu, Dandan; Ehrenfeld, Jesse M; High, Kevin; Barrett, Tyler W; McNaughton, Candace D; Self, Wesley H
Induction doses of etomidate during rapid sequence intubation cause transient adrenal dysfunction, but its clinical significance on trauma patients is uncertain. Ketamine has emerged as an alternative for rapid sequence intubation induction. Among adult trauma patients intubated in the emergency department, we compare clinical outcomes among those induced with etomidate and ketamine. The study entailed a retrospective evaluation of a 4-year (January 2011 to December 2014) period spanning an institutional protocol switch from etomidate to ketamine as the standard induction agent for adult trauma patients undergoing rapid sequence intubation in the emergency department of an academic Level I trauma center. The primary outcome was hospital mortality evaluated with multivariable logistic regression, adjusted for age, vital signs, and injury severity and mechanism. Secondary outcomes included ICU-free days and ventilator-free days evaluated with multivariable ordered logistic regression using the same covariates. The analysis included 968 patients, including 526 with etomidate and 442 with ketamine. Hospital mortality was 20.4% among patients induced with ketamine compared with 17.3% among those induced with etomidate (adjusted odds ratio [OR] 1.41; 95% confidence interval [CI] 0.92 to 2.16). Patients induced with ketamine had ICU-free days (adjusted OR 0.80; 95% CI 0.63 to 1.00) and ventilator-free days (adjusted OR 0.96; 95% CI 0.76 to 1.20) similar to those of patients induced with etomidate. In this analysis spanning an institutional protocol switch from etomidate to ketamine as the standard rapid sequence intubation induction agent for adult trauma patients, patient-centered outcomes were similar for patients who received etomidate and ketamine. Copyright © 2016 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.
Hajjar, Waseem M; Alsubaie, Nourah; Nouh, Thamer A; Al-Nassar, Sami A
Traumatic chest injury is one of the leading causes of death in motor vehicle accident (MVA). A complete tracheobronchial injury occurred in 1% of trauma cases and most of the cases died before arrival to the emergency department. We report a 37-year-old female involved in MVA presented to the emergency room (ER) with normal vital signs. Ten minutes later, her saturation dropped to 75%, which required ventilation; however, two attempts for endotracheal intubation failed. The third time frova airway intubating introducer used and succeeded. Immediately after tracheal intubation, the patient started to have extensive subcutaneous emphysema and severe hypoxia; chest X-ray showed right side tension pneumothorax which was not relieved by a chest tube insertion. Bronchoscopy confirmed total transection of the right main bronchus and lower tracheal laceration and injury. Emergency thoracotomy and repair of both trachea and the right main bronchus were successful.
Goksu, Erkan; Kilic, Taylan; Yildiz, Gunay; Unal, Aslihan; Kartal, Mutlu
We aimed to compare the performance of the C-MAC video laryngoscope (C-MAC) to the Macintosh laryngoscope for intubation of blunt trauma patients in the ED. This was a prospective randomized study. The primary outcome measure is overall successful intubation. Secondary outcome measures are first attempt successful intubation, Cormack-Lehane (CL) grade, and indicators of the reasons for unsuccessful intubation at the first attempt with each device. Adult patients who suffered from blunt trauma and required intubation were randomized to video laryngoscopy with C-MAC device or direct laryngoscopy (DL). During a 17-month period, a total of 150 trauma intubations were performed using a C-MAC and DL. Baseline characteristics of patients were similar between the C-MAC and DL group. Overall success for the C-MAC was 69/75 (92%, 95% CI 0.83 to 0.96) while for the DL it was 72/75 (96%, 95% CI 0.88 to 0.98). First attempt success for the C-MAC was 47/75 (62.7%, 95% CI 0.51 to 0.72) while for the DL it was 44/75 patients (58.7%, 95% CI 0.47 to 0.69). The mean time to achieve successful intubation was 33.4 ± 2.5 s for the C-MAC versus 42.4 ± 5.1 s for the DL (p = 0.93). There was a statistically significant difference between the DL and C-MAC in terms of visualizing the glottic opening and esophageal intubation in favor of the C-MAC (p = 0.002 and p = 0.013 respectively). The overall success rates were similar. The C-MAC demonstrated improved glottic view and decrease in esophageal intubation rate.
Pre-hospital endotracheal intubation and positive pressure ventilation is associated with hypotension and decreased survival in hypovolemic trauma patients: an analysis of the National Trauma Data Bank.
Shafi, Shahid; Gentilello, Larry
Studies of pre-hospital endotracheal intubation (ETI) from single EMS systems have shown contradictory results, which may represent local differences in paramedic training and experience. An alternative hypothesis is that positive pressure ventilation increases mortality because positive pressure ventilation causes hypotension in severely injured hypovolemic patients. A national sample (National Trauma Data Bank, 1994-2002) was used to minimize effects of local paramedic training and experience. All patients with pre-hospital GCS < 8 (most likely to warrant early ETI) and ISS > 16 (most likely to be hypovolemic) were included. Patients intubated in the field (pre-hospital group, n = 871) and in the emergency department (ED group, n = 6581) were compared. To determine whether pre-hospital ETI was an independent predictor of hypotension and mortality, logistic regression was used to control for potential confounders, including age, ISS, body region injured, AIS scores, pre-hospital IV fluids, and other variables. Physiologic variables were not used, as they may be influenced by ETI and positive pressure ventilation, and were therefore considered outcomes, rather than predictors. Groups were comparable in age, gender, anatomic distribution of injuries, likelihood of at least one severe injury (AIS >3) and other variables, except for head injury (ED 83%, pre-hospital 71%, p < 0.001) and ISS (ED 33 +/- 0.2, pre-hospital 36 +/- 0.6, p < 0.001). Patients intubated in the field were more likely to be hypotensive upon arrival in the ED (SBP < or = 90 mm Hg; ED 33%, pre-hospital 54%, p < 0.001), and had worse survival (ED 45% versus pre-hospital 24%, p < 0.001). Even after controlling for potential confounders, pre-hospital ETI was still an independent predictor of hypotension upon arrival in ED (OR 1.7, 95% CI 1.46 -2.09, p < 0.001) and decreased survival (OR 0.51, 95% C.I. 0.43-0.62, p < 0.001). Pre-hospital endotracheal intubation in trauma patients is associated with
Mańka-Malara, Katarzyna; Gawlak, Dominika; Hovhannisyan, Anahit; Klikowska, Marta; Kostrzewa-Janicka, Jolanta
Endotracheal intubation is a procedure performed during general anaesthesia with the use of an endotracheal tube in order to maintain a patent airway. This routinely used procedure is connected with a risk of complications within the region of the masticatory system. Trauma of teeth, their surrounding structures and the soft tissue of the oral cavity is observed in app. 1.38 per 1000 procedures. The main causes of this damage are the surgical skills and experience of the surgeon, the anatomical conditions present and the mode of conducting the procedure. In order to reduce the risk of postoperative complications, patients with a high risk of sustaining an injury during endotracheal intubation should be equipped with elastic mouthguards, which reduces the possibility of damage. The scoring in a scale of endotracheal intubation difficulty should be used for qualification for the use of such mouthguards.
Moon, Young-Jin; Kim, Juyoung; Seo, Dong-Woo; Kim, Jae-Won; Jung, Hye-Won; Suk, Eun-Ha; Ha, Seung-Il; Kim, Sung-Hoon; Kim, Joung-Uk
The ideal alternative airway device should be intuitive to use, yielding proficiency after only a few trials. The Clarus Video System (CVS) is a novel optical stylet with a semi-rigid tip; however, the learning curve and associated orodental trauma are poorly understood. Two novice practitioners with no CVS experience performed 30 intubations each. Each trial was divided into learning (first 10 intubations) and standard phases (remaining 20 intubations). Total time to achieve successful intubation, number of intubation attempts, ease of use, and orodental trauma were recorded. Intubation was successful in all patients. In 51 patients (85%), intubation was accomplished in the first attempt. Nine patients required two or three intubation attempts; six were with the first 10 patients. Learning and standard phases differed significantly in terms of success at first attempt, number of attempts, and intubation time (70% vs. 93%, 1.4 ± 0.7 vs. 1.1 ± 0.3, and 71.4 ± 92.3 s vs. 24.6 ± 21.9 s, respectively). The first five patients required longer intubation times than the subsequent five patients (106.8 ± 120.3 s vs. 36.0 ± 26.8 s); however, the number of attempts was similar. Sequential subgroups of five patients in the standard phase did not differ in the number of attempts or intubation time. Dental trauma, lip laceration, or mucosal bleeding were absent. Ten intubations are sufficient to learn CVS utilization properly without causing any orodental trauma. A relatively small number of experiences are required in the learning curve compared with other devices.
Mittal, Geeta; Mittal, Rajinder K.; Katyal, Sunil; Uppal, Sanjeev; Mittal, Varun
Background: There are various techniques available for airway management in patients with maxillofacial trauma. Patients with panfacial injuries may need surgical airway access like submental intubation or tracheostomy, which have their associated problems. We have been managing these types of cases by a novel technique, i.e, intraoperative change of nasotracheal to orotracheal intubation. Aim: To review our experience about various techniques for the airway management in patient with maxillofacial trauma. To analyse the possibility of using nasotracheal intubation and intraoperative change of nasotracheal to orotracheal intubation in panfacial fractures. Materials and Methods: In a tertiary care centre four hundred eighty seven patients of maxillofacial injuries, operated over a period of 2 years were reviewed in relation to age, sex, mode of injury, type of facial fractures, methods of airway management and their associated complications. Results: Young patients with male predominance is the most common affected population. Panfacial fracture is the most common type of injury (39.83%) among facial fractures. Airway was managed with intraoperative change of nasotracheal to orotracheal intubation in 33.05% of the patients whereas submental intubation or tracheostomy was done in 8.62% of the patients. Conclusion: Nasal route for endotracheal intubation is not a contraindication in the presence of nasal fractures, base of skull fractures and CSF leak. By changing the nasotracheal intubation to orotracheal intubation intraoperatively in cases panfacial fractures, most of the tracheostomies and submental intubations can be avoided. PMID:24783087
Panczykowski, David M; Tomycz, Nestor D; Okonkwo, David O
The current standard of practice for clearance of the cervical spine in obtunded patients suffering blunt trauma is to use CT and an adjuvant imaging modality (such as MR imaging). The objective of this study was to determine the comparative effectiveness of multislice helical CT alone to diagnose acute unstable cervical spine injury following blunt trauma. The authors performed a meta-analysis of studies comparing modern CT with adjunctive imaging modalities and required that studies present acute traumatic findings as well as treatment for unstable injuries. Study quality, population characteristics, diagnostic protocols, and outcome data were extracted. Positive disease status included all injuries necessitating surgical or orthotic stabilization identified on imaging and/or clinical follow-up. Seventeen studies encompassing 14,327 patients met the inclusion criteria. Overall, the sensitivity and specificity for modern CT were both > 99.9% (95% CI 0.99-1.00 and 0.99-1.00, respectively). The negative likelihood ratio of an unstable cervical injury after a CT scan negative for acute injury was < 0.001 (95% CI 0.00-0.01), while the negative predictive value of a normal CT scan was 100% (95% CI 0.96-1.00). Global severity of injury, CT slice thickness, and study quality did not significantly affect accuracy estimates. Modern CT alone is sufficient to detect unstable cervical spine injuries in trauma patients. Adjuvant imaging is unnecessary when the CT scan is negative for acute injury. Results of this meta-analysis strongly show that the cervical collar may be removed from obtunded or intubated trauma patients if a modern CT scan is negative for acute injury.
Wang, Henry E.; Balasubramani, G. K.; Cook, Lawrence J.; Lave, Judith R.; Yealy, Donald M.
Study objective Previous studies suggest improved patient outcomes for providers who perform high volumes of complex medical procedures. Out-of-hospital tracheal intubation is a difficult procedure. We seek to determine the association between rescuer procedural experience and patient survival after out-of-hospital tracheal intubation. Methods We analyzed probabilistically linked Pennsylvania statewide emergency medicine services, hospital discharge, and death data of patients receiving out-of-hospital tracheal intubation. We defined tracheal intubation experience as cumulative tracheal intubation during 2000 to 2005; low=1 to 10 tracheal intubations, medium=11 to 25 tracheal intubations, high=26 to 50 tracheal intubations, and very high=greater than 50 tracheal intubations. We identified survival on hospital discharge of patients intubated during 2003 to 2005. Using generalized estimating equations, we evaluated the association between patient survival and out-of-hospital rescuer cumulative tracheal intubation experience, adjusted for clinical covariates. Results During 2003 to 2005, 4,846 rescuers performed tracheal intubation. These individuals performed tracheal intubation on 33,117 patients during 2003 to 2005 and 62,586 patients during 2000 to 2005. Among 21,753 cardiac arrests, adjusted odds of survival was higher for patients intubated by rescuers with very high tracheal intubation experience; adjusted odds ratio (OR) versus low tracheal intubation experience: very high 1.48 (95% confidence interval [CI] 1.15 to 1.89), high 1.13 (95% CI 0.98 to 1.31), and medium 1.02 (95% CI 0.91 to 1.15). Among 8,162 medical nonarrests, adjusted odds of survival were higher for patients intubated by rescuers with high and very high tracheal intubation experience; adjusted OR versus low tracheal intubation experience: very high 1.55 (95% CI 1.08 to 2.22), high 1.29 (95% CI 1.04 to 1.59), and medium 1.16 (95% CI 0.97 to 1.38). Among 3,202 trauma nonarrests, survival was not
Kumar, Ravi Raja; Vyloppilli, Suresh; Thangavelu, Annamala; Joseph, Benny; Ahsan, Auswaf
Objectives To assess submental route intubation as an alternative technique to a tracheostomy in the management of the airway in cranio-maxillofacial trauma, along with an assessment of its morbidity and complications. Materials and Methods Submental intubation was performed in 17 patients who had maxillofacial panfacial trauma and management was done under general anesthesia during a period of one year from 2013 to 2014 at Departments of Oral and Maxillofacial Surgery and Dentistry, the Malankara Orthodox Syrian Church Medical College, Kochi, India. Results In all 17 cases, the technique of submental intubation was found to be simple and reliable. Hypertrophic scars were noted in three cases, orocutaneous fistula and mucocele in one case each. All these complications were managed comfortably without significant morbidity to the patient. Conclusion Submental intubation is a good technique that can be used regularly in the management of the airway in cranio-maxillofacial trauma, but with some manageable complications. PMID:27429937
Nicholson, Amanda; Smith, Andrew F; Lewis, Sharon R; Cook, Tim M
independent review of titles, data extraction and risk of bias assessment by two investigators. Three eligible studies were identified, all comparing the use of an FIS with a VLS. All studies were small, with only 131 participants in total across all trials. It was impossible for the intubators to be unaware of the device used, so all studies were at high risk of performance and detection bias for outcomes related to intubation. Because of substantial differences in design between the studies, we did not combine their results in meta-analyses. The results for all outcomes were inconclusive, with no differences noted between FIS and VLS. Two studies with experienced intubators reported first attempt success rates greater than 70% in both groups and less than 5% of participants requiring a change of intubation device. No evidence was found of any difference in difficulty or time taken between FIS and VLS intubation. No serious complications or airway trauma was reported, so we were unable to address these outcomes. Bleeding was uncommon, occurring in less than 5% of participants, and we found no evidence that it was more likely in the FIS group. One small study with a novice intubator reported no successful intubations using an FIS and compared with the use of an intubating SAD and stylet, as well as with a VLS. With only five participants in each group, no conclusions can be drawn from these additional comparisons. The evidence base is sparse, and the existing literature does not address the clinical questions of patient safety posed by this review. We are therefore unable to draw any conclusions on safety or effectiveness. More primary research is needed to investigate optimal intubation techniques in obese patients, and new studies should be powered to detect differences in complications and in success rates rather than process measures such as speed, which are of limited clinical importance.
Schaefer, H G; Marsch, S C; Keller, H L; Strebel, S; Anselmi, L; Drewe, J
One hundred ASA grade 1 and 2 patients requiring orotracheal intubation for various general surgical procedures were randomly assigned to receive either expert rigid laryngoscopic or novice fibreoptic orotracheal intubation under total intravenous anaesthesia. Five anaesthesia residents in the 4th year, with no prior experience in fibreoptic laryngoscopy, participated in a fibreoptic training course, viewing two instructional videos and practising on the intubation manikin. Each resident intubated 20 patients in a randomised fashion either as an expert laryngoscopist or as a fibreoptic novice. The time (SEM) to achieve successful intubation was statistically different for fibreoptic and rigid intubation (77.2 (5.1) s vs 17.7 (1.6) s, p < 0.01). The time to achieve successful rigid laryngoscopic intubation remained constant over the ten intubations, whereas time required for fibreoptic intubation decreases significantly (p < 0.01). The learning objectives (fibreoptic intubation times in 60 s or less and with 90% or greater success rate on the first intubation attempt) were met by all residents. The haemodynamic profile was similar for fibreoptically intubated and conventionally intubated patients and there was no difference between the first two or the last two fibreoptic or rigid intubations. The study was designed to detect a difference of 10% in means (assuming alpha = 0.05 and beta < or = 0.2). The incidence of postoperative sore throat, dysphagia or hoarseness was similar in both groups.(ABSTRACT TRUNCATED AT 250 WORDS)
Olives, Travis D; Nystrom, Paul C; Cole, Jon B; Dodd, Kenneth W; Ho, Jeffrey D
Profound agitation in the prehospital setting confers substantial risk to patients and providers. Optimal chemical sedation in this setting remains unclear. The goal of this study was to describe intubation rates among profoundly agitated patients treated with prehospital ketamine and to characterize clinically significant outcomes of a prehospital ketamine protocol. This was a retrospective cohort study of all patients who received prehospital ketamine, per a predefined protocol, for control of profound agitation and who subsequently were transported to an urban Level 1 trauma center from May 1, 2010 through August 31, 2013. Identified records were reviewed for basic ambulance run information, subject characteristics, ketamine dosing, and rate of intubation. Emergency Medical Services (EMS) ambulance run data were matched to hospital-based electronic medical records. Clinically significant outcomes are characterized, including unadjusted and adjusted rates of intubation. Overall, ketamine was administered 227 times in the prehospital setting with 135 cases meeting study criteria of use of ketamine for treatment of agitation. Endotracheal intubation was undertaken for 63% (85/135) of patients, including attempted prehospital intubation in four cases. Male gender and late night arrival were associated with intubation in univariate analyses (χ2=12.02; P=.001 and χ2=5.34; P=.021, respectively). Neither ketamine dose, co-administration of additional sedating medications, nor evidence of ethanol (ETOH) or sympathomimetic ingestion was associated with intubation. The association between intubation and both male gender and late night emergency department (ED) arrival persisted in multivariate analysis. Neither higher dose (>5mg/kg) ketamine nor co-administration of midazolam or haloperidol was associated with intubation in logistic regression modeling of the 120 subjects with weights recorded. Two deaths were observed. Post-hoc analysis of intubation rates suggested a
Association between off-hour presentation and endotracheal-intubation-related adverse events in trauma patients with a predicted difficult airway: A historical cohort study at a community emergency department in Japan.
Ono, Yuko; Sugiyama, Takuya; Chida, Yasuyuki; Sato, Tetsuya; Kikuchi, Hiroaki; Suzuki, Daiji; Ikeda, Masakazu; Tanigawa, Koichi; Shinohara, Kazuaki
A reduction in medical staff such as occurs in hospitals during nights and weekends (off hours) is associated with a worse outcome in patients with several unanticipated critical conditions. Although difficult airway management (DAM) requires the simultaneous assistance of several appropriately trained medical caregivers, data are scarce regarding the association between off-hour presentation and endotracheal intubation (ETI)-related adverse events, especially in the trauma population. The aim of this study was to determine whether off-hour presentation was associated with ETI complications in injured patients with a predicted difficult airway. This historical cohort study was conducted at a Japanese community emergency department (ED). All patients with inhalation burn, comminuted facial trauma (Abbreviated Injury Scale Score Face ≥3), and penetrating neck injury who underwent ETI from January 2007 to January 2016 in our ED were included. Primary exposure was off-hour presentation, defined as the period from 6:01 PM to 8:00 AM weekdays plus the entire weekend. The primary outcome measure was the occurrence of an ETI-related adverse event, including hypoxemia, unrecognized esophageal intubation, regurgitation, cardiac arrest, ETI failure rescued by emergency surgical airway, cuff leak, and mainstem bronchus intubation. Of the 123 patients, 75 (61.0 %) were intubated during off hours. Crude analysis showed that off-hour presentation was significantly associated with an increased risk of ETI-related adverse events [odds ratio (OR), 2.5; 95 % confidence interval (CI), 1.1-5.6; p = 0.033]. The increased risk remained significant after adjusting for potential confounders, including operator being an anesthesiologist, use of a paralytic agent, and injury severity score (OR, 3.0; 95 % CI, 1.1-8.4; p = 0.034). In this study, off-hour presentation was independently associated with ETI-related adverse events in trauma patients with a predicted difficult airway
Tabatabaie, Syed Ziaeddin; Rajabi, Mohammad Taher; Rajabi, Mohammad Bagher; Eshraghi, Bahram
Background The purpose of this study was to compare the efficacy of self-retaining stent (SRS) bicanalicular intubation with bicanalicular silicone (Crawford) intubation in patients with canalicular and punctal obstruction. Methods In this prospective, randomized clinical trial, 38 patients with canalicular or punctal obstruction (25 partial, 13 complete) and epiphora were randomized into two groups. Twenty-one patients (14 with partial and seven with complete obstruction) underwent SRS intubation and 17 patients underwent bicanalicular silicon intubation in a randomized fashion. Results After a mean follow-up of 6 months following tube removal, 16 (76%, 12 partial, four complete) of the 21 eyes in the SRS intubation group and 13 (76%, 10 partial, three complete) in the bicanalicular silicon intubation group had a successful outcome and remained symptom-free. For partial obstructions, the success rate was 85% and 90% for the SRS and bicanalicular silicon intubation groups, respectively. The corresponding values for complete obstruction were 63% and 50% for the SRS and bicanalicular silicon intubation groups, respectively. Conclusion SRS could effectively substitute for a more extensive procedure such as bicanalicular silicon intubation in patients with canalicular obstruction, particularly those with partial obstruction. The newly developed SRS intubation procedure has the advantages of simple, easy implementation and extubation, low cost, and a lower rate of trauma when compared with bicanalicular silicon intubation. PMID:22259230
Humberg, Alexander; Göpel, Wolfgang
Procedure of intubation of children is different to intubation in adults and requires specific considerations. Before intubation management of difficult airway problems should be anticipated. Risk of developing hypoxia is common in children usually due to a reduced apnea tolerance and demands skill of the medical team. Due to soft tissues of the upper airways and the V-shaped epiglottis several laryngoscopes are available. Attention should be kept on a physiological subglottic stenosis, which determines the size of the endotracheal tube. Beyond neonatal period cuffed tubes can be applied when cuff pressure is regularly monitored. Long time complications of traumatic intubations comprise subglottic stenosis or granulomas. © Georg Thieme Verlag KG Stuttgart · New York.
Mackenzie, Colin F; Xiao, Yan; Hu, Fu-Ming; Seagull, F Jacob; Fitzgerald, Mark
We illustrate how audio-video data records can improve emergency medical care, using airway management to show how such video data may help to identify unsafe acts, accident precursors, and latent and systems failures and to evaluate performance. This was a retrospective analysis of videos of real patient resuscitation in a trauma center. Participant care providers reviewing their own videos of tracheal intubation identified failures to use diagnostic equipment, fixation errors, and team and communication errors. Neutral expert observers noted team coordination failures and poor error recovery. Comparison with a consensus guideline for a tracheal intubation task/communication pathway showed that communications were unclear or not made, and key tasks were omitted by team members. Differences were detected between performance of tracheal intubation in elective and emergency circumstances. Revised practices ("3 Cs": clinical examination, communication, carbon dioxide) mitigated task performance and communication deficiencies. Video is complementary to traditional quality improvement methods for improving performance in airway management and emergency medical and trauma care, assessing standard operating procedures, and reviewing communications. Video data identify performance details not found in quality improvement approaches, including medical record review or recall by participant care providers. Weaknesses in using video for data include lengthy video review processes, poor audio, and the inability to adequately analyze events outside the field of view. Opportunities are to use video audit for quality improvement of other emergency tasks. Video buffering reduces personnel requirements for capture and simplifies data extraction. Medicolegal and confidentiality threats are significant.
Wurmb, Thomas Erik; Schlereth, Stefan; Kredel, Markus; Muellenbach, Ralf M; Wunder, Christian; Brederlau, Jörg; Roewer, Norbert; Kenn, Werner; Kunze, Ekkehard
Missed or delayed detection of progressive neuronal damage after traumatic brain injury (TBI) may have negative impact on the outcome. We investigated whether routine follow-up CT is beneficial in sedated and mechanically ventilated trauma patients. The study design is a retrospective chart review. A routine follow-up cCT was performed 6 hours after the admission scan. We defined 2 groups of patients, group I: patients with equal or recurrent pathologies and group II: patients with new findings or progression of known pathologies. A progression of intracranial injury was found in 63 patients (42%) and 18 patients (12%) had new findings in cCT 2 (group II). In group II a change in therapy was found in 44 out of 81 patients (54%). 55 patients with progression or new findings on the second cCT had no clinical signs of neurological deterioration. Of those 24 patients (44%) had therapeutic consequences due to the results of the follow-up cCT. We found new diagnosis or progression of intracranial pathology in 54% of the patients. In 54% of patients with new findings and progression of pathology, therapy was changed due to the results of follow-up cCT. In trauma patients who are sedated and ventilated for different reasons a routine follow-up CT is beneficial.
Simons, T; Söderlund, T; Handolin, L
Pediatric prehospital endotracheal intubation (PHETI) is a difficult and rarely performed procedure that remains the gold standard for prehospital airway management when ventilation and/or anesthesia is required, but high complications rates, including malposition continue to concern. We reviewed the experience in our institution of pediatric intubations with particular emphasis on the position of the endotracheal tube (ETT) tip within the trachea and related complications. Intubated pediatric patients presenting directly from the scene to our level 1 trauma center, between 2006 and 2014, were included in our study. Patient records and radiographs were retrospectively reviewed to identify the ETT tip-to-carina distance and possible intubation-related complications. ETT tips identified beyond the carina on radiographs or by clinical diagnosis were defined as misplaced. Because head movement causes a significant ETT movement within the trachea, which is age related, we also defined ETT tip placement (1) less than 2 cm above the carina in children younger than 8 and (2) less than 3 cm above the carina in children 8 years or older as "near miss" intubations. From a total of 34 cases, ETT misplacement was identified in seven cases. Diagnosis was made radiologically in five cases and clinically in two cases. Four of these patients had left lung atelectasis due to tube misplacement. Tube thoracotomy was performed in two of these patients without concurrent evidence of chest injury. "Near miss" intubations accounted for 7/9 and 9/25 in children <8 years and ≥8 years old, respectively, totaling 16/34, with two of these leading to late displacements. Pediatric endotracheal tube intubation carries a high rate of tube malposition and left lung atelectasis in our experience of pediatric trauma patients, with less than a third of ETTs placed in a safe position.
Longmuir, Susannah Q; McConnell, Lindsay; Oral, Resmiye; Dumitrescu, Alina; Kamath, Sameer; Erkonen, Gwen
To define the diagnoses associated with the presence of retinal hemorrhages, to clarify the association between retinal hemorrhages, cardiopulmonary resuscitation (CPR), and coagulopathy, and to describe the type of retinal hemorrhages found in intubated critically ill patients <4 years of age. This was a prospective observational study of intubated patients <4 years of age admitted to the pediatric intensive care unit of a tertiary care center from March 2010 to May 2012. The presence and description of retinal hemorrhages was recorded along with diagnoses, international normalized ratio (INR), CPR (in minutes), and mortality. A total of 85 intubated, critically ill patients (37 females) were included; average patient age was 8.2 months (range, 0.1-46.8 months). Of the 85 patients, 6 (7%) had retinal hemorrhages (95% CI, 0.029-0.153). Of the 6 patients with RH, abusive head trauma (AHT) was diagnosed in 4 patients, 1 patient had direct head trauma, and 1 had CPR. There were 8 patients with CPR out of the 85. AHT was highly associated with severe multilayered retinal hemorrhages (P = 0.0001) but coagulopathy (P = 0.2671) and CPR (P = 0.5342) were not. Severe multilayered retinal hemorrhages were associated with AHT in this cohort of patients. Without a history of trauma, retinal hemorrhages occurred in only 1 of 85 patients; in this case the hemorrhages were mild, confined to the posterior pole, and found only in the retinal layer. Copyright © 2014 American Association for Pediatric Ophthalmology and Strabismus. Published by Mosby, Inc. All rights reserved.
Shailaja, S.; Nichelle, S. M.; Shetty, A. Kishan; Hegde, B. Radhesh
Background: Difficult tracheal intubation contributes to significant morbidity and mortality during induction of anesthesia. There are divided opinions regarding ease of intubation in obese patients. Moreover, the definition of difficult intubation is not uniform; hence we have use the Intubation Difficulty Scale (IDS) to find the incidence of difficult intubation in obese patients. Aims: The primary aim of the following study is to find out the incidence of difficult intubation in obese and lean patients using IDS and secondary aim is to assess the performance of bedside screening tests to predict difficult intubation, mask ventilation and laryngoscopy in obese and lean patients. Materials and Methods: A prospective, observational cohort study of 200 patients requiring general anesthesia were categorized into 100 each based on body mass index (BMI) into lean (BMI <25 kg/m2) and obese (BMI ≥25 kg/m2) groups. IDS score ≥5 was termed as difficult intubation. Pre-operative airway assessment included Mallampati score, mouth opening, neck circumference (NC), upper lip bite test, thyromental distance, sternomental distance (SMD) and head neck mobility. Patients having difficulty in mask ventilation and laryngoscopy was recorded. Results: Over all in 200 patients the incidence of difficult intubation was 9%. Obese patients were slightly more difficult to intubate than lean (11% vs. 7%, P = 0.049). Age >40 years, NC >35 cm, SMD <12.5 cm and restricted head neck mobility were factors which were associated with IDS ≥5. Multivariate analysis revealed SMD <12.5 cm to predict difficult intubation in obese patients. Obese patients were difficult to mask ventilate (6% vs. 1%, P = 0.043). There was no difference regarding grading of laryngoscopy between the two groups. Conclusion: Obese patients are difficult to mask ventilate and intubate. During intubation of obese patients who is more than 40 years age and SMD <12.5 cm, it is preferable to have a second skilled
Strøm, C; Barnung, S; Kristensen, M S; Bøttger, M; Tvede, M F; Rasmussen, L S
Videolaryngoscopes with sharp angulated blades improve the view of the vocal cords but this does not necessarily result in higher success rates of intubation The aim of this study was to evaluate the efficacy of using Boedeker intubation forceps in conjunction with McGrath Series 5 Videolaryngoscope (MVL) in patients with predictors for difficult intubation. The study was conducted at the Department of Anaesthesia, Copenhagen University Hospital from September to December 2013. Patients with one or more predictors of difficult intubation scheduled for general anaesthesia were assessed for eligibility. Patients were intubated using Boedeker intubation forceps and MVL. The primary endpoint was time to intubation. The secondary endpoints were intubation success rate, number of intubation attempts, intubation conditions and post-operative hoarseness. Thirty-three patients were assessed for eligibility, and 25 patients were included in the study with a median SARI score of 3 (IQR 3-4). Twenty-two (88%, 95% confidence interval [74-100%]) of the patients were successfully intubated by the method with a median time to intubation of 115 s (IQR 78-247). Steering and advancement of the tube were reported as acceptable in 21 (84%) and 22 cases (88%), respectively, and excellent in 10 cases (45%) for both measures. Ten cases (40%) were intubated on the first attempt. There were three cases (12%) of failed intubation; in these cases, successful intubation was obtained by using a styletted tube. Most patients with anticipated difficult intubation can be successfully intubated with Boedeker intubation forceps and MVL. However, endotracheal tube placement failed in 3/25 patients despite a good laryngeal view. © 2015 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.
fold increase in the odds of death. The use of propofol for the induction of anesthesia for endotracheal intubation in critically ill burned patients...did not increase the odds of hypotension or death. In burn patients requiring emergent endotracheal intubation in the BICU, the care team should...01 DEC 2012 2. REPORT TYPE N/A 3. DATES COVERED - 4. TITLE AND SUBTITLE Risk factors for hypotension in urgently intubated burn patients 5a
Cheong, Yuseon; Kang, Seong Sik; Kim, Minsoo; Son, Hee Jeong; Park, Jaewoo; Kim, Jeong-Mo
Airway management in patients with complex maxillofacial injuries is a challenge to anesthesiologists. Submental intubation is a useful technique that is less invasive than tracheostomy in securing the airways where orotracheal and nasotracheal intubation cannot be performed. This procedure avoids the use of tracheostomy and bypasses its associated morbidities. A flexible and kink-resistant reinforced endotracheal tube with detachable universal connector is commonly used for submental intubation. Herein, we report cases involving submental intubation using a reinforced endotracheal tube with a non-detachable universal connector in patients with complex maxillofacial injuries. PMID:27924286
Lozano, Luis Manuel Barrera; Perel, Pablo; Ker, Katharine; Cirocchi, Roberto; Farinella, Eriberto; Morales, Carlos Hernando
This is the protocol for a review and there is no abstract. The objectives are as follows: To assess the effects of thromboprophylaxis in trauma patients on mortality and incidence of DVT and PE. To compare the effects of different thromboprophylaxis interventions and their relative effects according to the type of trauma. PMID:25267908
Dennis, Christopher J; Chung, Kevin K; Holland, Seth R; Yoon, Brian S; Milligan, Daun J; Nitzschke, Stephanie L; Maani, Christopher V; Hansen, Jacob J; Aden, James K; Renz, Evan M
When urgently intubating patient in the burn intensive care unit (BICU), various induction agents, including propofol, are utilized that may induce hemodynamic instability. A retrospective review was performed of consecutive critically ill burn patients who underwent urgent endotracheal intubation in BICU. Basic burn-related demographic data, indication for intubation, and induction agents utilized were recorded. The primary outcomes of interest were clinically significant hypotension requiring immediate fluid resuscitation, initiation or escalation of vasopressors immediately after intubation. Secondary outcomes included ventilator days, stay length, and in-hospital mortality. Between January 2003 and August 2010, we identified 279 urgent intubations in 204 patients. Of these, the criteria for presumed sepsis were met in 60% (n=168) of the intubations. After intubation, 117 patients (42%) experienced clinically significant hypotension. Propofol (51%) was the most commonly utilized induction agent followed by etomidate (23%), ketamine (15%), and midazolam (11%). On multiple logistic regression, %TBSA (OR 1.016, 95% CI 1.004-1.027, p<0.001) and presumed sepsis (OR 1.852, 95% CI 1.100-3.117, p=0.02) were the only significant predictors of hypotension. None of the induction agents, including propofol, were significantly associated with hypotension in patients with or without presumed sepsis. In critically ill burn patients undergoing urgent endotracheal intubation, specific induction agents, including propofol, were not associated with clinically significant hypotension. Presumed sepsis and %TBSA were the most important risk factors. Published by Elsevier Ltd.
Dziadz'ko, A M
Clinical pattern of anesthesia, hemodynamic and gas exchange states were evaluated in 64 patients with congenital or acquired damage of maxillary-facial region due to tumor or trauma. 51 patients were intubated under locoregional anesthesia of the upper respiratory tract (superior laryngeal nerves, glossopharyngeal nerves, intratracheal anesthesia) by means of blind nasal or oral fiberoptic retrograde and by using laryngeal mask technique. In 12 cases fiberoptic device was used for intubation under local anesthesia by lidocaine solution. There was no airways obstruction in any case. Satisfactory anesthesia in oropharynx, larynx and trachea was reached in all cases, the most profound blockage of airways and lack of pharyngeal and laryngeal reflexes being in patients under locoregional anesthesia. So locoregional anesthesia can be used for awake intubation.
Wang, Hao; Ding, Baochun
To approach the effect of low damage endotracheal intubation on reducing the occurrence of cuff-related intubation complication and prolonging the intubation time. On January 7th, 2015, 1 patient with respiratory failure after subarachnoid hemorrhage were admitted to Huludao Central Hospital. Immediate endotracheal intubation and ventilator assisted ventilation were performed. When the trachea was difficult to be removed in a short time, and tracheotomy was refused, a low damage endotracheal intubation was used for a long term. On the basis of the original high volume low pressure cuff, this tube was designed for inner cuff, the hole was allowed in the inner cuff to connect with the tube. During the period of ventilation, the cuff pressure changed with airway pressure automatically, therefore it would reduce the compression injury of tracheal mucosa, improve the tolerance of the patients, and prolong the intubation time. The patient was removed from the tube on October 12th, 2015 with an intubation day of 279, the intubation-related complications and severe aspiration pneumonia had not been observed during the application of low damage endotracheal intubation. Design of this intubation ensured the cuff pressure changes with airway pressure, therefore, it could effectively avoid the cuff pressure become too high, and reduce the occurrence of intubation-related complication. This low damage endotracheal had an evident superiority in the aspects of cuff management. It has a better practical significance, especially for patients with long intubation time.
Cocanour, C S; Miller-Crotchett, P; Reed, R L; Johnson, P C; Fischer, R P
Cutaneous mucormycosis is a rare but often fatal infection in trauma patients. We retrospectively reviewed a 9-year experience with mucormycosis among injured patients. Eleven patients had biopsy- or culture-proven mucormycosis. Nine patients were victims of blunt trauma, two patients had burns measuring greater than 50% TBSA. No patient was at increased risk because of underlying disease or immunosuppression prior to injury. All 11 patients had open wounds on admission. Four patients died of mucormycosis. All nonsurvivors had phycomycotic gangrenous cellulitis of the head, the trunk, or both. In contrast, survivors had involvement of only the extremities. Because of underlying disease, contaminating wounds, antibiotic use, or immunocompromise secondary to shock and sepsis, trauma patients are at risk of developing mucormycosis. To successfully treat mucormycosis, diagnosis must be prompt and accompanied by aggressive debridement and parenteral administration of amphotericin B.
Dashti, Majid; Amini, Shahram; Azarfarin, Rasoul; Totonchi, Ziae; Hatami, Maryam
Background: Tracheal intubation can be associated with considerable hemodynamic changes, particularly in patients with uncontrolled hypertension. The GlideScope® video-laryngoscope (GVL) is a novel video laryngoscope that does not need direct exposure of the vocal cords, and it can also produce lower hemodynamic changes due to lower degrees of trauma and stimuli to the oropharynx than a Macintosh direct laryngoscope (MDL). Objectives: The aim of this clinical trial was to compare hemodynamic alterations following tracheal intubation with a GVL and MDL in patients with uncontrolled hypertension. Patients and Methods: Sixty patients who had uncontrolled hypertension and scheduled for elective surgery requiring tracheal intubation, were randomly assigned to receive intubated with either a GVL (n = 30) or a MDL (n = 30). Intubation time, heart rate, rate pressure product (RPP), and mean arterial blood pressure (MAP), were compared between the two groups at; baseline, following induction of anesthesia, after intubation, and at one minute intervals for 5 minutes. Results: A total of 59 patients finished the study. Intubation time was longer in the GVL group (9.80 ± 1.27 s) than in the MDL group (8.20 ± 1.17 s) (P < 0.05). MAP, pulse rate, and RPP were lower in the GVL than the MDL group after endotracheal intubation (P < 0.05). MAP, heart rate, and RPP returned to pre-intubation values at 3 and 4 minutes after intubation in the GVL and MDL groups, respectively (P < 0.05). Conclusions: Hemodynamic fluctuations in patients with uncontrolled hypertension after endotracheal intubation were lower with the GVL than the MDL technique. PMID:25478537
Umesh, Goneppanavar; Tim, Thomas Joseph; Prabhu, Manjunath; Prasad, Krishnamurthy N; Jasvinder, Kaur
Oesophageal intubation can lead to life threatening complications if left undetected. Several devices and techniques are available to confirm tracheal intubation and for early detection of oesophageal intubation. This study was carried out to evaluate the utility of the Umesh's intubation detector device for rapid and reliable differentiation of tracheal from oesophageal intubation by novice users. In this prospective, double blind and randomised study, 100 healthy patients undergoing general anaesthesia with endotracheal intubation received two identical size endotracheal tubes; one inserted into trachea and the other into the oesophagus. The Umesh's intubation detector was connected to one of the tubes randomly and a novice was asked to observe for inflation of the reservoir bag of the device while two chest compressions of approximately one inch each were given to the patient. Out of the total 100 tracheal intubations, 96 were correctly identified while the observers could not clearly conclude whether the tube was in trachea or oesophagus in the other four patients. Out of the total 100 oesophageal intubations, 99 were correctly identified. There were no complications related to the study. Umesh's intubation detector device can be used by novices for rapid and reliable differentiation of tracheal from oesophageal intubation in healthy adult patients.
Kabata, Yoshiaki; Goto, Satoshi; Takahashi, Genichiro; Tsuneoka, Hiroshi
To evaluate the changes in vision-related quality of life in patients with lacrimal passage obstructions undergoing silicone tube intubations. Prospective, consecutive, comparative, interventional case series. Forty-five patients with the chief complaint of epiphora diagnosed with complete and unilateral lacrimal passage obstructions were enrolled. Exclusion criteria included history of congenital nasolacrimal stenosis; lacrimal passage obstructions resulting from trauma, tumor, or chemotherapy; previous lacrimal passage surgery; and partial and functional nasolacrimal duct obstructions. Silicone tube intubation using a Nunchaku-style tube was performed under direct visualization with dacryoendoscope in all patients. Operations were considered as successful when the irrigating fluid could pass through the lacrimal passage and the disappearance of dye was observed in dye disappearance test and the patients' epiphora symptoms improved 3 months postoperatively. The 25-item National Eye Institute Visual Function Questionnaire (NEI VFQ-25) was self-administered in all patients preoperatively and 3 months postoperatively. Patients' preoperative and 3-months-postoperative NEI VFQ-25 scores were compared. Operations were successful in 40 patients (89%). Fully completed questionnaires were received from 32 patients (80%). Silicone tube intubation using a Nunchaku-style tube was associated with a significant improvement of the NEI VFQ-25 composite score (P = .0001), ocular pain score (P < .0001), and mental health score (P = .0003). Relief of epiphora by silicone tube intubation using a Nunchaku-style tube treatment significantly improved the vision-related quality of life in patients with lacrimal passage obstructions. Copyright © 2011 Elsevier Inc. All rights reserved.
Liu, Zi-Jia; Yi, Jie; Guo, Wen-Juan; Ma, Chao; Huang, Yu-Guang
Abstract Difficult and failed intubations account for the major causes of morbidity and mortality in current anesthetic practice. Several devices including McGrath Series 3 videolaryngoscope are available which may facilitate tracheal intubation by improving view of the larynx compared with Macintosh blade laryngoscopy. But no studies demonstrate whether McGrath Series 3 performs better than Macintosh laryngoscope in normal airway intubations by inexperienced anesthetists so far. We therefore designed this randomized controlled study to compare McGrath with Macintosh in routine tracheal intubation performed by inexperienced anesthetists. In total, 180 adult patients with normal-appearing airways requiring orotracheal intubation for elective surgery were randomly allocated to be intubated by 9 inexperienced anesthetists with McGrath or Macintosh. The primary outcome was time to intubation. Ease of intubation was assessed by a 5-point ordinal scale. Intubation attempts/failures, best laryngoscopy view using the Cormack–Lehane grade, associated complications and hemodynamic changes during intubation were recorded. We found that there was no significant difference between McGrath and Macintosh in the median time to intubation (P = 0.46); the Cormack–Lehane views attained using McGrath were superior (P < 0.001); the difference of ease of intubation was statistically significant (P = 0.01). No serious trauma occurred in both groups. And there was statistically significant difference in the systolic blood pressure changes between 2 groups (P < 0.05). We demonstrated that in orotracheal intubation in patients with normal airway by inexperienced anesthetists, McGrath compared with the Macintosh allows superior glottis views, greater ease of intubation, less complications, and hemodynamic changes with noninferior intubation time. And it remained a potential selection for inexperienced anesthetists in uncomplicated intubation. PMID:26765472
de Moraes, Alice Gallo; Racedo Africano, Carlos J.; Hoskote, Sumedh S.; Reddy, Dereddi Raja S.; Tedja, Rudy; Thakur, Lokendra; Pannu, Jasleen K.; Hassebroek, Elizabeth C.; Smischney, Nathan J.
Case series Patient: Male, 77 • Male, 25 • Male, 63 • Male, 70 • Male, 70 • Female, 61 Final Diagnosis: — Symptoms: Hypotension • respiratory failure Medication: Ketamine • Propofol • Etomidate Clinical Procedure: Endotracheal intubation Specialty: Critical Care Medicine Objective: Educational Purpose (only if useful for a systematic review or synthesis) Background: Endotracheal intubation is a common procedure performed for critically ill patients that can have immediate life-threatening complications. Induction medications are routinely given to facilitate the procedure, but most of these medications are associated with hypotension. While etomidate is known for its neutral hemodynamic profile, it has been linked with increased mortality in septic patients and increased morbidity in trauma patients. Ketamine and propofol are effective anesthetics with counteracting cardiovascular profiles. No data are available about the use of this combination in critically ill patients undergoing endotracheal intubation. Case Series: We describe 6 cases in which the combination of ketamine and propofol (“ketofol”) was used as an induction agent for endotracheal intubation in critically ill patients with a focus on hemodynamic outcomes. All patients received a neuromuscular blocker and fentanyl, while 5 patients received midazolam. We recorded mean arterial pressure (MAP) 1 minute before induction and 15 minutes after intubation with the combination. Of the 6 patients, 5 maintained a MAP ≥65 mmHg 15 minutes after intubation. One patient was on norepinephrine infusion with a MAP of 64 mmHg, and did not require an increase in the dose of the vasopressor 15 minutes after intubation. No hemodynamic complications were reported after any of the intubations. Conclusions: This case series describes the use of the “ketofol” combination as an induction agent for intubation in critically ill patients when hemodynamic stability is desired. Further research is
Cebrián-Carretero, J L; Saavedra, B; Rivas-Vila, S; Chamorro-Pons, M; Muñoz-Caro, J M; Rodríguez-Reinoso, M; Barreiro, M D
Airway management in patients with middle third facial skeleton fractures is a challenge for anesthesiologists and surgeons, given that the natural routes for intubation--the nose and mouth--are both compromised by trauma. In this setting, the airway can only be accessed by tracheotomy. Tracheotomy, however, is an invasive technique that should be reserved for cases in which it is absolutely necessary. To establish the utility of submental intubation as an alternative to tracheotomy in patients with middle third facial skeletal fractures. We reviewed the cases of the 15 patients intubated with the aforementioned technique between 1996 and 2002 in Hospital Universitario La Paz in Madrid, Spain. We describe the surgical technique and postoperative course recorded for those patients. The courses of surgery and postoperative recovery were without complications. All extubations were uneventful and no patient required a tracheotomy. Submental intubation is a simple, useful technique for managing the airway of patients with middle third facial skeletal fractures. The technique has few complications.
Péan, D; Floch, H; Beliard, C; Piot, B; Testa, S; Bazin, V; Lejus, C; Asehnoune, K
The most recommended technique for the management of patients with a difficult airway is fiberoptic intubation (FOI). The aim of this study was to compare propofol and sevoflurane for FOI performance in patients who were difficult to intubate. Seventy-eight patients scheduled for maxillo-facial surgery were included in this prospective, randomized study. The airway was topically anesthetized with lidocaine 5% before performance of FOI with propofol TCI (group P) or sevoflurane (group S). The following parameters were recorded: rate of success, duration of the induction and of the FOI, BIS and PETCO2 values. A visual analogic scale (VAS) was used to monitor the technical difficulties as well as the recall of patients and their satisfaction. The respiratory and hemodynamic complications were also evaluated. Induction and procedure duration were significantly shorter in group S compared with group P. The rate of successful FOI was not different: 38 cases (97%) in group P and 35 cases (90%) in group S. No significant differences were observed between groups regarding BIS values and VAS values for technical difficulties and for patient recall and satisfaction. The incidence of hypertension or tachycardia was significantly higher in group S compared with group P. The incidence of respiratory complications was not significantly different between the groups, but three patients experienced obstructive dyspnea with hypoxemia. Propofol and sevoflurane provide a high success rate for the performance of FOI in patients who are difficult to intubate.
Lockey, D J; Healey, B; Crewdson, K; Chalk, G; Weaver, A E; Davies, G E
Treatment of airway compromise in trauma patients is a priority. Basic airway management is provided by all emergency personnel, but the requirement for on-scene advanced airway management is controversial. We attempted to establish the demand for on-scene advanced airway interventions. Trauma patients managed with standard UK paramedic airway interventions were assessed to determine whether airway compromise had been effectively treated or whether more advanced airway management was required. A prospective observational study was conducted to identify trauma patients requiring prehospital advanced airway management attended by a doctor-paramedic team. The team assessed and documented airway compromise on arrival, interventions performed before and after their arrival, and their impact on airway compromise. Four hundred and seventy-two patients required advanced airway intervention and received 925 airway interventions by ground-based paramedics. Two hundred and sixty-nine patients (57%) still had airway compromise on arrival of the enhanced care team; no oxygen had been administered to 52 patients (11%). There were 45 attempted intubations by ground paramedics with a 64% success rate and 11% unrecognized oesophageal intubation rate. Doctor-paramedic teams delivering prehospital anaesthesia achieved definitive airway management for all patients. A significant proportion of severely injured trauma patients required advanced airway interventions to effectively treat airway compromise. Standard ambulance service interventions were only effective for a proportion of patients, but might not have always been applied appropriately. Complications of advanced airway management occurred in both provider groups, but failed intubation and unrecognized oesophageal intubation were a particular problem in the paramedic intubation group. © The Author 2014. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions
Tuzuner-Oncul, Aysegul Mine; Kucukyavuz, Zuhal
The failure to maintain a patent airway after the induction of general anesthesia is a major concern for anesthesiologists. For securing the airway, tracheal intubation using direct laryngoscopy remains the method of choice in most cases. However, direct laryngoscopic intubation is difficult in 1% to 4%, and impossible in 0.05% to 0.35%, of patients who have seemingly normal airways. This study sought to determine the prevalence of difficult intubation in maxillofacial surgery patients, and to evaluate the usefulness of various predictive tests for difficult intubation. This study was conducted on 208 patients undergoing maxillofacial surgery. During the preoperative visit, patients were examined in terms of the test of Mallampati et al (Can Anaesth Soc J 32:429, 1985), thyromental distance, sternomental distance, and interincisal distance. Direct laryngoscopic grading, as defined by Cormack and Lehane (Anesthesia 39:1105, 1984), was recorded for each patient. An intubation of "no difficulty" was noted when the tube was inserted into the fully visualized larynx with little effort on the first attempt. Intubation was possible in all patients. Combinations of different predictive tests resulted in higher sensitivity. Among all test types, that of Cormack and Lahene was thought to exhibit the highest sensitivity and positive predictive values when used alone. The prevalence of difficult intubation in our group of maxillofacial surgery patients was 15.4%. It may be concluded that a combination of predictive variables can be used to improve sensitivity. We demonstrated that combining the Mallampati test with other instruments of measurement resulted in higher sensitivity than when either test was used alone.
Awake intubation is usually performed electively in the presence of a difficult airway. A detailed airway examination is time-consuming and often not feasible in an emergency. A simple 1-2-3 rule for airway examination allows one to identify potential airway difficulty within a minute. A more detailed airway examination can give a better idea about the exact nature of difficulty and the course of action to be taken to overcome it. When faced with an anticipated difficult airway, the anaesthesiologist needs to consider securing the airway in an awake state without the use of anaesthetic agents or muscle relaxants. As this can be highly discomforting to the patient, time and effort must be spent to prepare such patients both psychologically and pharmacologically for awake intubation. Psychological preparation is best initiated by an anaesthesiologist who explains the procedure in simple language. Sedative medications can be titrated to achieve patient comfort without compromising airway patency. Additional pharmacological preparation includes anaesthetising the airway through topical application of local anaesthetics and appropriate nerve blocks. When faced with a difficult airway, one should call for the difficult airway cart as well as for help from colleagues who have interest and expertise in airway management. Preoxygenation and monitoring during awake intubation is important. Anxious patients with a difficult airway may need to be intubated under general anaesthesia without muscle relaxants. Proper psychological and pharmacological preparation of the patient by an empathetic anaesthesiologist can go a long way in making awake intubation acceptable for all concerned. PMID:22174458
Law-Koune, Jean-Dominique; Liu, Ngai; Szekely, Barbara; Fischler, Marc
Airway management may be difficult in acromegalic patients. The purpose of the study was to evaluate the intubating laryngeal mask airway (ILMA) as a primary tool for ventilation and intubation in acromegalic patients. Twenty-three consenting consecutive adult acromegalic patients presenting for transsphenoidal resection of pituitary adenoma were enrolled in the study. Anesthesia was induced using propofol (1.5 mg/kg followed by 0.5-mg/kg increments); the ILMA was inserted when the bispectral index fell below 50. The ILMA was successful as a primary airway for oxygenation and ventilation at the first attempt for 21 (91%) patients, while 2 (9%) patients required a second attempt. Patient movement was noticed in five (21.7%) of the patients during ILMA insertion. An attempt at tracheal intubation through the ILMA was performed following administration of a mean 395 +/- 168-mg dose of propofol. Overall success rates for tracheal intubation were 82% (19 patients). The first-attempt success rate for tracheal intubation was 52.6% (10 patients), second- and third-attempt success rates were 42.1% (8 patients) and 5.3% (1 patient), respectively. Coughing or movement during intubation was observed in 12 (63.2%) of the patients. Direct laryngoscopy permitted intubation in three cases and blind intubation using a bougie in the fourth case. ILMA can be used as a primary airway for oxygenation in acromegalic patients (manual bag ventilation), but the rate of failed blind intubation through the ILMA precludes its use as a first choice for elective airway management.
Gianakis, Anastasia; McNett, Molly; Belle, Josie; Moran, Cristina; Grimm, Dawn
Ventilator-associated pneumonia (VAP) rates remain highest among trauma and brain injured patients; yet, no research compares VAP risk factors between the 2 groups. This retrospective, case-controlled study identified risk factors for VAP among critically ill trauma patients with and without brain injury. Data were abstracted on trauma patients with (cases) and without (controls) brain injury. Data gathered on n = 157 subjects. Trauma patients with brain injury had more emergent and field intubations. Age was strongest predictor of VAP in cases, and ventilator days predicted VAP in controls. Trauma patients with brain injury may be at higher risk for VAP.
Potter, Patricia; Schallom, Marilyn; Davis, Susan; Sona, Carrie; McSweeney, Maryellen
Recent research indicates that oral measurement of body temperature is a reliable option in orally intubated patients. In situations such as protective isolation, where dedicated electronic thermometers are not available, are single-use chemical dot thermometers an acceptable alternative? To determine the accuracy of single-use chemical dot thermometers in orally intubated adult patients. Subjects included a convenience sample of 85 adult patients admitted to 1 of 2 intensive care units (surgical trauma and neuroscience). For each patient, oral temperatures were measured concurrently (within 5 minutes) with a chemical dot thermometer and an electronic thermometer. The sequence of temperature measurements was alternated with each subsequent patient. Both thermometers were placed in the same posterior sublingual pocket opposite the side of the endotracheal tube. Measurements obtained with electronic and single-use chemical dot thermometers correlated strongly (r = 0.937). With the chemical dot thermometer, body temperature was overestimated in 11.8% of the measurements and underestimated in 10.8% of the measurements by 0.4 degree C or more. The difference between oral temperatures measured with the 2 different thermometers was not related to the patient's age, sex, or sublingual pocket location or to the order of thermometer use. The chemical dot thermometer is useful and reliable for measuring body temperature of orally intubated patients. When measurements of body temperature have important consequences for decisions about treatment, clinicians should use an electronic thermometer to confirm measurements made with a chemical dot thermometer.
Beckers, Stefan K; Brokmann, Jörg C; Rossaint, Rolf
Securing the airway to provide sufficient oxygenation and ventilation is of paramount importance in the management of all types of emergency patients. Particularly in severely injured patients, strategies should be adapted according to useful recent literature findings. The role of out-of-hospital endotracheal intubation in patients with severe traumatic brain injury as prevention of hypoxia still persists, and the ideal neuromuscular blocking agent will be a target of research. Standardized monitoring, including capnography and the use of standardized medication protocols without etomidate, can reduce further complications. Prophylactic noninvasive ventilation may be useful for patients with blunt chest trauma without respiratory insufficiency. An algorithm-based approach to airway management can prevent complications due to inadequate oxygenation or procedural difficulties in trauma patients; therefore, advanced equipment for handling a difficult airway is needed. After securing the airway, ventilation must be monitored by capnography, and normoventilation involving the early use of protective ventilation with low-tidal volume and moderate positive end-expiratory pressure must be the target. After early identification of patients with blunt chest trauma at risk for respiratory failure, noninvasive ventilation might be a treatment strategy, which should be evaluated in future research.
Dohrn, Niclas; Sommer, Thorbjørn; Bisgaard, Jannie; Rønholm, Ebbe; Larsen, Jens Fromholt
Endotracheal intubation is commonly perceived to be more difficult in obese patients than in lean patients. Primarily, we investigated the association between difficult tracheal intubation (DTI) and obesity, and secondarily, the association between DTI and validated scoring systems used to assess the airways, the association between DTI and quantities of anesthetics used to induce general anesthesia, and the association between DTI and difficulties with venous and arterial cannulation. This is a monocentric prospective observational clinical study of a consecutive series of 539 obese patients undergoing gastric bypass. Tracheal intubation was done preoperatively together with scoring of Intubation Score (IS), Mallampati (MLP), and Cormack-Lehane classification (CLC) and registration of the quantities of anesthetics and total attempts on cannulation. The overall proportion of patients with DTI was 3.5 % and the patients with DTI were more frequently males, had higher CLC, higher American Society of Anesthesiologists physical status classification (ASA), and noticeably, a lower BMI compared to the patients with easy tracheal intubation. After adjustment with multivariable analyses body mass index (BMI) <40, CLC >2, ASA scores >2, and male gender were risk factors of DTI. Males generally had higher CLC, MLP, and ASA scores compared to females, but no difference in BMI. There was no difference in quantities of anesthetics used between the two groups with or without DTI. Intra-venous and intra-arterial cannulation was succeeded in first attempt in 85 and 86 % of the patients, respectively, and there were no association between BMI and difficult vascular access. We found no association between increasing BMI and DTI.
Kajekar, Payal; Mendonca, Cyprian; Danha, Rati; Hillermann, Carl
Background and Aims: Pentax airway scope (AWS) has been successfully used for managing difficult intubations. In this case series, we aimed to evaluate the success rate and time taken to complete intubation, when AWS was used for awake tracheal intubation. Methods: We prospectively evaluated the use of AWS for awake tracheal intubation in 30 patients. Indication for awake intubation, intubation time, total time to complete tracheal intubation, laryngoscopic view (Cormack and Lehane grade), total dose of local anaesthetic used, anaesthetists rating and patient's tolerance of the procedure were recorded. Results: The procedure was successful in 25 out of the 30 patients (83%). The mean (standard deviation) intubation time and total time to complete the tracheal intubation was 5.4 (2.4) and 13.9 (3.7) min, respectively in successful cases. The laryngeal view was grade 1 in 24 and grade 2 in one of 25 successful intubations. In three out of the five patients where the AWS failed, awake tracheal intubation was successfully completed with the assistance of flexible fibre optic scope (FOS). Conclusion: Awake tracheal intubation using AWS was successful in 83% of patients. Success rate can be further improved using a combination of AWS and FOS. Anaesthesiologists who do not routinely use FOS may find AWS easier to use for awake tracheal intubation using an oral route. PMID:25197114
Holmes, James; Peng, James; Bair, Aaron
The utility of prehospital intubation is controversial, as uncontrolled studies in trauma patients suggest adverse outcomes with prehospital intubation, perhaps secondary to inappropriate ventilation once intubation is accomplished. The objectives were 1) to establish, immediately upon arrival to the emergency department (ED), the prevalence of abnormal end-tidal carbon dioxide (ETCO(2)) levels in patients with prehospital intubation and 2) to describe the relationship between abnormal ETCO(2) levels on ED arrival and mortality. This was a prospective, observational cohort study of patients with prehospital intubation. Patients were excluded if they underwent prehospital cardiopulmonary resuscitation (CPR). On ED arrival, the initial ETCO(2) measurement from the patient's endotracheal tube was immediately obtained prior to purposeful intervention in the patient's ventilation by using an Oridion Surestream Sure VentLine H Set with a Welch Allyn Propaq CS monitor. For each patient, the treating physician documented the ETCO(2) measurement, patient demographics, and details of the transport. The primary outcome was an abnormal ETCO(2) value (<30 mmHg or >45 mmHg). The secondary outcome was mortality. One hundred eligible patients were enrolled, with a median age of 30 years (interquartile range [IQR] 15, 48 years). Esophageal intubations were identified in four cases, and those cases were excluded from further analysis. Mechanisms included trauma, 74; medical, 12; and burn, 10. The median ETCO(2) value was 32 mmHg (IQR 27, 38 mmHg), range 18-80 mmHg. Forty-six of 96 (48%, 95% confidence interval [CI] 38%, 58%) patients had abnormal ETCO(2) values, including 37 (39%, 95% CI 29%, 49%) with low ETCO(2) levels and nine (9%, 95% CI 4%, 17%) with high ETCO(2) levels. Death was higher in those trauma patients with abnormal ETCO(2) levels (10/33, 30%, 95% CI 16%, 49%) than in those with normal ETCO(2) levels (2/41, 5%, 95% CI 0.6%, 17%), relative risk = 6.2 (95% CI 1.5, 26
Schober, Patrick; Krage, Ralf; van Groeningen, Dick; Loer, Stephan A; Schwarte, Lothar A
Airway management in entrapped casualties with restricted access to the head is challenging. If tracheal intubation is required and conventional laryngoscopy is not possible, intubation must be attempted in a face-to-face approach. Traditionally, this is performed with a standard laryngoscope held in the right hand with the blade facing upward. Recently, alternative methods have been developed to facilitate difficult intubations, and we hypothesised that such techniques are also useful for face-to-face intubations. 24 (trainee) anaesthesiologists attempted tracheal intubation in a patient simulator (SimMan, Laerdal, Norway) using three techniques in random order: (1) direct laryngoscopy (Macintosh blade #3), (2) indirect optical laryngoscopy (Airtraq, Prodol, Spain) and (3) video laryngoscopy (McGrath, Aircraft Medical, UK). The manikin was sitting with the neck immobilised and only accessible from the left anterolateral side. Success rate (percentage (95% CI)) and tube insertion time (median (IQR)) were recorded. Success rate did not differ significantly (Airtraq and McGrath 100% (84% to 100%), direct laryngoscopy 88% (68% to 96%)). Intubation was faster with Airtraq (25 s (22-34), p<0.001) and direct laryngoscopy (34 s (22-48), p<0.05) compared with the McGrath technique (55 s (37-96)). All three techniques have a high success rate, but the usefulness of the video laryngoscope is limited due to longer intubation duration. Inverse direct laryngoscopy showed reasonable intubation times and, given the widespread availability of Macintosh laryngoscopes, seems a useful technique. Intubation was always successful and tended to be fastest with the Airtraq device, suggesting that this technique may be a promising alternative. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
Ma, Kevin C; Chung, Augustine; Aronson, Kerri I; Krishnan, Jamuna K; Barjaktarevic, Igor Z; Berlin, David A; Schenck, Edward J
American Society of Anesthesiologists guidelines recommend the use of bronchoscopic intubation as a rescue technique in critically ill patients. We sought to assess the safety and efficacy of bronchoscopic intubation as an initial approach in critically ill patients. We performed a retrospective cohort study of patients who underwent endotracheal intubation in the medical intensive care unit of a tertiary urban referral center over 1 academic year. The primary outcome was first-pass success rate. We identified 219 patients who underwent either bronchoscopic (n=52) or laryngoscopic guided (n=167) intubation as the initial attempt. There was a higher first-pass success rate in the bronchoscopic intubation group than in the laryngoscopic group (96% vs 78%; P=.003). The bronchoscopic intubation group had a higher body mass index (28.4 vs 25.9; P=.027) and higher preintubation fraction of inspired oxygen requirement (0.73±0.27 vs 0.63±0.30; P=.044) than the laryngoscopic group. There were no cases of right mainstem intubation, esophageal intubation, or pneumothorax with bronchoscopic intubation. Rates of postintubation hypotension and hypoxemia were similar in both groups. The association with first-pass success remained with multivariate and propensity matched analysis. Bronchoscopic intubation as an initial strategy in critically ill patients is associated with a higher first-pass success rate than laryngoscopic intubation, and is not associated with an increase in complications. Copyright © 2016 Elsevier Inc. All rights reserved.
Miller, Joseph B.; Nicholas, Katherine S.; Varelas, Panayiotis N.; Harsh, Donna M.; Durkalski, Valerie; Silbergleit, Robert; Wang, Henry E.
Introduction Limited data describe the frequency, timing, or indications for endotracheal intubation (ETI) in patients with status epilepticus. A better understanding of the characteristics of patients with status epilepticus requiring airway interventions could inform clinical care. We sought to characterize ETI use in patients with prehospital status epilepticus. Methods This study was a secondary analysis of the Rapid Anticonvulsant Medication Prior to Arrival Trial, a multi-center, randomized trial comparing intravenous lorazepam to intramuscular midazolam for prehospital status epilepticus treatment. Subjects received ETI in the prehospital, Emergency Department (ED), or inpatient setting at the discretion of caregivers. Results Of 1023 enrollments, 218 (21 %) received ETI. 204 (93.6 %) of the ETIs were performed in the hospital and 14 (6.4 %) in the prehospital setting. Intubated patients were older (52 vs 41 years, p < 0.001), and men underwent ETI more than women (26 vs 21 %, p = 0.047). Patients with ongoing seizures on ED arrival had a higher rate of ETI (32 vs 16 %, p < 0.001), as did those who received rescue anti-seizure medication (29 vs 20 %, p = 0.004). Mortality was higher for intubated patients (7 vs 0.4 %, p < 0.001). Most ETI (n = 133, 62 %) occurred early (prior to or within 30 min after ED arrival), and late ETI was associated with higher mortality (14 vs 3 %, p = 0.002) than early ETI. Conclusions ETI is common in patients with status epilepticus, particularly among the elderly or those with refractory seizures. Any ETI and late ETI are both associated with higher mortality. PMID:25623785
Amini, Shahram; Shakib, Majid
Endotracheal intubation is usually associated with hemodynamic changes, especially in patients undergoing cesarean section by general anesthesia. GlideScope® videolaryngoscope (GVL) is a novel video laryngoscope, which does not need direct exposure of vocal cords and produces lesser hemodynamic changes due to lower degrees of trauma and stimuli to oropharynx than the Macintosh direct laryngoscope (MDL). The aim of this study was to compare hemodynamic changes following endotracheal intubation with GVL and MDL in patients undergoing cesarean section by general anesthesia. Seventy patients undergoing elective cesarean section by general anesthesia requiring endotracheal intubation were randomly allocated to be intubated with either GVL (n = 35) or MDL (n = 35). Systolic, diastolic and mean arterial blood pressure (MAP), as well as pulse rates, and rate pressure product (RPP) were compared at baseline, after induction of anesthesia, and after intubation at one-minute interval for five minutes between the two groups. The patients were also compared for Mallampati score, sore throat, intubation time and neonates' Apgar scores. The patients were similar regarding systolic, diastolic and mean arterial blood pressure. Pulse rate changes were significantly lower only at 1 and 3 minutes in the GVL group. The intubation times were 9.3 ± 1.4 and 10.6 ± 1.7 seconds in the MDL and GVL groups, respectively (P > 0.05). RPP was also lower in the GVL group at 1 and 2 minutes (P < 0.05) and returned to baseline afterwards. There was no significant difference between the groups for Mallampati score, sore throat and Apgar scores. Our study revealed that hemodynamic parameters with GVL are only better preserved in the first three minutes after intubation in patients undergoing elective cesarean section and patients are similar regarding intubation time, sore throat and Apgar score.
Moustafa, Moustafa Abdelaziz; Arida, Emad A; Zanaty, Ola M; El-Tamboly, Sameh Fathy
Ultrasound has growing applications in airway management during anesthesia. The aim of the present study was to evaluate the feasibility of real-time ultrasound-guided tracheal intubation in patients with cervical spine immobilization relative to fiberscope-guided tracheal intubation. This randomized controlled study was carried out on 266 adult patients who have a rigid neck collar in place for cervical spine immobilization and were randomly allocated into two equal groups. All patients were subjected to the same anesthetic protocol. After full neuromuscular blockade, neck collar was removed and tracheal intubation was done in the neutral position. In group A, the trachea was intubated guided by a 5-12-MHz linear ultrasound probe attached to a Sonoscape A5 ultrasound machine. In group B, the trachea was intubated by an endotracheal tube mounted over a fiberscope (Karl Storz, working length 65 cm, distal tip diameter 5.6 mm). Hemodynamic measurements and oxygen saturation were recorded. Tracheal intubation criteria for both groups including duration of the intubation procedure, number of intubation attempts, success rate at each attempt, and the lowest oxygen saturation recorded during tracheal intubation were recorded. Ultrasound and fiberscope achieved comparable time for tracheal intubation (57 ± 12 vs. 55 ± 10 s), respectively. Success rate of tracheal intubation at the first attempt was higher in the fiberscope group than the ultrasound group, with a P value of 0.032. The overall success rate was not significantly different between the two groups. Ultrasound-guided tracheal intubation showed a lower first attempt success rate in patients with cervical spine immobilization compared to fiberscope-guided tracheal intubation but the overall success rates were comparable. Ultrasound can be an alternative technique for guiding tracheal intubation in patients with cervical spine immobilization. PACTR201602001476292.
Bloom, Matthew B; Serna-Gallegos, Derek; Ault, Mark; Khan, Ahsan; Chung, Rex; Ley, Eric J; Melo, Nicolas; Margulies, Daniel R
Pleural effusions occur frequently in mechanically ventilated patients, but no consensus exists regarding the clinical benefit of effusion drainage. We sought to determine the impact of thoracentesis on gas exchange in patients with differing severities of acute lung injury (ALI). A retrospective analysis was conducted on therapeutic thoracenteses performed on intubated patients in an adult surgical intensive care unit of a tertiary center. Effusions judged by ultrasound to be 400 mL or larger were drained. Subjects were divided into groups based on their initial P:F ratios: normal >300, ALI 200 to 300, and acute respiratory distress syndrome (ARDS) <200. Baseline characteristics, physiologic variables, arterial blood gases, and ventilator settings before and after the intervention were analyzed. The primary end point was the change in measures of oxygenation. Significant improvements in P:F ratios (mean ± SD) were seen only in patients with ARDS (50.4 ± 38.5, P = 0.001) and ALI (90.6 ± 161.7, P = 0.022). Statistically significant improvement was observed in the pO2 (31.1, P = 0.005) and O2 saturation (4.1, P < 0.001) of the ARDS group. The volume of effusion removed did not correlate with changes in individual patient's oxygenation. These data support the role of therapeutic thoracentesis for intubated patients with abnormal P:F ratios.
Lee, Ju-Hwan; Jung, Hoe-Chang; Shim, Ji-Hoon; Lee, Cheol
Optimal head and neck positioning and clinical experience are important factors for successful endotracheal intubation in patients with a difficult airway. This study aimed to investigate the rate of successful endotracheal intubation between the sniffing and ramped positions in patients with an expected difficult intubation. The study included 204 patients with an expected difficult intubation (airway difficulty score ≥ 8) based on the preoperative airway assessment. The patients were randomized into the following groups: group S was placed in the sniffing position, and group R was placed in the ramped position during direct laryngoscopy. The primary outcome was successful endotracheal intubation and the secondary measure was laryngeal view in the ramped or sniffing position when the operating table was placed at two different heights. Group R showed a higher rate of successful endotracheal intubation and better laryngeal view than group S (P < 0.05). The rate of successful endotracheal intubation was higher in group R than in group S at both heights of the operating table; but, it was not different within each group. Laryngeal view was not different between the two groups and within each group when the two heights of the operating table were used. Fully trained and experienced attending anesthesiologists achieved a higher rate of successful endotracheal intubation than less experienced residents in group R (P < 0.05) but not in group S. Ramped position and clinical experience can be important factors for laryngeal view and success rate of endotracheal intubation in patients with an expected difficult intubation.
Capella, Jeannette; Smith, Stephen; Philp, Allan; Putnam, Tyler; Gilbert, Carol; Fry, William; Harvey, Ellen; Wright, Andi; Henderson, Krista; Baker, David; Ranson, Sonya; Remine, Stephen
We investigated these questions: Does formal team training improve team behaviors in the trauma resuscitation bay? If yes, then does improved teamwork lead to more efficiency in the trauma bay and/or improved clinical outcomes? This intervention study used a pretraining/posttraining design. The intervention was TeamSTEPPS augmented by simulation. The evaluation instrument, which was the Trauma Team Performance Observation Tool (TPOT), was used by trained evaluators to assess teams' performance during trauma resuscitations. From November 2008 to February 2009, a convenience sample (n = 33) of trauma resuscitations was evaluated. From February to April 2009, team training was conducted. From May to July 2009, another sample (n = 40) of resuscitations were evaluated. Clinical data were gathered from our trauma registry. The clinical parameters included time from arrival to computed tomography (CT) scanner, arrival to intubation, arrival to operating room, arrival to Focused Assessment Sonography in Trauma (FAST) examination, time in emergency department (ED), hospital length of stay (LOS), intensive care unit LOS, complications, and mortality. Comparing pretraining and posttraining resuscitations, we calculated means, standard deviations, and p values for teamwork ratings and clinical parameters, and we determined significance using the independent samples t-test. Level I Trauma Center. The trauma team included surgery residents, faculty, and nurses. Our trauma team showed significant improvement in all teamwork domain ratings and overall ratings from pretraining to posttraining-leadership (2.87-3.46, p = 0.003), situation monitoring (3.30-3.91, p = 0.009), mutual support (3.40-3.96, p = 0.004), communication (2.90-3.46, p = 0.001), and overall (3.12-3.70, p < 0.001). The times from arrival to the CT scanner (26.4-22.1 minutes, p = 0.005), endotracheal intubation (10.1-6.6 minutes, p = 0.49) and the operating room (130.1-94.5 minutes, p = 0.021) were decreased
Mohta, Medha; Sethi, A K; Tyagi, Asha; Mohta, Anup
The clinician manages trauma patients in the emergency room, operation theatre, intensive care unit and trauma ward with an endeavour to provide best possible treatment for physical injuries. At the same time, it is equally important to give adequate attention to behavioural and psychological aspects associated with the event. Knowledge of the predisposing factors and their management helps the clinician to prevent or manage these psychological problems. Various causes of psychological disturbances in trauma patients have been highlighted. These include pain, the sudden and unexpected nature of events and the procedures and interventions necessary to resuscitate and stabilise the patient. The ICU and trauma ward environment, sleep and sensory deprivation, impact of injury on CNS, medications and associated pre-morbid conditions are also significant factors. Specific problems that concern the traumatised patients are helplessness, humiliation, threat to body image and mental symptoms. The patients react to these stressors by various defence mechanisms like conservation withdrawal, denial, regression, anger, anxiety and depression. Some of them develop delirium or even more severe problems like acute stress disorder or post-traumatic stress disorder. Physical, pharmacological or psychological interventions can be performed to prevent or minimise these problems in trauma patients. These include adequate pain relief, prevention of sensory and sleep deprivation, providing familiar surroundings, careful explanations and reassurance to the patient, psychotherapy and pharmacological treatment whenever required.
Ydemann, M; Rovsing, L; Lindekaer, A L; Olsen, K S
Several potential problems can arise from airway management in morbidly obese patients, including difficult mask ventilation and difficult intubation. We hypothesised that endotracheal intubation of morbidly obese patients would be more rapid using the GlideScope(®) (GS) (Verathon Inc Corporate Headquarters, Bothell, WA, USA) than with the Fastrach™ (FT) (The Laryngeal Mask Company Ltd, Le Rocher, Victoria, Mahe, Seychelles). One hundred patients who were scheduled for bariatric surgery were randomised to tracheal intubation using either a GS or an FT. The inclusion criteria were age 18-60 years and a body mass index of ≥ 35 kg/m(2) . The primary end point was intubation time, and if intubation was not achieved after two attempts, the other method was used for the third attempt. The mean intubation time was 49 s using the GS and 61 s using the FT (P = 0.86). A total of 92% and 84% of the patients were intubated on the first attempt using the GS and the FT, respectively. One tracheal intubation failed on the second attempt when the GS was used, and five failed on the second attempt when the FT was used. There were no incidents of desaturation and no differences between the groups in terms of mucosal damage or intubation difficulty. We experienced one oesophageal intubation using GS and six oesophageal intubations in five patients using FT. There was no difference between the pain scores or incidence of post-operative hoarseness associated with the two intubation techniques. No significant difference between the two methods was found. The GS and the FT may therefore be considered to be equally good when intubating morbidly obese patients. © 2012 The Authors. Acta Anaesthesiologica Scandinavica © 2012 The Acta Anaesthesiologica Scandinavica Foundation.
Murthi, Sarah B; Dutton, Richard P; Edelman, Bennett B; Scalea, Thomas M; Hess, John R
Injured patients stress the transfusion service with frequent demands for uncrossmatched red cells and plasma, occasional requirements for large amounts of blood products and the need for new and better blood products. Transfusion services stress trauma centers with demands for strict accountability for individual blood component units and adherence to indications in a clinical field where research has been difficult, and guidance opinion-based. New data suggest that the most severely injured patients arrive at the trauma center already coagulopathic and that these patients benefit from prompt, specific, corrective treatment. This research is clarifying trauma system requirements for new blood products and blood-product usage patterns, but the inability to obtain informed consent from severely injured patients remains an obstacle to further research. PMID:21083009
Tsukamoto, Masanori; Yokoyama, Takeshi
Apert syndrome is a rare autosomal dominant disorder characterized by craniofacial abnormalities, craniosynostosis and syndactyly. Nasotracheal intubation for a patient with Apert syndrome can be a challenge because of abnormal facial anatomy. We experienced the anesthetic management of a patient with Apert syndrome who underwent partial resection of mandible and cleft palate repair with nasotracheal intubation. Nasotracheal intubation using a gastric tube and extubation using an airway exchange catheter proved useful in this case of airway compromise. PMID:26398130
Tsukamoto, Masanori; Yokoyama, Takeshi
Apert syndrome is a rare autosomal dominant disorder characterized by craniofacial abnormalities, craniosynostosis and syndactyly. Nasotracheal intubation for a patient with Apert syndrome can be a challenge because of abnormal facial anatomy. We experienced the anesthetic management of a patient with Apert syndrome who underwent partial resection of mandible and cleft palate repair with nasotracheal intubation. Nasotracheal intubation using a gastric tube and extubation using an airway exchange catheter proved useful in this case of airway compromise.
Peiris, Kawshala; Frerk, Chris
Securing the airway is a core skill in anaesthesia, the gold standard of which is tracheal intubation. Normally this is achieved after induction of anaesthesia. However, some circumstances demand an awake approach. Awake intubation can be achieved via several methods. Using the fibreoptic laryngoscope is the most widely used technique in the UK with minimal patient discomfort and a wide margin of safety. When compared with attempts at difficult direct laryngoscopy, awake fibreoptic intubation provides excellent cardiovascular stability when performed under good topical anaesthesia and conscious sedation. Understanding the equipment used as well as preparing the patient and being aware of potential pitfalls are important elements to performing a successful awake intubation.
Barak, Michal; Bahouth, Hany; Leiser, Yoav; Abu El-Naaj, Imad
According to the Advanced Trauma Life Support recommendations for managing patients with life-threatening injuries, securing the airway is the first task of a primary caregiver. Airway management of patients with maxillofacial trauma is complex and crucial because it can dictate a patient's survival. Securing the airway of patients with maxillofacial trauma is often extremely difficult because the trauma involves the patient's airway and their breathing is compromised. In these patients, mask ventilation and endotracheal intubation are anticipated to be difficult. Additionally, some of these patients may not yet have been cleared of a cervical spine injury, and all are regarded as having a full stomach and having an increased risk of regurgitation and pulmonary aspiration. The requirements of the intended maxillofacial operation may often preclude the use of an oral intubation tube, and alternative methods for securing the airway should be considered before the start of the surgery. In order to improve the clinical outcome of patients with maxillofacial trauma, cooperation between maxillofacial surgeons, anesthesiologists, and trauma specialists is needed. In this review, we discuss the complexity and difficulties of securing the airway of patients with maxillofacial trauma and present our approach for airway management of such patients.
Barak, Michal; Bahouth, Hany; Leiser, Yoav; Abu El-Naaj, Imad
According to the Advanced Trauma Life Support recommendations for managing patients with life-threatening injuries, securing the airway is the first task of a primary caregiver. Airway management of patients with maxillofacial trauma is complex and crucial because it can dictate a patient's survival. Securing the airway of patients with maxillofacial trauma is often extremely difficult because the trauma involves the patient's airway and their breathing is compromised. In these patients, mask ventilation and endotracheal intubation are anticipated to be difficult. Additionally, some of these patients may not yet have been cleared of a cervical spine injury, and all are regarded as having a full stomach and having an increased risk of regurgitation and pulmonary aspiration. The requirements of the intended maxillofacial operation may often preclude the use of an oral intubation tube, and alternative methods for securing the airway should be considered before the start of the surgery. In order to improve the clinical outcome of patients with maxillofacial trauma, cooperation between maxillofacial surgeons, anesthesiologists, and trauma specialists is needed. In this review, we discuss the complexity and difficulties of securing the airway of patients with maxillofacial trauma and present our approach for airway management of such patients. PMID:26161411
Kirkpatrick, Andrew W.; Chun, Rosaleen; Brown, Ross; Simons, Richard K.
Hypothermia has profound effects on every system in the body, causing an overall slowing of enzymatic reactions and reduced metabolic requirements. Hypothermic, acutely injured patients with multisystem trauma have adverse outcomes when compared with normothermic control patients. Trauma patients are inherently predisposed to hypothermia from a variety of intrinsic and iatrogenic causes. Coagulation and cardiac sequelae are the most pertinent physiological concerns. Hypothermia and coagulopathy often mandate a simplified approach to complex surgical problems. A modification of traditional classification systems of hypothermia, applicable to trauma patients is suggested. There are few controlled investigations, but clinical opinion strongly supports the active prevention of hypothermia in the acutely traumatized patient. Preventive measures are simple and inexpensive, but the active reversal of hypothermia is much more complicated, often invasive and controversial. The ideal method of rewarming is unclear but must be individualized to the patient and is institution specific. An algorithm reflecting newer approaches to traumatic injury and technical advances in equipment and techniques is suggested. Conversely, hypothermia has selected clinical benefits when appropriately used in cases of trauma. Severe hypothermia has allowed remarkable survivals in the course of accidental circulatory arrest. The selective application of mild hypothermia in severe traumatic brain injury is an area with promise. Deliberate circulatory arrest with hypothermic cerebral protection has also been used for seemingly unrepairable injuries and is the focus of ongoing research. PMID:10526517
Kwak, Hyun Jeong; Lee, Sook Young; Lee, Su Youn; Kim, Yong Beom; Kim, Jong Yeop
Abstract Background: During McGrath videolaryngoscope (VL) intubation, a styletted endotracheal tube maintaining an upward distal tip angle is recommended by some manufacturers. However, a styletted endotracheal tube can elicit rare but potentially serious complications. The purpose of this study was to demonstrate that a nonstyletted tube with exaggerated curvature would be noninferior to a styletted tube for orotracheal intubation using McGrath VL in patients with expected normal airway, by comparing the time to intubation and ease of intubation. Methods: One hundred forty patients, ages 19 to 70 years (American Society of Anesthesiologists physical status I–II), undergoing tracheal intubation for elective surgery were randomly allocated to the nonstylet group (n = 70) or the stylet group (n = 70). Anesthesia induction consisted of propofol, remifentanil, and rocuronium. The primary outcome was time to intubation assessed by a blind observer. Cormack and Lehane glottic grade, easy of intubation, and intubation difficulty score (IDS) were also assessed. Results: Median time to intubation [interquartile range] was not different between the nonstylet group and the stylet group (26 [24–32.5] s vs 27 [25–31] s, P = 0.937). There was no significant in median IDS between the nonstylet group and the stylet group (P = 0.695). Conclusion: This study shows that a nonstyletted endotracheal tube with exaggerated curvature has a similar performance to a styletted tube with a hockey-stick curvature during intubation using McGrath VL regarding time taken to successful intubation and easiness of intubation. PMID:27902612
Jones, Andrew; Bilton, Diana; Evans, Timothy W; Finney, Simon J
Acute severe clinical deterioration of patients with cystic fibrosis (CF) may mandate endotracheal intubation. The benefits of intubation were evaluated by examining which pre-admission parameters were associated with intensive care unit (ICU) outcome and assessing the potential benefits of intubation for survivors in terms of time from ICU discharge to death. A retrospective analysis of data from a single centre was undertaken. Thirty patients required intubation on 34 occasions (8 per 1000 admissions). Eleven patients died in ICU and 7 after ICU but not hospital discharge. Fifty-nine per cent of 22 patients intubated for pneumothorax and/or haemoptysis survived to hospital discharge. Of the twelve intubated for infective exacerbations, 33% survived to hospital discharge. Those who died after hospital discharge survived 447 days. There were no significant differences for survivors in reasons for intubation, colonizing organism, frequency of infective exacerbations, severity of illness or pulmonary physiology. Osteoporosis and a greater fall in body mass index over the 24 months prior were more frequent in non-survivors. Patients with CF developing haemoptysis and/or pneumothorax should be admitted to ICU and intubated promptly, should this be required. Chronic disease markers may be more relevant prognostically than rates of hospitalization or forced expiratory volume in 1 s decline which should not be bars to invasive ventilation. © 2013 The Authors. Respirology © 2013 Asian Pacific Society of Respirology.
Comparative study of heart rate responses to laryngoscopic endotracheal intubation and to endotracheal intubation using intubating laryngeal mask airway under general anaesthesia in patients with pure mitral stenosis for closed mitral commissurotomy.
Das, Soumi; Gupta, Sampa Dutta; Goswampi, Anupam; Kundu, Kanak Kanti
The various drugs and methods studied in an attempt to curb the haemodynamic stress response associated with conventional laryngoscopic endotracheal intubation have not been found to be ompletely satisfactory. The rise in heart rate can be detrimental to patients with mitral stenosis. This study was aimed to compare the heart rate responses to endotracheal intubation using conventional laryngoscope and with the help of intubating laryngeal mask airway (ILMA) in patients with isolated mitral stenosis. Thirty-four adult patients of either sex, aged between 18 and 40 years with isolated mitral stenosis to undergo closed mitral commissurotomy were randomly allocated into two groups : Group A (n=17)- To be intubated using laryngoscopy. Group B (n=17)- To be intubated with the help of ILMA. The heart rate was recorded immediately preinduction, just prior to introducing the intubating device and postintubation every minute up to first 5 minutes. On applying statistical tests, it was found that the median heart rate values in group A at 2, 3, 4 and 5 minutes postintubation were significantly higher than in group B (p<0.05). Although use of both laryngosope and ILMA for endotracheal intubation was associated with rise in heart rate, the rise was less with ILMA compared to laryngoscope. Hence, it can be concluded that use of ILMA may be a preferable device for endotracheal intubation laryngoscopy in patients with isolated mitral stenosis.
Lee, Ju-Hwan; Jung, Hoe-Chang; Shim, Ji-Hoon
Background Optimal head and neck positioning and clinical experience are important factors for successful endotracheal intubation in patients with a difficult airway. This study aimed to investigate the rate of successful endotracheal intubation between the sniffing and ramped positions in patients with an expected difficult intubation. Methods The study included 204 patients with an expected difficult intubation (airway difficulty score ≥ 8) based on the preoperative airway assessment. The patients were randomized into the following groups: group S was placed in the sniffing position, and group R was placed in the ramped position during direct laryngoscopy. The primary outcome was successful endotracheal intubation and the secondary measure was laryngeal view in the ramped or sniffing position when the operating table was placed at two different heights. Results Group R showed a higher rate of successful endotracheal intubation and better laryngeal view than group S (P < 0.05). The rate of successful endotracheal intubation was higher in group R than in group S at both heights of the operating table; but, it was not different within each group. Laryngeal view was not different between the two groups and within each group when the two heights of the operating table were used. Fully trained and experienced attending anesthesiologists achieved a higher rate of successful endotracheal intubation than less experienced residents in group R (P < 0.05) but not in group S. Conclusions Ramped position and clinical experience can be important factors for laryngeal view and success rate of endotracheal intubation in patients with an expected difficult intubation. PMID:25844128
Carrick, Matthew M.; Leonard, Jan; Slone, Denetta S.; Mains, Charles W.
Hemorrhagic shock is a principal cause of death among trauma patients within the first 24 hours after injury. Optimal fluid resuscitation strategies have been examined for nearly a century, more recently with several randomized controlled trials. Hypotensive resuscitation, also called permissive hypotension, is a resuscitation strategy that uses limited fluids and blood products during the early stages of treatment for hemorrhagic shock. A lower-than-normal blood pressure is maintained until operative control of the bleeding can occur. The randomized controlled trials examining restricted fluid resuscitation have demonstrated that aggressive fluid resuscitation in the prehospital and hospital setting leads to more complications than hypotensive resuscitation, with disparate findings on the survival benefit. Since the populations studied in each randomized controlled trial are slightly different, as is the timing of intervention and targeted vitals, there is still a need for a large, multicenter trial that can examine the benefit of hypotensive resuscitation in both blunt and penetrating trauma patients. PMID:27595109
Ollerton, J E; Parr, M J A; Harrison, K; Hanrahan, B; Sugrue, M
Background: Emergency airway management for trauma adults is practised by physicians from a range of training backgrounds and with differing levels of experience. The indications for intubation and technique employed are factors that vary within EDs and between hospitals. Objectives: To provide practical evidence based guidance for airway management in trauma resuscitation: first for the trauma adult with potential cervical spine injury and second the management when a difficult airway is encountered at intubation. Search strategy and methodology: Full literature search for relevant articles in Medline (1966–2003), EMBASE (1980–2003), and the Cochrane Central Register of Controlled Trials. Relevant articles relating to adults and written in English language were appraised. English language abstracts of foreign articles were included. Studies were critically appraised on a standardised data collection sheet to assess validity and quality of evidence. The level of evidence was allocated using the methods of the Australian National Health and Medical Research Council. PMID:16373795
Ollerton, J E; Parr, M J A; Harrison, K; Hanrahan, B; Sugrue, M
Emergency airway management for trauma adults is practised by physicians from a range of training backgrounds and with differing levels of experience. The indications for intubation and technique employed are factors that vary within EDs and between hospitals. To provide practical evidence based guidance for airway management in trauma resuscitation: first for the trauma adult with potential cervical spine injury and second the management when a difficult airway is encountered at intubation. Full literature search for relevant articles in Medline (1966-2003), EMBASE (1980-2003), and the Cochrane Central Register of Controlled Trials. Relevant articles relating to adults and written in English language were appraised. English language abstracts of foreign articles were included. Studies were critically appraised on a standardised data collection sheet to assess validity and quality of evidence. The level of evidence was allocated using the methods of the Australian National Health and Medical Research Council.
Arteau-Gauthier, Isabelle; Leclerc, Jacques E; Godbout, Audrey
To find predictors of a difficult intubation in infants with an isolated or a syndromic cleft lip/palate. Retrospective review: single-blind trial. Tertiary care centre. A total of 145 infants born with cleft lip/palate were enrolled. Three clinical and seven lip/palate anatomic parameters were evaluated. The grade of intubation was determined by the anesthesiologist at the time of the labioplasty/staphylorrhaphy surgery at 3 and 10 months, respectively. Intubation grade. The relative risk of a difficult intubation in the cleft lip, cleft palate without the Pierre Robin sequence, cleft lip-palate, and cleft palate with Pierre Robin sequence groups was 0, 2.7, 10, and 23%, respectively. The infants born with the Pierre Robin sequence had a statistically significant higher intubation grade. The degree of difficulty was increased in cases with early airway and feeding problems (p < .0001). Within the group of cleft palate patients without any lip malformation, a wider cleft was associated with a higher intubation grade with statistical significance (p = .0323). Infants born with Pierre Robin sequence have a statistically significantly higher risk of difficult intubation. Within this group, of all the studied factors, a clinical history of early airway and feeding problems was the best predictor of a difficult endotracheal intubation. In cleft palate patients without any cleft lip, larger width of the cleft is also a significant predictor.
Ali, J; Adam, R U; Gana, T J; Williams, J I
We have previously demonstrated a significant improvement in trauma patient outcome after the Advanced Trauma Life Support (ATLS) program in Trinidad and Tobago. In January of 1992, a Prehospital Trauma Life Support (PHTLS) program was also instituted. This study assessed trauma patient outcome after the PHTLS program. Morbidity (length of stay and degree of disability), mortality, injury severity score, mechanism of injury, age, and sex among all adult trauma patients transported by ambulance to the major trauma hospital were assessed between July of 1990 to December of 1991 (pre-PHTLS, n = 332) and January of 1994 to June of 1995 (post-PHTLS, n = 350). Age, sex distribution, percentage blunt injury, and injury severity score were similar for both groups. Mortality pre-PHTLS (15.7%) was greater than post-PHTLS (10.6%). Length of stay and disability were statistically significantly decreased post-PHTLS. Age, injury severity score, and mechanism of injury were positively correlated with mortality in both periods. The previously reported post-ATLS mortality was similar to the pre-PHTLS mortality. Post-PHTLS mortality and morbidity were significantly decreased, suggesting a positive impact of the PHTLS program on trauma patient outcome.
Eizadi-Mood, Nastaran; Yaraghi, Ahmad; Alikhasi, Mahsa; Jabalameli, Mitra; Farsaei, Shadi; Sabzghabaee, Ali Mohammad
Some opioid-poisoned patients do not respond appropriately to naloxone; consequently, intubation is required. Although various measures have been used to evaluate the level of consciousness of poisoned patients, no study has assessed the role of the bispectral index (BIS) to ascertain the depth of anesthesia in opioid-poisoned patients who require endotracheal intubation. To compare BIS scores between opioid-poisoned patients with and without intubation, and to determine the BIS cut-off point for endotracheal intubation in these patients. In the present cross-sectional study, conducted in an Iranian university referral hospital for poisoning emergencies between 2012 and 2013, opioid-poisoned patients (n=41) were divided into two groups according to their requirement for endotracheal intubation. BIS analyses were performed at the time of admission and at the time of intubation for those who required it. In addition, electromyography and signal quality index were evaluated for all patients at the time of admission, and cardiorespiratory monitoring was performed during the hospitalization period. Using ROC curves, and sensitivity and specificity analyses, the optimal BIS cut-off point for prediction of intubation of these patients was determined. The optimal cut-off point for prediction of intubation was BIS ≤78, which had a sensitivity of 86.7% (95% CI 66.1 to 98.8) and specificity of 88.5% (95% CI 73.9% to 98.8%); the positive and negative predictive values were 81.2 % and 92%, respectively. BIS may be considered an acceptable index to determine the need for intubation in opioid-poisoned patients whose response to naloxone is inadequate.
Barker, Jennifer; Martino, Rosemary; Reichardt, Beatrix; Hickey, Edward J.; Ralph-Edwards, Anthony
Background Cardiac surgery is frequently associated with prolonged endotracheal intubation. Because oral feeding is an important component of patient recovery after high-risk surgery, we sought to examine the contribution of dysphagia in the recuperation process after prolonged endotracheal intubation. Methods All 254 adult patients who survived cardiac surgery between 2001 and 2004 at the Toronto General Hospital and in whom endotracheal intubation lasted for 48 hours or longer were eligible for our retrospective review. We used multivariate regression analysis and parametric modelling to identify patient-specific characteristics associated with postextubation dysphagia and the subsequent resumption of normal oral feeding. Results Dysphagia was diagnosed in 130 (51%) patients. Incremental factors associated with an increased risk for postextubation dysphagia included duration of endotracheal intubation (p < 0.001), the occurrence of a perioperative cerebrovascular event (p = 0.014) and the presence of perioperative sepsis (p = 0.016). Neither preoperative patient risks nor index procedural characteristics were influential factors. The occurrence of dysphagia (p < 0.001) and the duration of endotracheal intubation (p < 0.001) were the only independent factors associated with a delayed return to normal oral feeding. In contrast, several independent factors were associated with a delay to hospital discharge, including the presence of dysphagia (p < 0.001), occurrence of perioperative stroke (p < 0.001), duration of endotracheal intubation (p < 0.001) and number of endotracheal intubation events (p < 0.006). Conclusion Dysphagia is more common in patients with prolonged endotracheal intubation after cardiac surgery than has previously been reported. The duration of postoperative endotracheal intubation is a strong predictor of subsequent dysphagia that both prolongs the return to normal oral feeding and delays subsequent hospital discharge. Patient-or procedure
Barker, Jennifer; Martino, Rosemary; Reichardt, Beatrix; Hickey, Edward J; Ralph-Edwards, Anthony
Cardiac surgery is frequently associated with prolonged endotracheal intubation. Because oral feeding is an important component of patient recovery after high-risk surgery, we sought to examine the contribution of dysphagia in the recuperation process after prolonged endotracheal intubation. All 254 adult patients who survived cardiac surgery between 2001 and 2004 at the Toronto General Hospital and in whom endotracheal intubation lasted for 48 hours or longer were eligible for our retrospective review. We used multivariate regression analysis and parametric modelling to identify patient-specific characteristics associated with postextubation dysphagia and the subsequent resumption of normal oral feeding. Dysphagia was diagnosed in 130 (51%) patients. Incremental factors associated with an increased risk for postextubation dysphagia included duration of endotracheal intubation (p < 0.001), the occurrence of a perioperative cerebrovascular event (p = 0.014) and the presence of perioperative sepsis (p = 0.016). Neither preoperative patient risks nor index procedural characteristics were influential factors. The occurrence of dysphagia (p < 0.001) and the duration of endotracheal intubation (p < 0.001) were the only independent factors associated with a delayed return to normal oral feeding. In contrast, several independent factors were associated with a delay to hospital discharge, including the presence of dysphagia (p < 0.001), occurrence of perioperative stroke (p < 0.001), duration of endotracheal intubation (p < 0.001) and number of endotracheal intubation events (p < 0.006). Dysphagia is more common in patients with prolonged endotracheal intubation after cardiac surgery than has previously been reported. The duration of postoperative endotracheal intubation is a strong predictor of subsequent dysphagia that both prolongs the return to normal oral feeding and delays subsequent hospital discharge. Patient-or procedure-specific factors are not good predictors. To
Mashour, George A; Stallmer, Meghan L; Kheterpal, Sachin; Shanks, Amy
Cervical spine function is of paramount importance to the management of the airway. What has not been reported in the literature is a systematic analysis of airway management in patients with cervical spine limitation (CSL) compared with their normal counterparts or a predictive model of difficult intubation (DI) in patients with CSL. We reviewed the electronic charts of 14,053 patients and identified those with CSL based on the preoperative airway evaluation. We then compared various airway parameters in patients with CSL to those without CSL and further assessed risk factors for DI in patients with CSL. We develop a predictive model on the basis of multivariate analysis of such risk factors. Of the cohort studied, 1145 or 8.1% of patients were documented as having some form of CSL, with an average age of 60. In the <60 population, CSL was associated with a statistically significant increase in difficult and impossible mask ventilation, difficult laryngoscopy, and DI. In the population > or =60 years old, CSL was associated with a statistically significant increase in difficult laryngoscopy and DI. There were no significant differences in mask ventilation between normal and CSL patients in the population > or =60. Multivariate modeling revealed age > or =48, Mallampati 3 or 4, and thyromental distance <6 cm as independent preoperative risk factors of DI in patients with CSL. A predictive model is developed on the basis of these findings. Limitations of cervical spine mobility are relatively common and increase the incidence of difficulty throughout the spectrum of airway management. DI should be anticipated in CSL patients who are > or =48 years old, have a Mallampati class 3 or 4, and a thyromental distance of <6 cm.
Ghatak, Tanmoy; Samanta, Sukhen; Baronia, Arvind Kumar
Insertion of a nasogastric tube in an unconscious intubated patient may be difficult as they cannot follow the swallowing instructions, and therefore has a high first attempt failure rate. We describe here a new technique to insert nasogastric tube in an unconscious intubated patient by neck flexion and using angiography catheter as a stylet and manipulating the cricoid ring of trachea for easy passage of nasogastric tube. The technique is easy and helpful for nasogastric insertion in unconscious intubated patients. Additionally, it neither alters vital responses nor increases intracranial pressure like with laryngoscopy.
Ghatak, Tanmoy; Samanta, Sukhen; Baronia, Arvind Kumar
Background: Insertion of a nasogastric tube in an unconscious intubated patient may be difficult as they cannot follow the swallowing instructions, and therefore has a high first attempt failure rate. Aim and Methods: We describe here a new technique to insert nasogastric tube in an unconscious intubated patient by neck flexion and using angiography catheter as a stylet and manipulating the cricoid ring of trachea for easy passage of nasogastric tube. Results and Conclusions: The technique is easy and helpful for nasogastric insertion in unconscious intubated patients. Additionally, it neither alters vital responses nor increases intracranial pressure like with laryngoscopy. PMID:23378961
Freij, R M; Mullett, S T
Complications following nasogastric intubation in patients with basal skull fractures are well documented. This report is of a rare cause of inadvertent intracranial placement of a nasogastric (NG) tube in a non-trauma patient. The patient subsequently died. The use of NG tubes, their place in airway management, and lessons to be learned from this case are discussed. Images Figure 1 Figure 2 p46-b PMID:9023626
Intubation Biomechanics: Laryngoscope Force and Cervical Spine Motion during Intubation in Cadavers—Cadavers vs. Patients, the Effect of Repeated Intubations, and the Effect of Type II Odontoid Fracture on C1-C2 Motion
Hindman, Bradley J.; From, Robert P.; Fontes, Ricardo B.; Traynelis, Vincent C.; Todd, Michael M.; Zimmerman, M. Bridget; Puttlitz, Christian M.; Santoni, Brandon G.
Introduction The aims of this study were to characterize: 1) cadaver intubation biomechanics, including the effect of repeated intubations; and 2) the relationship between intubation force and the motion of an injured cervical segment. Methods Fourteen cadavers were serially intubated using force-sensing Macintosh and Airtraq laryngoscopes in random order, with simultaneous cervical spine motion recorded with lateral fluoroscopy. Motion of the C1-C2 segment was measured in the intact and injured state (Type II odontoid fracture). Injured C1-C2 motion was proportionately corrected for changes in intubation forces that occurred with repeated intubations. Results Cadaver intubation biomechanics were comparable to those of patients in all parameters other than C2-C5 extension. In cadavers, intubation force (Set 2/Set1 force ratio = 0.61 [95% CI: 0.46, 0.81]; P=0.002) and Oc-C5 extension (Set 2 –Set 1 difference = −6.1 degrees [95% CI: −11.4, −0.9]; P=0.025) decreased with repeated intubations. In cadavers, C1-C2 extension did not differ: 1) between intact and injured states; or 2) in the injured state, between laryngoscopes (with and without force correction). With force correction, in the injured state, C1-C2 subluxation was greater with the Airtraq (mean difference 2.8 mm [95% CI: 0.7, 4.9 mm]; P=0.004). Discussion With limitations, cadavers may be clinically relevant models of intubation biomechanics and cervical spine motion. In the setting of a Type II odontoid fracture, C1-C2 motion during intubation with either the Macintosh or Airtraq does not appear to greatly exceed physiologic values or to have a high likelihood of hyperextension or direct cord compression. PMID:26288267
Intubation Biomechanics: Laryngoscope Force and Cervical Spine Motion during Intubation in Cadavers-Cadavers versus Patients, the Effect of Repeated Intubations, and the Effect of Type II Odontoid Fracture on C1-C2 Motion.
Hindman, Bradley J; From, Robert P; Fontes, Ricardo B; Traynelis, Vincent C; Todd, Michael M; Zimmerman, M Bridget; Puttlitz, Christian M; Santoni, Brandon G
The aims of this study are to characterize (1) the cadaver intubation biomechanics, including the effect of repeated intubations, and (2) the relation between intubation force and the motion of an injured cervical segment. Fourteen cadavers were serially intubated using force-sensing Macintosh and Airtraq laryngoscopes in random order, with simultaneous cervical spine motion recorded with lateral fluoroscopy. Motion of the C1-C2 segment was measured in the intact and injured state (type II odontoid fracture). Injured C1-C2 motion was proportionately corrected for changes in intubation forces that occurred with repeated intubations. Cadaver intubation biomechanics were comparable with those of patients in all parameters other than C2-C5 extension. In cadavers, intubation force (set 2/set 1 force ratio = 0.61; 95% CI, 0.46 to 0.81; P = 0.002) and Oc-C5 extension (set 2 - set 1 difference = -6.1 degrees; 95% CI, -11.4 to -0.9; P = 0.025) decreased with repeated intubations. In cadavers, C1-C2 extension did not differ (1) between intact and injured states; or (2) in the injured state, between laryngoscopes (with and without force correction). With force correction, in the injured state, C1-C2 subluxation was greater with the Airtraq (mean difference 2.8 mm; 95% CI, 0.7 to 4.9 mm; P = 0.004). With limitations, cadavers may be clinically relevant models of intubation biomechanics and cervical spine motion. In the setting of a type II odontoid fracture, C1-C2 motion during intubation with either the Macintosh or the Airtraq does not appear to greatly exceed physiologic values or to have a high likelihood of hyperextension or direct cord compression.
Tsutsui, T; Setoyama, K
We used Trachlight for blind orotracheal intubation (ordinary tracheal tube or Portex Blueline in 305 cases, and reinforced tube or Mallinckrodt Safety-Flex in 206 cases) for general anesthetic procedures, and evaluated its technical features along with related complications. With ordinary tubes, 93% of the patients could be intubated successfully at the first attempt. Unsuccessful intubation even at the third attempt occurred in 3 patients (1%). One patient was complicated with a long epiglottis and the cause was unknown in the other patients. With reinforced tubes, 83% of the patients could be intubated at the first attempt but 8 patients (4%) could not. Of them, four patients received too large reinforced tubes straightening the bending of the stylet. Each of the three patients had a narrow larynx, mandibular retraction or obese neck making transillumination difficult. In the remaining one patient, the cause was unknown. Complication found in 30% of the patients was sore throat that seemed severer than that caused by laryngoscope. One patient developed minor tracheal bleeding probably due to injury of the mucosa. The elevation of the blood pressure at intubation with this device was not as high as that by direct laryngoscopy. We conclude that Trachlight leads to intubation with a high success rate, and that care should be taken not to damage the tracheal mucosa by blind insertion.
Pang, Lei; Feng, Yan-Hua; Ma, Hai-Chun; Dong, Su
In the event of a high degree of airway obstruction, endotracheal intubation can be impossible and even dangerous, because it can cause complete airway obstruction, especially in patients with high tracheal lesions. However, a smaller endotracheal tube under the guidance of a bronchoscope can be insinuated past obstructive tumor in most noncircumferential cases. Here we report a case of successful fiberoptic bronchoscopy-assisted endotracheal intubation in a patient undergoing surgical resection of a large, high tracheal tumor causing severe tracheal stenosis. A 42-year-old Chinese man presented with dyspnea, intermittent irritable cough, and sleep deprivation for one and a half years. X-rays and computed tomography scan of the chest revealed an irregular pedunculated soft tissue mass within the tracheal lumen. The mass occupied over 90% of the lumen and caused severe tracheal stenosis. Endotracheal intubation was done to perform tracheal tumor resection under general anesthesia. After several failed conventional endotracheal intubation attempts, fiberoptic bronchoscopy-assisted intubation was successful. The patient received mechanical ventilation and then underwent tumor resection and a permanent tracheostomy. This case provides evidence of the usefulness of the fiberoptic bronchoscopy-assisted intubation technique in management of an anticipated difficult airway and suggests that tracheal intubation can be performed directly in patients with a tracheal tumor who can sleep in the supine position, even if they have occasional sleep deprivation and severe tracheal obstruction as revealed by imaging techniques.
Levitan, Richard M
Concern about patient safety and failed rapid sequence intubation has led to an increased awareness of potentially difficult laryngoscopy situations and algorithms promoting techniques in awake patients. Given the low overall incidence of failed laryngoscopy, however, prediction of difficult laryngoscopy has poor positive predictive value and uncertain clinical utility, especially in emergency settings. Non-rapid sequence intubation approaches have comparatively lower chances of intubation success, require more time, and are associated with more complications. As a specialty, emergency medicine has adopted rapid sequence intubation as the mainstay of emergency airway treatment for many appropriate reasons; the problem that must be addressed is how patient safety can be ensured while what is an inherently dangerous procedure is performed. A novel way to conceptualize patient risk and safety issues in rapid sequence intubation is to examine how inherent risk is managed in skydiving. Metaphorical lessons from skydiving that are applicable to rapid sequence intubation include (1) a redundancy of safety; (2) a methodic approach to primary chute deployment; (3) use of backup chutes that are fast, simple, and easy to deploy; (4) attention to monitoring; and (5) equipment vigilance. This article reviews how each of these lessons apply metaphorically to rapid sequence intubation, wherein the primary chute is laryngoscopy, the backup chute is rescue ventilation, and monitoring involves pulse oximetry.
Liu, Jin-Jen; Chou, Fan-Hao; Yeh, Shu-Hui
This study was conducted to investigate the basic needs and communication difficulties of intubated patients in surgical intensive care units (ICUs) and to identify predictors of the basic needs from the patient characteristics and communication difficulties. In this descriptive correlational study, 80 surgical ICU patients were recruited and interviewed using 3 structured questionnaires: demographic information, scale of basic needs, and scale of communication difficulties. The intubated patients were found to have moderate communication difficulties. The sense of being loved and belonging was the most common need in the intubated patients studied (56.00 standardized scores). A significantly positive correlation was found between communication difficulties and general level of basic needs (r = .53, P < .01), and another positive correlation was found between the length of stay in ICUs and the need for love and belonging (r = .25, P < .05). The basic needs of intubated patients could be significantly predicted by communication difficulties (P = .002), use of physical restraints (P = .010), lack of intubation history (P = .005), and lower educational level (P = .005). These 4 predictors accounted for 47% of the total variance in basic needs. The intubated patients in surgical ICUs had moderate basic needs and communication difficulties. The fact that the basic needs could be predicted by communication difficulties, physical restraints, and educational level suggests that nurses in surgical ICUs need to improve skills of communication and limit the use of physical restraints, especially in patients with a lower educational level.
Stewart, Robert; Perez, Ricardo; Musial, Bogdan; Lukens, Carrie; Adjepong, Yaw Amoateng; Manthous, Constantine A
High doses of sedating drugs are often used to manage critically ill patients with alcohol withdrawal syndrome. To describe outcomes and risks for pneumonia and endotracheal intubation in patients with alcohol withdrawal syndrome treated with high-dose intravenous sedatives and deferred endotracheal intubation. Observational cohort study of consecutive patients treated in the intensive care unit (ICU) of a university-affiliated, community hospital for alcohol withdrawal syndrome, where patients were not routinely intubated to receive high-dose or continuously infused sedating medications. We studied 188 patients hospitalized with alcohol withdrawal syndrome from 2008 through 2012 at one medical center. The mean age (SD) of the subjects was 50.8 ± 9.0 years and their mean ICU admission APACHE (Acute Physiology and Chronic Health Evaluation) II score was 6.2 ± 3.4. Thirty subjects (16%) developed pneumonia, and 38 (20.2%) required intubation. All of the 188 patients received lorazepam (median total dose, 42.5 mg), and 170 of 188 received midazolam, all but 2 by continuous intravenous infusion (median total dose, 527 mg; all administered in ICU); 19 received propofol (median total dose, 6,000 mg); and 19 received dexmedetomidine (median total dose, 1,075 mg). Intubated patients received substantially more benzodiazepine (median total dose, 761 mg of lorazepam equivalent vs. 229 mg for subjects in the nonintubated group; P < 0.0001). Endotracheal intubation was associated with pneumonia and higher acuity of illness (APACHE II score, >10). Intubated patients had a longer duration of hospital stay (median, 15 d vs. 6 d; P ≤ 0.0001). One patient did not survive hospitalization. In this single-center, observational study, where endotracheal intubation was deferred until aspiration or cardiopulmonary decompensation, treatment of alcohol withdrawal syndrome with high-dose, continuously infused sedating medications was not associated with excess morbidity
Yang, Dong; Deng, Xiao-Ming; Tong, Shi-Yi; Liu, Ju-Hui; Sui, Jing-Hu; Zhang, Yan-Ming; Liu, Jian-Hua; Wei, Ling-Xin; Xu, Kun-Lin
To evaluate the feasibility of the fibreoptic intubating laryngeal mask airway (LMA) CTrach (CTrach) in anticipated difficult airway caused by face and neck scar contracture. Totally 33 patients undergoing selective face and neck scar plastic surgery and requiring general anesthesia were enrolled in our study. After anesthesia induction, the CTrach was inserted and the viewer was attached, which allowed fibreoptic visualization of the larynx before and during passage of the tracheal tube through the vocal cords. The duration and the success rates of CTrach insertion, tracheal intubation, and CTrach removal were recorded. The view of glottis on viewer and the adjusting maneuvers for improving the laryngeal view were recorded. Noninvasive blood pressures and heart rates were recorded before and after anesthesia induction and at CTrach insertion, tracheal intubation, and CTrach removal. The CTrach was successfully inserted in all patients, among whom 4 patients succeeded at the second attempt. The full view of glottis were shown in 10 patients, while partial view and no view of glottis were shown in 8 and 15 patients, respectively. The good view of glottis was achieved by adjusting manoeuvres. Tracheal intubation via the CTrach was successful in 27 patients at the first attempt and in 6 patients at the second attempt. Hemodynamic changes during the performance with the CTrach were minimal. The CTrach can be easily inserted, with clear view and high success rate of tracheal intubation. Therefore, it is an effective way to resolve difficulty intubation caused by face and neck scar contracture.
Mathew, Deepak G; Ramachandran, Rashmi; Rewari, Vimi; Trikha, Anjan; Chandralekha
The aim of our study was to evaluate the success rate of fiberoptic-guided endotracheal intubation through an Intubating Laryngeal Mask Airway (ILMA), a Cobra Perilaryngeal Airway (Cobra PLA), and a C-Trach Laryngeal Mask Airway (C-Trach) in patients whose necks are stabilized in a hard cervical collar. One hundred and eighty ASA I-II patients were randomized to undergo endotracheal intubation after general anesthesia via an ILMA (group ILMA), a C-Trach (group C-Trach) or a Cobra PLA (group CPLA) with the application of an appropriately-sized hard cervical collar. A fiberoptic bronchoscope was used for intubation via the ILMA and Cobra PLA. Rate of successful insertion of an endotracheal tube through the three devices was the primary aim. Other parameters compared were time taken for device insertion, endotracheal intubation, hemodynamic changes, incidence of hypoxia, and mucosal injury during the procedure. The incidence of postoperative sore throat was also compared between the three groups. The success rates of intubation in the ILMA, C-Trach, and CPLA groups were 100, 100, and 98% respectively. The first-attempt success rate was significantly better with the C-Trach compared to Cobra PLA (100 vs. 85%, p < 0.05). The time taken for device insertion was significantly more with the Cobra PLA as compared to that taken with an ILMA or a C-Trach (35.7 vs. 30.3 and 27.5 s, respectively). Intubation through a C-Trach took the least amount of time (84.4 s) as compared to an ILMA (117.9 s) or a Cobra PLA (139.2 s). The incidence of hypoxia and airway morbidity was similar between the groups. The success rates of fiberoptic-guided endotracheal intubation through an ILMA and a Cobra PLA are similar to the success rate of intubation using a C-Trach in patients whose cervical spines are immobilized with a hard cervical collar.
Shirawi, Nehad; Arabi, Yaseen
A significant proportion of trauma patients require tracheostomy during intensive care unit stay. The timing of this procedure remains a subject of debate. The decision for tracheostomy should take into consideration the risks and benefits of prolonged endotracheal intubation versus tracheostomy. Timing of tracheostomy is also influenced by the indications for the procedure, which include relief of upper airway obstruction, airway access in patients with cervical spine injury, management of retained airway secretions, maintenance of patent airway and airway access for prolonged mechanical ventilation. This review summarizes the potential advantages of tracheostomy versus endotracheal intubation, the different indications for tracheostomy in trauma patients and studies examining early versus late tracheostomy. It also reviews the predictors of prolonged mechanical ventilation, which may guide the decision regarding the timing of tracheostomy. PMID:16356202
Bhangu, A; Hood, E; Datta, A; Mangaleshkar, S
Informed consent in the modern era is a common and important topic both for the well-informed patient and to prevent unnecessary litigation. However, the effectiveness of informed consent in trauma patients is an under-researched area. This paper aims to assess the differences in patient recall of the consent process and desire for information by performing a comparative analysis between orthopaedic trauma and elective patients. Information from 41 consecutive elective operations and 40 consecutive trauma operations was collected on the first post-operative day. 100% of elective patients and 90% of trauma patients knew what operation they had received (p = 0.06). Overall recall of complications was poor, but was significantly lower in trauma patients compared with elective patients (62% vs 22%, p<0.001). 30% of trauma patients desired more information about their operation compared to 12% of elective patients (p = 0.049), although only 35% of trauma patients wanted written as well as verbal explanations, compared to 85% of elective patients p<0.001). Overall 100% of elective and 90% of trauma patients were happy with the consent process (p = 0.06). Subset analysis of neck of femur compared to other trauma patients showed that the above factors were not significantly different between the two groups. Recall of complications in the trauma patients is significantly lower than in elective patients, although both groups scored poorly overall. Repeated verbal explanations should be reinforced with the option of additional information leaflets for trauma operations. Further research into the usefulness of DVDs for commonly performed operations is warranted, although official internet resources may be more cost-effective.
Hardcastle, T C; Goff, T
To audit indications for and practice (in terms of training/qualification) of definitive airway management compared with current UK practices. Consecutive observational study. Tygerberg Academic Hospital Trauma Service, Western Cape. All trauma patients either arriving intubated or requiring intubation at the Trauma unit during the period 1 - 31 August 2006. A data collection proforma was completed either at the time of intubation or from medical records. Results. Fifty-seven patients required definitive airway management. In the unit 32 patients (56%) were intubated by emergency medicine registrars or medical officers, with rapid sequence intubations (RSIs) in all 32 (100%). Seven patients (12.3%) were intubated by paramedics pre-hospital, and 18 patients (31.6%) were intubated at referring hospitals by non-anaesthetists. Endotracheal intubation was successful in 55 patients (96.4%). Two patients (3.6%) could not be intubated and therefore underwent surgical cricothyroidotomy at the unit. Clinical outcomes included 12 patients (21%) extubated for ward transfer, 7 patients (12.3%) admitted to an intensive care unit (ICU), 21 patients (36.8%) taken for surgery, and 17 patients (29.8%) died. Motor vehicle accident (MVA) was the predominant mechanism of injury, accounting for 30 (52.6%) patients, while 16 patients (28.1%) had penetrating injuries (gunshot and/or stab wounds), 6 patients (10.5%) had blunt trauma, and the remaining 5 patients (8.8%) suffered serious burns. The most common indication for intubation was a Glasgow Coma Score (GCS) of less than 8, typically in the polytrauma patient with suspected head injury due to MVA. Emergency doctors managed 100% of definitive airway in-hospital, and RSI was the favoured method. This differs greatly from the UK where non-anaesthetists only perform between 31% and 56% of trauma intubations, with the rest performed by anaesthetists. Outcome was, however, similar to that described in the literature.
Truong, Angela; Truong, Dam-Thuy
A considerable challenge arises when passage of an endotracheal tube between the teeth is impossible because of severe trismus and the presence of concomitant contraindications to nasotracheal intubation. We report a novel technique to circumvent the need for tracheostomy by using the retromolar space for oral fibreoptic intubation. A 50-yr-old female with a history of pharyngeal cancers treated with surgery and radiotherapy presented for right dacryocystorhinostomy. She had undergone left dacryocystorhinostomy after nasotracheal intubation one week earlier. This time, orotracheal intubation was requested since surgery would involve the right nostril and left nasal intubation might dislodge the recently placed nasolacrimal tube. Due to severe trismus, the patient's interincisor distance was only 9 mm, and it was impossible to pass a 6.0 mm endotracheal tube through that gap. A flexible bronchoscope loaded with a 6.0 mm tracheal tube was inserted through the retromolar space into the pharynx and maneuvered through the vocal cords for endotracheal intubation. The retromolar space is located between the last molar and the ascending ramus of the mandible. Even with complete mandibular occlusion, it is usually able to accommodate a 7.0 mm endotracheal tube. Despite its hidden location, it can be used successfully for orotracheal fibreoptic intubation. With practice, the expertise achieved in performing this technique will confer a much needed option for securing the airway in this challenging situation.
Darlong, Vanlal; Chandrashish, Chakravarty; Chandralekha; Mohan, Virender Kumar
Supraglottic airways (SGA) through which blind endotracheal intubation is made possible is an area of considerable interest. Our study aimed at comparing the Cobra Perilaryngeal Airway (CPLA) with the Intubating Laryngeal Mask Airway (ILMA) with regard to the performance of the former as a conduit for facilitating blind endotracheal intubation. American Society of Anesthesiologists (ASA) I-II patients consenting to the study, with no predictors of difficult airway, scheduled for elective surgery were randomized into two groups of 30 each. Anesthesia was induced with fentanyl, propofol and vecuronium. CPLA was inserted in Group I and ILMA in Group II. Fibreoptic scoring of the laryngeal view was done through the SGA. Blind intubation through either CPLA or ILMA was then carried out with cuffed polyvinyl chloride (PVC) tube in Group I and ILMA-tracheal tube in Group II. Demographic and surgical data were comparable between the two groups. The success rate of intubation (87% through CPLA and 90% through ILMA) (p value 1), number of attempts made and the fibreoptic scores (p value 0.12) were comparable between the two groups. Insertion time was significantly longer in Group I as compared with Group II (9 s vs. 4 s; p value 0.004). Trauma and sore throat were more common in Group I (p value -0.1, 0.19 respectively). Hemodynamic monitoring showed more tachycardia during CPLA insertion as compared with ILMA (p value 0.006). We conclude that CPLA can be used as an effective conduit for blind endotracheal intubation with cuffed PVC tube and has comparable efficacy in tracheal intubation as that with ILMA. Copyright © 2011. Published by Elsevier B.V.
Tantri, Aida Rosita; Firdaus, Riyadh; Salomo, Sahat Tumpal
Background Failure to maintain an adequate airway can lead to brain damage and death. To reduce the risk of difficulty in maintaining an airway during general anesthesia, there are several known predictors of difficult intubation. People with a Malay background have different craniofacial structures in comparison with other individuals. Therefore, different predictors should be used for patients of Malay race. Objectives The aim of this study was to determine the ability to predict difficult visualization of the larynx (DVL) in Malay patients based on several predictors, such as the modified Mallampati test (MMT), thyromental distance (TMD), and hyomental distance ratio (HMDR). Patients and Methods This cross-sectional study included 277 consecutive patients requiring general anesthesia. All subjects were evaluated using the MMT, TMD, and HMDR, and the cut-off points for the airway predictors were Mallampati III and IV, < 6.5 cm, and < 1.2, respectively. During direct laryngoscopy, the laryngeal view was graded using the Cormack-Lehane (CL) classification. CL grades III and IV were considered difficult visualization. The area under the curve (AUC), sensitivity, and specificity for each predictor were calculated both as sole and combined predictors. Logistic regression analysis was used to determine independent predictors of DVL. Results Difficulty in visualizing the larynx was found in 28 (10.1%) patients. The AUC, sensitivity, and specificity for the three airway predictors were as follows: MMT: 0.614, 10.7%, and 99.2%; HMDR: 0.743, 64.2%, and 74%; and TMD: 0.827, 82.1%, and 64.7%. The combination providing the best prediction in our study involved the MMT, HMDR, and TMD with an AUC, sensitivity, and specificity of 0.835, 60.7%, and 88.8%, respectively. Logistic regression analysis showed that the MMT, HMDR, and TMD were independent predictors of DVL. Conclusions The TMD, with a cut-off point of 65 mm, had superior diagnostic value compared with the HMDR and
Bauer, Philippe R; Gajic, Ognjen; Nanchal, Rahul; Kashyap, Rahul; Martin-Loeches, Ignacio; Sakr, Yasser; Jakob, Stephan M; François, Bruno; Wittebole, Xavier; Wunderink, Richard G; Vincent, Jean-Louis
The optimal timing of endotracheal intubation in critically ill patients requiring invasive mechanical ventilation remains undefined. In a secondary analysis of the large, prospective ICON database, we used a piecewise proportional hazards model to compare outcomes in patients who underwent intubation early (within two days after intensive care unit [ICU] admission) or later. After excluding 5340 patients already intubated on admission or with therapeutic limitation, 4729 patients were analyzed, of whom 4074 never underwent intubation. Of the remaining 655 patients, 449 underwent intubation early and 206 later. Despite similar severity scores on ICU admission, unadjusted ICU (27.6 vs. 18.2%) and hospital (33.3 vs. 23.4%) mortality rates were higher in patients intubated later than in those intubated earlier, as were ICU (9 [5-16] vs. 4 [2-9] days) and hospital (24 [9-35] vs. 13 [7-24] days) lengths-of-stay (all p<0.001). After adjustment, the hazard for ICU and hospital death was significantly greater >10days after ICU admission for patients intubated late. In this large cohort of critically ill patients requiring intubation, intubation >2days after admission was associated with increased mortality later in the hospital course. Copyright © 2017 Elsevier Inc. All rights reserved.
Kim, J S; Park, S Y; Min, S K; Kim, J H; Lee, S Y; Moon, B K
The Freeman-Sheldon syndrome is a congenital disease primarily affecting the facial, limb and respiratory muscles that give rise to classical clinical features including typical whistling face and short webbed neck associated with difficult intubation. We present successful awake nasotracheal intubation in a 6-year-old patient with typical clinical features of Freeman-Sheldon syndrome by using fiberoptic bronchoscope on two separate occasions.
Choi, Pamela M; Yu, Jennifer; Keller, Martin S
We sought to determine the incidence and characteristics of missed injuries and unplanned readmissions at a Level-1 pediatric trauma center. We conducted a retrospective review of all trauma patients who presented to our ACS-verified Level-1 pediatric trauma center from 2009 to 2014. Overall, there were 27 readmissions and 27 missed injuries (0.38%). Patients who were unplanned readmissions had a greater Injury Severity Score (ISS) (8.6 vs 5.2, p=0.03), had longer hospitalizations (4.9 vs 2.5days, p=0.02), and were more likely to have required operative intervention (51.9% vs 32.3%, p=0.04). Similarly, patients identified with missed injuries had a higher ISS (15.2 vs 5.2, p<0.0001), greater length of stay (12.7 vs 2.5days, p<0.0001), and were also more likely to be intubated (25.9% vs 3.6%, p<0.0001) or require critical care (48.1% vs 10.3%, p<0.0001). Seven missed injuries were in patients who were deemed nonaccidental trauma (25.9%) and significantly altered their hospital course while 10 patients (37%) required operative intervention. On multivariate analysis, only ISS was found to be an independent risk factor for readmissions and missed injuries. Missed injuries and unplanned readmissions were rare occurrences among our pediatric patient population. These events, however, did result in longer hospitalizations and additional procedures. Patients with multisystem injuries and compromised physical exam are at higher risk. IV. Copyright © 2016 Elsevier Inc. All rights reserved.
Farzanegan, Roya; Farzanegan, Behrooz; Zangi, Mahdi; Golestani Eraghi, Majid; Noorbakhsh, Shahram; Doozandeh Tabarestani, Neda; Shadmehr, Mohammad Behgam
Background Tracheal stenosis is one of the worst complications associated with endotracheal intubation and it is the most common reason for reconstructive airway surgeries. Due to various local risk factors, the incidence rate of tracheal stenosis may vary in different countries. In order to estimate the incidence rate of post-intubation tracheal stenosis (PITS) in patients admitted to an intensive care unit (ICU), a follow-up study was planned. As there was no similar methodological model in the literature, a feasibility step was also designed to examine the whole project and to enhance the follow-up rate. Objectives To estimate the PITS incidence rate in patients admitted to ICUs, as well as to evaluate the feasibility of the study. Methods This prospective cohort study was conducted in five hospitals in two provinces (Tehran and Arak) of Iran from November 2011 to March 2013. All patients admitted to ICUs who underwent more than 24 hours of endotracheal intubation were included. Upon their discharge from the ICUs, the patients received oral and written educational materials intended to ensure a more successful follow-up. The patients were asked to come back for follow-up three months after their extubation, or sooner in case of any symptoms developing. Those with dyspnea or stridor underwent a bronchoscopy. The asymptomatic patients were given a spirometry and then they underwent a bronchoscopy if the flow-volume loop suggested airway stenosis. Results Some seventy-three patients (70% men) were included in the study. Multiple trauma secondary to motor vehicle accidents (52%) was the most common cause of intubation. Follow-ups were completed in only 14 (19.2%, CI = 0.109 - 0.300) patients. One patient (7%, CI = 0.007 - 0.288) developed symptomatic tracheal stenosis that was confirmed by bronchoscopy. The barriers to a successful follow-up were assessed on three levels: ineffective oral education upon discharge, improper usage of educational materials, and
Tsai, Yung-Fong; Luo, Chiao-Fen; Illias, Amina; Lin, Chih-Chung; Yu, Huang-Ping
The "Rusch" intubation stylet is used to make endotracheal tube intubation easy. We designed this study to evaluate the usage of this equipment in the guidance of nasogastric tube (NGT) insertion. A total of 103 patients, aged 23 to 70 years, undergoing gastrointestinal or hepatic surgeries that required intraoperative NGT insertions were enrolled into our study. The patients were randomly allocated to the control group (Group C) or the stylet group (Group S) according to a computerized, random allocation software program. In the control group, the NGT was inserted with the patient's head in an intubating position. In the stylet group, the NGT was inserted with the assistance of a "Rusch" intubation stylet tied together at the tips by a slipknot. The success rates of the two methods, the durations of the insertions, and the occurrences of complications were recorded. All of the failed cases in the control group were subjected to the new technique used in the stylet group, and the successful rescue rate was also evaluated. Successful insertions were recorded for 52/53 patients (98.1%) in Group S and for 32/50 patients (64%) in Group C. The mean insertion times were 39.5 ± 19.5 seconds in Group C and 40.3 ± 23.2 seconds in Group S. Successful rescues of failure cases in Group C were achieved in 17/18 patients (94.4%) with the assistance of a "Rusch" intubation stylet. The "Rusch" intubation stylet-guided method is reliable with a high success rate of NGT insertion in anesthetized and intubated patients. Institutional Review Board of Chang Gung Memorial Hospital (IRB: 98-2669B) and Australian New Zealand Clinical Trials Registry (ACTRN12611000423910).
Jawa, Randeep S; Stothert, Joseph C; Shostrom, Valerie K; Yetter, Diane L; Templin, Heather R; Cemaj, Samuel K; Lander, Lina; Forse, Armour R; Young, David H
As alcohol use is highly prevalent in trauma patients, we hypothesized that a significant proportion of hospitalized trauma patients would demonstrate alcohol withdrawal (AW). The trauma registries at a joint trauma center system from 1999 to 2008 were evaluated for patients aged at least 16 years. Of 19,369 trauma admissions, 159 patients had AW. Blood alcohol concentration (BAC) testing was performed in 31.5% of the patients. BAC was significantly higher in AW patients versus other traumas (205.7 ± 130.1 vs 102.9 ± 121.7 mg/dL). BAC was 0 in 14.4% of AW patients. As compared with other trauma patients, patients with AW had a significantly greater age (50.2 vs 42.1 years), hospital length of stay (10 vs 3 days), intensive care unit length of stay (2 vs 0 days), need for mechanical ventilation (34% vs 12.7%), and pneumonia (12% vs 2.3%). AW patients were less frequently discharged to home (59.8% vs 69.9%). Mortality was not different. AW was diagnosed in few patients. Of note, it occurred in patients with an initial BAC of 0. AW is associated with adverse outcomes. Published by Elsevier Inc.
Kim, Joungmin; Im, Kyong Shil; Lee, Jae Myeong; Ro, Jaehun; Yoo, Kyung Yeon; Kim, Jong Bun
To determine the correlation between anatomical features of the upper airway (evaluated via computed tomography imaging) and the ease of light wand-assisted endotracheal intubation in patients undergoing ear, nose and throat surgery under general anaesthesia. Mallampati class, laryngoscopic grade, thyromental distance, neck circumference, body mass index, mouth opening and upper lip bite class were assessed. Epiglottis length and angle, tongue size and narrowest pharyngeal distance were determined using computed tomography imaging. Intubation success rate, time to successful intubation (intubating time) and postoperative throat symptoms were documented. Of 152 patients, 148 (97.4%) were successfully intubated on the first attempt (mean intubating time 11.5 ± 6.7 s). Intubating time was positively correlated with laryngoscopic grade and body mass index in both male and female patients, and Mallampati class and neck circumference in male patients. Epiglottis length was positively correlated with intubating time. Ease of intubation was influenced by epiglottis length. Radiological evaluation may be useful for preoperative assessment of patients undergoing endotracheal intubation with light wand. © The Author(s) 2015.
Background The “Rusch” intubation stylet is used to make endotracheal tube intubation easy. We designed this study to evaluate the usage of this equipment in the guidance of nasogastric tube (NGT) insertion. Methods A total of 103 patients, aged 23 to 70 years, undergoing gastrointestinal or hepatic surgeries that required intraoperative NGT insertions were enrolled into our study. The patients were randomly allocated to the control group (Group C) or the stylet group (Group S) according to a computerized, random allocation software program. In the control group, the NGT was inserted with the patient’s head in an intubating position. In the stylet group, the NGT was inserted with the assistance of a “Rusch” intubation stylet tied together at the tips by a slipknot. The success rates of the two methods, the durations of the insertions, and the occurrences of complications were recorded. All of the failed cases in the control group were subjected to the new technique used in the stylet group, and the successful rescue rate was also evaluated. Results Successful insertions were recorded for 52/53 patients (98.1%) in Group S and for 32/50 patients (64%) in Group C. The mean insertion times were 39.5 ± 19.5 seconds in Group C and 40.3 ± 23.2 seconds in Group S. Successful rescues of failure cases in Group C were achieved in 17/18 patients (94.4%) with the assistance of a “Rusch” intubation stylet. Conclusions The “Rusch” intubation stylet-guided method is reliable with a high success rate of NGT insertion in anesthetized and intubated patients. Trial registration Institutional Review Board of Chang Gung Memorial Hospital (IRB: 98-2669B) and Australian New Zealand Clinical Trials Registry (ACTRN12611000423910) PMID:22853453
El-Jawahri, Areej; Mitchell, Susan L; Paasche-Orlow, Michael K; Temel, Jennifer S; Jackson, Vicki A; Rutledge, Renee R; Parikh, Mihir; Davis, Aretha D; Gillick, Muriel R; Barry, Michael J; Lopez, Lenny; Walker-Corkery, Elizabeth S; Chang, Yuchiao; Finn, Kathleen; Coley, Christopher; Volandes, Angelo E
Decisions about cardiopulmonary resuscitation (CPR) and intubation are a core part of advance care planning, particularly for seriously ill hospitalized patients. However, these discussions are often avoided. We aimed to examine the impact of a video decision tool for CPR and intubation on patients' choices, knowledge, medical orders, and discussions with providers. This was a prospective randomized trial conducted between 9 March 2011 and 1 June 2013 on the internal medicine services at two hospitals in Boston. One hundred and fifty seriously ill hospitalized patients over the age of 60 with an advanced illness and a prognosis of 1 year or less were included. Mean age was 76 and 51% were women. Three-minute video describing CPR and intubation plus verbal communication of participants' preferences to their physicians (intervention) (N = 75) or control arm (usual care) (N = 75). The primary outcome was participants' preferences for CPR and intubation (immediately after viewing the video in the intervention arm). Secondary outcomes included: orders to withhold CPR/intubation, documented discussions with providers during hospitalization, and participants' knowledge of CPR/ intubation (five-item test, range 0-5, higher scores indicate greater knowledge). Intervention participants (vs. controls) were more likely not to want CPR (64% vs. 32%, p <0.0001) and intubation (72% vs. 43%, p < 0.0001). Intervention participants (vs. controls) were also more likely to have orders to withhold CPR (57% vs. 19%, p < 0.0001) and intubation (64% vs.19%, p < 0.0001) by hospital discharge, documented discussions about their preferences (81% vs. 43%, p < 0.0001), and higher mean knowledge scores (4.11 vs. 2.45; p < 0.0001). Seriously ill patients who viewed a video about CPR and intubation were more likely not to want these treatments, be better informed about their options, have orders to forgo CPR/ intubation, and discuss preferences with providers
Brodsky, Martin B; Gellar, Jonathan E; Dinglas, Victor D; Colantuoni, Elizabeth; Mendez-Tellez, Pedro A; Shanholtz, Carl; Palmer, Jeffrey B; Needham, Dale M
The purpose of this study is to evaluate demographic and clinical factors associated with self-reported dysphagia after oral endotracheal intubation and mechanical ventilation in patients with acute lung injury (ALI). This is a prospective cohort study of 132 ALI patients who had received mechanical ventilation via oral endotracheal tube. The primary outcome was binary, whether clinically important symptoms of dysphagia at hospital discharge were reported by patients, using the Sydney Swallowing Questionnaire score 200 or more. Of 132 patients, 29% reported clinically important symptoms of dysphagia. Of 18 relevant demographic and clinical variables, only 2 were found to be independently associated with clinically important symptoms of dysphagia in a multivariable logistic regression model: upper gastrointestinal comorbidity (odds ratio, 2.82; 95% confidence interval, 1.09-7.26) and duration of oral endotracheal intubation (odds ratio, 1.79; [95% confidence interval, 1.15-2.79] per day for first 6 days, after which additional days of intubation were not associated with a further increase in the odds of dysphagia). In ALI survivors, patient-reported, postexubation dysphagia at hospital discharge was significantly associated with upper gastrointestinal comorbidity and a longer duration of oral endotracheal intubation during the first 6 days of intubation. Copyright © 2014 Elsevier Inc. All rights reserved.
Joseph, Bellal; Khalil, Mazhar; Zangbar, Bardiya; Kulvatunyou, Narong; Orouji, Tahereh; Pandit, Viraj; O'Keeffe, Terence; Tang, Andrew; Gries, Lynn; Friese, Randall S; Rhee, Peter; Davis, James W
Domestic violence is an extremely underreported crime and a growing social problem in the United States. However, the true burden of the problem remains unknown. To assess the reported prevalence of domestic violence among trauma patients. A 6-year (2007-2012) retrospective analysis of the prospectively maintained National Trauma Data Bank. Trauma patients who experienced domestic violence and who presented to trauma centers participating in the National Trauma Data Bank were identified using International Classification of Diseases, Ninth Revision diagnosis codes (995.80-995.85, 995.50, 995.52-995.55, and 995.59) and E codes (E967.0-E967.9). Patients were stratified by age into 3 groups: children (≤18 years), adults (19-54 years), and elderly patients (≥55 years). Trend analysis was performed on April 10, 2014, to assess the reported prevalence of domestic violence over the years. Trauma patients presenting to trauma centers participating in the National Trauma Data Bank. To assess the reported prevalence of domestic violence among trauma patients. A total of 16 575 trauma patients who experienced domestic violence were included. Of these trauma patients, 10 224 (61.7%) were children, 5503 (33.2%) were adults, and 848 (5.1%) were elderly patients. The mean (SD) age was 15.9 (20.6), the mean (SD) Injury Severity Score was 10.9 (9.6), and 8397 (50.7%) were male patients. Head injuries (46.8% of patients) and extremity fractures (31.2% of patients) were the most common injuries. A total of 12 515 patients (75.1%) were discharged home, and the overall mortality rate was 5.9% (n = 980). The overall reported prevalence of domestic violence among trauma patients was 5.7 cases per 1000 trauma center discharges. The prevalence of domestic violence increased among children (14.0 cases per 1000 trauma center discharges in 2007 to 18.5 case per 1000 trauma center discharges in 2012; P = .001) and adults (3.2 cases per 1000 discharges in 2007 to 4.5 cases per
Weinstock, Robert J; Lewis, Tashorn; Miller, Jared; Clarkson, Earl I
Thyroid crisis, also known as thyroid storm, is a rare complication of thyrotoxicosis that results in a hypermetabolic and hyperadrenergic state. This condition requires prompt recognition and treatment because the mortality from thyroid crisis approaches 30%. Thyrotoxicosis alone will usually not progress to thyroid crisis. Thyroid crisis will typically be precipitated by some concomitant event such as infection, iodine-containing contrast agents, medications such as amiodarone, pregnancy, or surgery. Trauma is a rare precipitator of thyroid crisis. Several published studies have reported thyroid crisis resulting from blunt or penetrating neck trauma. Significant systemic trauma, such as motor vehicle accidents, has also been reported to precipitate thyroid crisis. It is very unusual for minor trauma to precipitate thyroid crisis. In the present study, we report the case of a patient who had incurred relatively minor maxillofacial trauma and developed thyroid crisis 2 weeks after the initial trauma.
Toker, Serdar; Hak, David J.; Morgan, Steven J.
Deep vein thrombosis (DVT) and pulmonary embolism (PE) are known collectively as venous thromboembolism (VTE). Venous thromboembolic events are common and potentially life-threatening complications following trauma with an incidence of 5 to 63%. DVT prophylaxis is essential in the management of trauma patients. Currently, the optimal VTE prophylaxis strategy for trauma patients is unknown. Traditionally, pelvic and lower extremity fractures, head injury, and prolonged immobilization have been considered risk factors for VTE; however it is unclear which combination of risk factors defines a high-risk group. Modalities available for trauma patient thromboprophylaxis are classified into pharmacologic anticoagulation, mechanical prophylaxis, and inferior vena cava (IVC) filters. The available pharmacologic agents include low-dose heparin (LDH), low molecular weight heparin (LMWH), and factor Xa inhibitors. Mechanical prophylaxis methods include graduated compression stockings (GCSs), pneumatic compression devices (PCDs), and A-V foot pumps. IVCs are traditionally used in high risk patients in whom pharmacological prophylaxis is contraindicated. Both EAST and ACCP guidelines recommend primary use of LMWHs in trauma patients; however there are still controversies regarding the definitive VTE prophylaxis in trauma patients. Large randomized prospective clinical studies would be required to provide level I evidence to define the optimal VTE prophylaxis in trauma patients. PMID:22084663
Shibata, Shinpei; Khemani, Robinder G; Markovitz, Barry
To describe intubation practices and duration of mechanical ventilation in children with status asthmaticus admitted from emergency departments (ERs) to pediatric intensive care units (PICUs). Retrospective cohort study using the Virtual PICU Performance System database (VPS, LLC) of children with status asthmaticus admitted to a participating PICU between December 2003 and September 2006. The primary outcome measure was intubation prior to intensive care unit (ICU) admission. Secondary outcomes included length of intubation and medical length of stay. Thirty-five PICUs in the United States. Children who were intubated and mechanically ventilated during their ICU stay for asthma and were admitted from an ER. A total of 4051 patients with status asthmaticus were identified. Intubation data were available from 35 of the 53 centers. Of all, 187 children were intubated for asthma, of which 157 were admitted from an ER and had complete data. Of all, 85 patients were from community hospital ERs and 72 were from the institution's own ER. In all, 115 (73%) patients were intubated prior to ICU admission and 42 (27%) patients were intubated after PICU admission. Of patients who received mechanical ventilation for status asthmaticus and were intubated prior to PICU admission, a greater proportion were intubated at community hospital ERs than in the institutions' own ERs. Eighty-five percent of the patients from community hospital ERs were intubated prior to PICU admission as opposed to 60% from institution's own ERs (P = .0004). However, median duration of intubation and PICU stay from community hospital ERs was significantly shorter than from the hospitals' own ERs (25 vs 42 hours P = .011; 57 vs 98 hours P = .0013, respectively). Logistic regression analysis revealed that after controlling for the effects of age, race, gender, and a revised version of the Paediatric Index of Mortality score of patients who were admitted for status asthmaticus and required mechanical
Basra, Sushil K; Vives, Michael J; Reilly, Mark C; Reiter, Mitchell F; Kushins, Lawrence G
Methemoglobinemia, a condition associated with cyanosis and diminished pulse oximetry values, has been reported after use of local anesthetics to facilitate fiberoptic intubation. The majority of reports in the literature detail this development during diagnostic procedures such as endoscopy and bronchoscopy. A case of methemoglobinemia in a multiple-injury patient with an unstable compressive-flexion injury of the cervical spine undergoing fiberoptic intubation is presented. A literature review of this entity is also presented. The patient underwent fiberoptic intubation using topical pharyngeal anesthetics before planned cervical corpectomy, strut grafting and instrumentation. He became acutely cyanotic with abruptly diminished pulse oximetry readings. Subsequent blood gas analysis demonstrated methemoglobinemia. Intravenous methylene blue administration led to an uncomplicated resolution of the condition. Surgeons and anesthesiologists who manage such patients should be aware of methemoglobinemia, a rare but potentially fatal complication related to topical airway anesthetics.
Coburn, M; Röhl, A B; Knobe, M; Stevanovic, A; Stoppe, C; Rossaint, R
The demographic change is accompanied by an increasing number of elderly trauma patients. Geriatric patients with trauma often show several comorbidities and as a result have a high perioperative risk to develop postoperative morbidity and mortality. The 30-day mortality is high. This article presents an overview of the perioperative management of elderly trauma patients in order to improve the perioperative outcome of these high risk patients. A literature search was carried out focusing on the latest developments in the field of elderly trauma patients in order to present guidance on preoperative, intraoperative and postoperative anesthesiological management. Elderly trauma patients should undergo operative interventions as soon as possible. Many of these patients have a high risk profile. This can be estimated using risk scores in order to allow a prognosis for the outcome of patients. The informed consent needs to be discussed accordingly. The perioperative management is ideally addressed in a multidisciplinary approach. An array of questions in perioperative management, such as the mode of anesthesia, the ideal individual transfusion trigger and fluid management have not yet been adequately addressed in studies. The level of evidence in the perioperative management of elderly trauma patients is poor; therefore, there is an urgent need for large prospective studies in order to define uniform standards and guidelines.
Abdollahifakhim, Shahin; Sheikhzadeh, Dariush; Shahidi, Nikzad; Nojavan, Gholamreza; Bayazian, Gholamreza; Aleshi, Hamideh
The aim of the current study was to identify the proper size of endotracheal tube for intubation of cleft lip and palate patients and intubation outcomes in these patients. In this analytic cross-sectional study, 60 nonsyndromic cleft lip and palate patients were selected who had surgery between April 2010 and April 2012 at Pediatrics Hospital, Tabriz University of Medical Sciences, Iran. Demographic findings, previous admissions, and surgical history were registered. The proper tube size was measured by normal children formulas. Then tube size was confirmed by patients' minimum resistance to intubation, proper ventilation reported by anesthesiologist, and appropriate air leakage at an airway pressure of 15-20 cm H₂O. If intubation was unsuccessful then smaller size of endotracheal tube would be tried. Frequency of intubation trials and the biggest endotracheal tube size were recorded. Their average age, weight and height were 21.39 ± 4.95 months, 9.97 ± 1.18 kg and 74.30 ± 26.61 cm, respectively. The average tracheal tube size and frequency of intubation trials were 4.34 ± 0.78 and 1.63 ± 0.80, respectively. Seven cases required an endotracheal tube size smaller than the recommended size for that age including one case in unilateral cleft palate, three cases in unilateral cleft lip, one case in unilateral cleft lip and palate, and two cases in bilateral cleft lip and palate. Findings proved that considering subglottic stenosis incidence in these children, it is reasonable to determine the tube size for nonsyndromic cleft lip and palate patients by applying the currently available standards for normal children. Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.
Bernard, S A; Smith, K; Porter, R; Jones, C; Gailey, A; Cresswell, B; Cudini, D; Hill, S; Moore, B; St Clair, T
Pre-hospital intubation by paramedics is widely used in comatose patients prior to transportation to hospital, but the optimal technique for intubation is uncertain. One approach is paramedic rapid sequence intubation (RSI), which may improve outcomes in adult patients with traumatic brain injury. However, many patients present to emergency medical services with coma of non-traumatic cause and the role of paramedic RSI in these patients remains uncertain. The electronic Victorian Ambulance Clinical Information System was searched for the term 'suxamethonium' between 2008 and 2011. We reviewed the patient care records and included patients with suspected non-traumatic coma who were treated and transported by road-based paramedics. Demographics, intubation conditions, vital signs (before and after drug administration) and complications were recorded. Younger patients (<60 years) were compared with older patients. There were 1152 paramedic RSI attempts of which 551 were for non-traumatic coma. The success rate for intubation was 97.5%. There was a significant drop in blood pressure in younger patients (<60 years) with the mean systolic blood pressure decreasing by 16 mm Hg (95% CI 11 to 21). In older patients, the systolic blood pressure also decreased significantly by 20 mm Hg (95% CI 17 to 24). Four patients suffered brief cardiac arrest during pre-hospital care, all of whom were successfully resuscitated and transported to hospital. Paramedic RSI in patients with non-traumatic coma has a high procedural success rate. Further studies are required to determine whether this procedure improves outcomes. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
Ezzat, Alaa; Fathi, Essam; Zarour, Ahmad; Singh, Rajvir; Abusaeda, M. Osama; Hussien, M. Magdy
Background Succinylcholine remains the drug of choice for satisfactory rapid-sequence tracheal intubation. It is not clear from the literature why the 1 mg/kg dose of succinylcholine has been traditionally used. The effective dose (ED95) of succinylcholine is less than 0.3 mg/kg. The dose of 1 mg/kg represents 3.5 to 4 times the ED95. Objectives To compare the effect of the traditionally used 1 mg/kg of succinylcholine with lower doses of 0.6 mg/kg and 0.45 mg/kg on intubation condition regarding the onset time, duration of action, duration of abdominal fasciculation, and the intubation grading. Methods This retrospective comparative study was carried into three groups of ASA III & IV (American Society of Anesthesiologist's Physical Status III and IV) non-prepared emergency patients who were intubated at emergency department of Hamad General Hospital, Doha, Qatar during January 1st 2007 to August 31, 2010. The Institutional Research Board (IRB) approval was obtained. This study was limited to 88 patients who received fentanyl 1µg/kg followed by etomidate 0.3 mg/kg intravenously as induction agents and succinylcholine as a muscle relaxant agent in doses of 0.45 mg/kg, 0.6 mg/kg, or 1 mg/kg. Results Increasing the succinylcholine dosage shortened the onset time, prolonged the duration of action, and prolonged the duration of abdominal fasciculation significantly (P<.001). Tracheal intubation was 100% successful in the three groups of patients. Conclusion Succinylcholine dose of 0.45 mg/kg provides an optimal intubation condition in ASA III & IV emergency non-prepared patients. Duration of action of succinylcholine is dose dependent; reducing the dose allows a more rapid return of spontaneous respiration and airway reflexes. PMID:21772925
Girgis, Karim K.; Youssef, Maha M. I.; ElZayyat, Nashwa S.
Background: One of the methods proposed in cases of difficult airway management in children is using a supraglottic airway device as a conduit for tracheal intubation. The aim of this study was to compare the efficacy of the Air-Q Intubating Laryngeal Airway (Air-Q) and the Cobra Perilaryngeal Airway (CobraPLA) to function as a conduit for fiber optic-guided tracheal intubation in pediatric patients. Materials and Methods: A total of 60 children with ages ranging from 1 to 6 years, undergoing elective surgery, were randomized to have their airway managed with either an Air-Q or CobraPLA. Outcomes recorded were the success rate, time and number of attempts required for fiber optic-guided intubation and the time required for device removal after intubation. We also recorded airway leak pressure (ALP), fiber optic grade of glottic view and occurrence of complications. Results: Both devices were successfully inserted in all patients. The intubation success rate was comparable with the Air-Q and the CobraPLA (96.7% vs. 90%), as was the first attempt success rate (90% vs. 80%). The intubation time was significantly longer with the CobraPLA (29.5 ± 10.9 s vs. 23.2 ± 9.8 s; P < 0.05), but the device removal time was comparable in the two groups. The CobraPLA showed a significantly higher ALP (20.8 ± 5.2 cmH2O vs. 16.3 ± 4.5 cmH2O; P < 0.001), but the fiber optic grade of glottic view was comparable with the two devices. The CobraPLA was associated with a significantly higher incidence of blood staining of the device on removal and post-operative sore throat. Conclusion: Both the Air-Q and CobraPLA can be used effectively as a conduit for fiber optic-guided tracheal intubation in children. However, the Air-Q proved to be superior due to a shorter intubation time and less airway morbidity compared with the CobraPLA. PMID:25422603
Johnson, P C; Satterwhite, T K; Monheit, J E; Parks, D
Primary cutaneous mucormycosis in trauma patients has been rarely reported. We describe three cases occurring in noncompromised hosts and review the literature. Prompt diagnosis and aggressive treatment with vigorous local care and appropriate antibiotics are recommended.
Masip, Josep; Páez, Joaquim; Merino, Montserrat; Parejo, Sandra; Vecilla, Francisco; Riera, Clara; Ríos, Araceli; Sabater, Joan; Ballús, Josep; Padró, J
Noninvasive ventilation may reduce the endotracheal intubation rate in patients with acute cardiogenic pulmonary edema. However, criteria for selecting candidates for this technique are not well established. We analyzed a cohort of patients with severe acute cardiogenic pulmonary edema managed by conventional therapy to identify risk factors for intubation. These factors were used as guide for indications for noninvasive ventilation. Observational cohort registry in the ICU and emergency and cardiology departments in a community teaching hospital. . 110 consecutive patients with acute cardiogenic pulmonary edema, 80 of whom received conventional oxygen therapy. Physiological measurements and blood gas samples registered upon admission. Twenty-one patients (26%) treated with conventional oxygen therapy needed intubation. Acute myocardial infarction, pH below 7.25, low ejection fraction (<30%), hypercapnia, and systolic blood pressure below 140 mmHg were independent predictors for intubation. Conversely, systolic blood pressure of 180 mmHg or higher showed to be a protective factor since only two patients with this blood pressure value required intubation (8%)], both presenting with a pH lower than 7.25. Considering systolic blood pressure lower than 180 mmHg, patients who showed hypercapnia presented a high intubation rate (13/21, 62%) whereas the rate of intubation in patients with normocapnia was intermediate (6/23, 26%). All normocapnic patients with pH less than 7.25 required intubation. No patient with hypocapnia was intubated regardless the level of blood pressure. Patients with pH less than 7.25 or systolic blood pressure less than 180 mmHg associated with hypercapnia should be promptly considered for noninvasive ventilation. With this strategy about 40% of the patients would be initially treated with this technique, which would involve nearly 90% of the patients that require intubation.
Meyer, P; Guérin, J M; Habib, Y; Lévy, C
Nosocomial pneumonia is a frequent infectious complication in ICU patients. All the patients with prolonged nasotracheal intubation presenting with nosocomial pneumonia according to Salata's criteria were examined for sinusitis in the prospective study. Diagnosis was confirmed via CT-scan views and transnasal sinus puncture. In eleven nasally intubated patients, CT-scan views showed air fluid levels and multiple sinus involvement. Bacteriological studies isolated the same gram negative bacilli in both sinus and bronchial aspirates. In four cases, a polymicrobial sinusitis was found with a single organism predominant. This predominant germ was always found in bronchial aspirate. Recovery from pneumonia was obtained only after sinus drainage. Treatment included removing the nasal tubes, or performing tracheostomy and systemic antibiotics. One patient required surgical maxillary sinus drainage after failure of medical management. The occurrence of nosocomial pneumonia in nasotracheally intubated patients should lead physicians to explore the paranasal sinuses. Sinus CT-scan views should be routinely obtained in the assessment of pulmonary sepsis in patients with prolonged nasotracheal intubation. Persistent or ignored nosocomial sinusitis in such circumstances could be a major source of treatment failure.
Konstantinidis, Agathoklis; Inaba, Kenji; Dubose, Joe; Barmparas, Galinos; Lam, Lydia; Plurad, David; Branco, Bernardino C; Demetriades, Demetrios
The epidemiology of vascular injuries in the geriatric patient population has not been described. The purpose of this study was to examine nationwide data on vascular injuries in the geriatric patients and to compare this with the nongeriatric adult patients with respect to the incidence, injury mechanisms, and outcomes. Geriatric patients aged 65 or older with at least one traumatic vascular injury were compared with an adult cohort aged 16 years to 64 years with a vascular injury using the National Trauma Databank version 7.0. During the study period, 29,736 (1.6%) patients with a vascular injury were identified. Of those, geriatric patients accounted for 7.6% (2,268) and the nongeriatric adult patients accounted for 83.1% (n=24,703). Compared with the nongeriatric adult patients, the geriatric vascular patients had a significantly higher Injury Severity Score (26.6±17.0 vs. 21.3±16.7; p<0.001) and less frequently sustained penetrating injuries (16.1% vs. 54.1%; p<0.001). The most commonly injured vessels in the elderly were vessels of the chest (n=637, 40.2%), including the thoracic aorta and innominate and subclavian vessels. The overall incidence of thoracic aorta injuries was significantly higher in geriatric patients (33.0% vs. 13.9%; p<0.001) and increased linearly with progressing age. After adjusting for confounding factors, geriatric patients demonstrated a fourfold increase in mortality following vascular injuries (adjusted odds ratio, 3.9; 95% confidence interval, 3.32-4.58; p<0.001). Vascular trauma is rare in the geriatric patient population. These injuries are predominantly blunt, with the thoracic aorta being the most commonly injured vessel. Although vascular injuries occur less frequently than in the nongeriatric cohort, in the geriatric patient, vascular injury is associated with a fourfold increase in adjusted mortality.
Sahu, Sandeep; Kishore, Kamal; Sachan, Vertika; Chatterjee, Arnidam
Nasogastric tube (NGT) placement in anesthetized and intubated is sometimes very challenging with more than 50% failure rate in the first attempt. We describe a newer innovative Sahu's three in one, technique with use of GlideScope and forward placement of intubated trachea by external laryngeal maneuver, these both techniques lead to separation of trachea from esophagus so that endoscopic jejunal feeding tube guide wire strengthen NGT can be guided and manipulated to esophagus under direct vision. After informed consent, we used Sahu's three in one combo technique to insert NGT in adult anesthetized and intubated patients of both the sexes with high success in the first attempt. We found this technique easy, helpful, less time consuming with high success rate. PMID:28298795
Sahu, Sandeep; Kishore, Kamal; Sachan, Vertika; Chatterjee, Arnidam
Nasogastric tube (NGT) placement in anesthetized and intubated is sometimes very challenging with more than 50% failure rate in the first attempt. We describe a newer innovative Sahu's three in one, technique with use of GlideScope and forward placement of intubated trachea by external laryngeal maneuver, these both techniques lead to separation of trachea from esophagus so that endoscopic jejunal feeding tube guide wire strengthen NGT can be guided and manipulated to esophagus under direct vision. After informed consent, we used Sahu's three in one combo technique to insert NGT in adult anesthetized and intubated patients of both the sexes with high success in the first attempt. We found this technique easy, helpful, less time consuming with high success rate.
Golden, S E; Shehab, Z M; Bjelland, J C; Ryan, K J; Ray, C G
We studied the utility of Gram-stained smears and semiquantitative cultures of endotracheal aspirates (ETAs) in diagnosing pneumonia in intubated patients in a pediatric intensive care unit. The chest radiographs of 35 intubated patients were independently reviewed by a pediatric radiologist and classified into probable, possible and unlikely pneumonias. Concomitant bacteriologic and radiographic information was available in 15 episodes of probable and 13 of possible pneumonia. These findings were compared with the ETAs obtained during the study from patients with no radiographic evidence of pneumonia (N = 21). There was a good correlation between ETA findings and radiographic evidence of pneumonia when ETAs were obtained within 60 minutes of initial intubation. Only a growth of greater than or equal to 3+ of a pathogen was associated with probable pneumonia when ETAs were obtained more than 60 minutes from initial intubation. There was a poor correlation between the microbiologic findings from ETAs and the results of blood cultures and postmortem examinations. Moreover 5 of 10 pairs of ETAs obtained within 18 hours of each other demonstrated discordant results. The ETAs from patients with indwelling endotracheal tubes correlated poorly with radiographic findings and are of questionable value in diagnosing the presence of pneumonia or its etiology in this group. They must be cautiously interpreted in critically ill patients.
Facktor, Matthew A.
Background Video-assisted thoracic surgery (VATS) is routinely performed with general anesthesia and double-lumen endotracheal intubation, but this technique may stress an elderly patient’s functional reserve. We chose to study the safety and efficacy of non-intubated VATS, utilizing local anesthesia, sedation, and spontaneous ventilation in the elderly. Methods The medical records of all patients aged 80 years and older who underwent VATS under local anesthesia and sedation during the time period 6/1/2002 to 6/1/2010 at Geisinger Health System (Pennsylvania, USA) and 10/1/2011 to 12/31/2014 at Sinai Hospital (Maryland, USA) were retrospectively reviewed. Unsuccessful attempts at this technique were eligible for inclusion but there were none. No patient was excluded based on comorbidity. Results A total of 96 patients ranging in age from 80 to 104 years underwent 102 non-intubated VATS procedures: pleural biopsy/effusion drainage with or without talc 73, drainage of empyema 17, evacuate hemothorax 4, pericardial window 3, lung biopsy 2, treat chylothorax 2, treat pneumothorax 1. No patient required intubation or conversion to thoracotomy. No patient required a subsequent procedure or biopsy. Complications occurred in three patients (3.1% morbidity): cerebrovascular accident, pulmonary embolism, prolonged air leak. One 94-year-old patient died from overanticoagulation and two 84-year-old patients died of their advanced lung cancers (3.1% morbidity). Conclusions Non-intubated VATS utilizing local anesthesia and sedation in the elderly is well tolerated and safe for a number of indications. PMID:26046042
Faul, Mark; Sasser, Scott M.; Lairet, Julio; Mould-Millman, Nee-Kofi; Sugerman, David
Introduction The most effective use of trauma center resources helps reduce morbidity and mortality, while saving costs. Identifying critical infrastructure characteristics, patient characteristics and staffing components of a trauma center associated with the proportion of patients needing major trauma care will help planners create better systems for patient care. Methods We used the 2009 National Trauma Data Bank-Research Dataset to determine the proportion of critically injured patients requiring the resources of a trauma center within each Level I–IV trauma center (n=443). The outcome variable was defined as the portion of treated patients who were critically injured. We defined the need for critical trauma resources and interventions (“trauma center need”) as death prior to hospital discharge, admission to the intensive care unit, or admission to the operating room from the emergency department as a result of acute traumatic injury. Generalized Linear Modeling (GLM) was used to determine how hospital infrastructure, staffing Levels, and patient characteristics contributed to trauma center need. Results Nonprofit Level I and II trauma centers were significantly associated with higher levels of trauma center need. Trauma centers that had a higher percentage of transferred patients or a lower percentage of insured patients were associated with a higher proportion of trauma center need. Hospital infrastructure characteristics, such as bed capacity and intensive care unit capacity, were not associated with trauma center need. A GLM for Level III and IV trauma centers showed that the number of trauma surgeons on staff was associated with trauma center need. Conclusion Because the proportion of trauma center need is predominantly influenced by hospital type, transfer frequency, and insurance status, it is important for administrators to consider patient population characteristics of the catchment area when planning the construction of new trauma centers or
Ryan, Mark L; Van Haren, Robert M; Thorson, Chad M; Andrews, David M; Perez, Eduardo A; Neville, Holly L; Sola, Juan E; Proctor, Kenneth G
Coagulation changes in pediatric trauma patients are not well defined. To fill this gap, we tested the hypothesis that trauma evokes a hypercoagulable response. A prospective observational study was conducted in hospitalized patients (age 8months to 14years) admitted for trauma or elective surgery. Informed consent was obtained from the parents and informed assent was obtained in patients 7years of age or older. Coagulation changes were evaluated on fresh whole blood using thromboelastography (TEG) and on stored plasma using assays for special clotting factors. Forty three patients (22 trauma, median injury severity score =9; and 21 uninjured controls) were evaluated. For trauma vs control, prothrombin time (PT) was higher by about 10% (p<0.001), but activated partial thromboplastin time was not altered. TEG clotting time (R;p=0.005) and fibrin cross-linking were markedly accelerated (K time, alpha angle; p<0.001) relative to the control patients. d-Dimer, Prothrombin Fragment 1+2, and Plasminogen Activator Inhibitor-1 were all elevated, whereas Protein S activity was reduced (all p<0.01). Importantly, a large fraction of TEG values and clotting factor assays in the pediatric control group were outside the published reference ranges for adults. A hypercoagulable state is associated with minor trauma in children. More work is needed to determine the functional significance of these changes and to establish normal pediatric reference ranges. Copyright © 2014 Elsevier Inc. All rights reserved.
Hernandez, Glenn; Peña, Hector; Cornejo, Rodrigo; Rovegno, Maximiliano; Retamal, Jaime; Navarro, Jose Luis; Aranguiz, Ignacio; Castro, Ricardo; Bruhn, Alejandro
Introduction Central venous oxygen saturation (ScvO2) has emerged as an important resuscitation goal for critically ill patients. Nevertheless, growing concerns about its limitations as a perfusion parameter have been expressed recently, including the uncommon finding of low ScvO2 values in patients in the intensive care unit (ICU). Emergency intubation may induce strong and eventually divergent effects on the physiologic determinants of oxygen transport (DO2) and oxygen consumption (VO2) and, thus, on ScvO2. Therefore, we conducted a study to determine the impact of emergency intubation on ScvO2. Methods In this prospective multicenter observational study, we included 103 septic and non-septic patients with a central venous catheter in place and in whom emergency intubation was required. A common intubation protocol was used and we evaluated several parameters including ScvO2 before and 15 minutes after emergency intubation. Statistical analysis included chi-square test and t test. Results ScvO2 increased from 61.8 ± 12.6% to 68.9 ± 12.2%, with no difference between septic and non-septic patients. ScvO2 increased in 84 patients (81.6%) without correlation to changes in arterial oxygen saturation (SaO2). Seventy eight (75.7%) patients were intubated with ScvO2 less than 70% and 21 (26.9%) normalized the parameter after the intervention. Only patients with pre-intubation ScvO2 more than 70% failed to increase the parameter after intubation. Conclusions ScvO2 increases significantly in response to emergency intubation in the majority of septic and non-septic patients. When interpreting ScvO2 during early resuscitation, it is crucial to consider whether the patient has been recently intubated or is spontaneously breathing. PMID:19413905
Johannes, Jimmy; Berlin, David A; Patel, Parimal; Schenck, Edward J; West, Frances Mae; Saggar, Rajan; Barjaktarevic, Igor Z
Patients with pulmonary hypertension and right heart failure have a high risk of clinical deterioration and death during or soon after endotracheal intubation. The effects of sedation, hypoxia, hypoventilation, and changes in intrathoracic pressure can lead to severe hemodynamic instability. In search for safer approach to endotracheal intubation in this cohort of patients, we evaluate the safety and feasibility of an alternative intubation technique. Retrospective data analysis. Two medical ICUs in large university hospitals in the United States. We report a case series of nine nonconsecutive patients with compromised right heart function, pulmonary hypertension, and severe acute hypoxemic respiratory failure who underwent endotracheal intubation with a novel technique combining awake bronchoscopic intubation supported with nasally delivered noninvasive positive pressure ventilation or high-flow nasal cannula. All patients were intubated in the first attempt without major complications and eight patients (88%) were alive 24 hours after intubation. Systemic hypotension was the most frequent complication following the procedure. Awake bronchoscopic intubation supported with a noninvasive positive pressure delivery systems may be feasible alternative to standard direct laryngoscopy approach. Further studies are needed to better assess its safety and applicability.
Soltani, Hassan-Ali; Hashemi, Seyed Jalal; Montazeri, Kamran; Dehghani, Alireza; Nematbakhsh, Mehdi
Background: Muscle relaxant agents usually use to facilitate tracheal intubation; however, sometimes limitations exist. Magnesium (Mg) sulfate is a candidate for muscle relaxant substitute. This study was designed to determine the effect of Mg sulfate accompanied with propofol and fentanyl in patients undergoing ophthalmic surgery. Materials and Methods: In a double-blind randomized protocol and before tracheal intubation, Mg sulfate 40, 45, or 50 mg/kg in 100 ml of saline (Groups 1–3, respectively) or saline alone (Group 4) were administrated intravenously in 100 patients (n = 25 in each group) with the American Society of Anesthesiologist (ASA) physical Status I, II, or III. The patients' intubation condition in all subjects were determined and described. Results: The patients' demographic data including age, ASA, systolic and diastolic blood pressures, intraocular pressure, and body mass index were not significantly different between the groups. A better mask ventilation feasibility in Mg sulfate 45 group (Group 2) was observed when compared with Mg sulfate 50 (Group 3) (P = 0.022) and saline group (Group 4) (P = 0.021). In addition, the vocal cord movement and muscle relaxant requirement in saline group were significantly different from others groups (P < 0.05). The laryngoscopic time in saline group was greater than other groups significantly (P < 0.0001). Conclusion: Intravenous administration of Mg sulfate accompanied with propofol and fentanyl facilitates the tracheal intubation without neuromuscular blocking agents. To avoid Mg level increasing in plasma; however, the low dose of Mg sulfate is suggested. PMID:28163742
Grap, Mary Jo; Munro, Cindy L; Hamilton, V Anne; Elswick, R K; Sessler, Curtis N; Ward, Kevin R
Ventilator-associated pneumonia (VAP) is an important complication of mechanical ventilation and is particularly common in trauma, burn, and surgical patients. Interventions that kill bacteria in the oropharynx reduce the pool of viable organisms available for translocation to the lung and thereby lessen the likelihood of developing VAP. Repeated administration of chlorhexidine (CHX) to the mouth and oropharynx has been shown to reduce the incidence of VAP, but use of a single dose has not been studied. This randomized, controlled clinical trial tested an early (within 12 hours of intubation) application of CHX by swab versus control (no swab) on oral microbial flora and VAP. A total of 145 trauma patients requiring endotracheal intubation were randomly assigned to the intervention (5 mL CHX) or control group. VAP (Clinical Pulmonary Infection Score [CPIS] ≥ 6) was evaluated on study admission and at 48 and 72 hours after intubation. A total of 145 patients were enrolled; 71 and 74 patients were randomized to intervention and control groups, respectively. Seventy percent of the patients were male, and 60% were white; their mean age was 42.4 years (±18.2). A significant treatment effect was found on CPIS both from admission to 48 hours (P = .020) and to 72 hours (P = .027). In those subjects without pneumonia at baseline (CPIS < 6), 55.6% of the control patients (10/18) had developed VAP by 48 or 72 hours versus only 33.3% of the intervention patients (7/21). an early, single application of CHX to the oral cavity significantly reduces CPIS and thus VAP in trauma patients. Copyright © 2011 Elsevier Inc. All rights reserved.
Mohr, Nicholas M; Pelaez Gil, Carlos A; Harland, Karisa K; Faine, Brett; Stoltze, Andrew; Pearson, Kent; Ahmed, Azeemuddin
The purpose of the study was to test the hypothesis that prehospital oral chlorhexidine administered to intubated trauma patients will decrease the Clinical Pulmonary Infection Score (CPIS) during the first 2 days of hospitalization. Prospective interventional concurrent-control study of all intubated adult trauma patients transported by air ambulance to a 711-bed Midwestern academic trauma center over a 1-year period. Patients transported by 2 university-based helicopters were treated with oral chlorhexidine after intubation, and the control group was patients transported by other air transport services. Sixty-seven patients were enrolled, of which 23 received chlorhexidine (9 patients allocated to the intervention were not treated). The change in CPIS score was no different between the intervention and control groups by intention to treat (1.06- vs 1.40-point reduction, P = .520), and no difference was observed in tracheal colonization (29.0% vs 36.7%, P = .586). No differences were observed in the rate of clinical pneumonia (8.7% vs 8.6%, P = .987) or mortality (P = .196) in the per-protocol chlorhexidine group. The prehospital administration of oral chlorhexidine does not reduce the CPIS score over the first 48 hours of admission for intubated trauma patients. Further study should explore other prehospital strategies of reducing complications of critical illness. Copyright © 2015 Elsevier Inc. All rights reserved.
de Toledo, Guilherme Lacerda; Bueno, Sebastião Cristian; Mesquita, Ricardo Alves; Amaral, Márcio Bruno Figueiredo
Submental endotracheal intubation, as compared to the use of tracheotomy, is an alternative for the surgical management of maxillofacial trauma, as described by Altemir FH (The submental route for endotracheal intubation: a new technique. J Maxillofac Surg 1986; 14: 64). Although the submental endotracheal intubation is a useful technique, a wide range of complications have been reported in the literature. The core aim of this article is to present additional data from 17 patients who have undergone submental endotracheal intubation and who have received at least 6 months of postoperative follow up. A prospective study was carried out on patients who suffered maxillofacial trauma between 2008 and 2011. Age, gender, etiology of trauma, fracture type, complications, and follow up were evaluated. Case series, as well as retrospective and prospective studies regarding submental endotracheal intubation in maxillofacial trauma, were also reviewed. This study demonstrated a low rate of complications in submental endotracheal intubation and no increase in operative time within the evaluated sample. The submental endotracheal intubation may be considered a simple, secure, and effective technique for operative airway control in major maxillofacial traumas. © 2013 John Wiley & Sons A/S.
Arslan, Zehra Ipek; Alparslan, Volkan; Ozdal, Pınar; Toker, Kamil; Solak, Mine
Airway management in emergency settings can be difficult due to limited access to the patient. The use of video laryngoscopes along with the Fastrach™ device improves tracheal intubation; however, the use of such devices in a face-to-face intubation model has not been evaluated in adult patients. After obtaining official approval from the Local Research Ethics Committee and written informed consent from the patients, 120 patients were enrolled in this prospective randomized study. The patients were ASA I and ASA II according to the American Society of Anesthesiologists Physical Status Classification System. Rocuronium was administered for neuromuscular blockade following standard anesthesia monitoring and induction. The patients were divided into three groups (40 patients per group) and their tracheas were intubated via a face-to-face approach with the Airtraq™, Glidescope™ or Fastrach™ devices. The intubation success rates of the Airtraq™, Glidescope™ and Fastrach™ devices were similar (100, 98 and 90 %; p = 0.07). The insertion time for the Airtraq™ [8.5 (6-11) s] was the shortest followed by the Glidescope™ [11 (7-19) s] and the Fastrach™ [16.5 (14.3-21.8) s; p < 0.001]. The intubation time for the Airtraq™ [14 (10.3-18.8) s] was shorter than the Glidescope™ [25 (18-45) s], and Fastrach™ devices [46.5 (40-65) s; p < 0.001]. The Glidescope™ device required a greater number of optimization maneuvers (p = 0.009) and intubation attempts than the Airtraq™ (p = 0.004). Esophageal intubation (p = 0.001) and mucosal damage were more common in the Fastrach™ group (p = 0.03). The Airtraq™ device provided faster insertion and intubation times and enabled better Cormack-Lehane grades. Additionally, the Airtraq™ device required the minimum number of optimization maneuvers and was associated with fewer complications and fewer intubation attempts than the Glidescope™ and Fastrach™ devices during face-to-face tracheal intubation.
Cornelius, Bryant; Sakai, Tetsuro
Inadvertent placement of the endotracheal tube into the right bronchus during intubation for general anesthesia is a fairly common occurrence. Many precautions should be taken by the anesthesia provider in order to minimize the incidence of endobronchial intubation, including bilateral auscultation of the lungs, use of the 21/23 rule, and palpation of the inflated endotracheal cuff at the sternal notch. These provisions, however, are not foolproof; anesthesia providers should realize that endobronchial intubation may occur from time to time because of variations in patient anatomy, changes in patient positioning, and cephalad pressures exerted during surgery. A 58-year-old man with chronic obstructive pulmonary disease received general endotracheal anesthesia for a laparoscopic cholecystectomy. His height was 165 cm (5 ft, 5 in) and the endotracheal tube was secured at his incisors at 21 cm after placement with a rigid laryngoscope. Bilateral breath sounds were confirmed with auscultation, although they were distant because of his chronic obstructive pulmonary disease. After radiographic examination in the postanesthesia care unit, a right main-stem intubation was revealed to have taken place, resulting in complete atelectasis of the left lung. After repositioning of the endotracheal tube, radiography confirmed that the patient had an anatomically short tracheal length.
Maybauer, Marc O; Geisser, Wolfgang; Wolff, Holger; Maybauer, Dirk M
To evaluate the frequency of use, placement site, success and misplacement rates, and need for intervention for tube thoracostomies (TTs), and the complications with endotracheal intubation associated with TT in the prehospital setting. We performed a five-year, retrospective study using the records of 1,065 patients who were admitted to the trauma emergency room at a university hospital and who had received chest radiographs or computed tomography (CT) scans within 30 minutes after admission. Seven percent of all patients received a TT (5% unilateral, 2% bilateral). Ninety-seven percent of all patients with a TT were endotracheally intubated. The success rate for correctly placed chest tubes was 78%. Twenty-two percent of the chest tubes were misplaced (i.e., too far in the chest, twisted, or bent); half of those had to be corrected, with one needing to be replaced. There were no statistical differences in the frequency of Monaldi or Bülau positions, or the frequency of left or right chest TT. In addition, the two positions did not differ in misplacement rates or the need for intervention. Helicopter emergency medical services physicians used the Monaldi position significantly more frequently than the Bülau position. In-hospital physicians performing interhospital transfer used the Bülau position significantly more frequently, whereas ground emergency medical physicians had a more balanced relationship between the two positions. Tube thoracostomy had no influence on endotracheal tube misplacement rates, and vice versa. Tube thoracostomy positioning mostly depends on the discretion of the physician on scene. The Monaldi and Bülau positions do not differ in misplacement or complication rates.
Payne, J T
Proper evaluation, nursing care, physical therapy, and attention to the patient's general comfort are essential to the successful management of animals with severe trauma. Evaluation is important because failure to identify all injuries early in the management of a trauma patient may have unfavorable effects on the eventual outcome of the case. Once therapy is underway, ensuring the patient's comfort, maintaining fluid and electrolyte balance, and providing a well-planned rehabilitation program are essential to speed an enhance the recovery of these patients.
Buckley, Christina E; Achakzai, Akbar Amin; O'Hanlon, Deirdre
Trismus and microstomia are commonly associated complications of neck irradiation. In recent years we are seeing an increase in the number of patients with various head and neck cancers being treated with radiotherapy. This can pose a significant challenge in performing oesophagogastroduodenoscopy (OGD) in this cohort of patients. We describe a novel technique for intubating the mouth during OGD in patients with previous neck radiation. Instead of placing a standard mouthpiece, we place the barrel of a 5 mm syringe, which is cut in half, into the patient's mouth. This method allows easy passage of the gastroscope, where the mouth opening is limited by trismus from prior radiation. It also serves to protect the patient's teeth during OGD. Successful intubation with a gastroscope is possible in patients with severe trismus using our novel technique. PMID:24849645
Zhu, Thein Hlaing; Hollister, Lisa; Opoku, Dazar; Galvagno, Samuel M
Recent studies using advanced statistical methods to control for confounders have demonstrated an association between helicopter transport (HT) vs. ground ambulance transport (GT) in terms of improved survival for adult trauma patients. The aim of this study was to apply a methodologically vigorous approach to determine if HT is associated with a survival benefit for when trauma patients are transported to a verified trauma center in a rural setting. The ascertainment of trauma patients age ≥15 years (n=469 cases) by HT and (n=580 cases) by GT between 1999 and 2012 was restricted to the scene of injury in a rural area of 10 to 35 miles from the trauma center. The propensity score (PS) was determined using data including demographics, prehospital physiology, intubation, total prehospital time and injury severity. The propensity score matching was performed with different calipers to select a higher percentage of matches of HT compared to GT patients. The outcome of interest was survival to discharge from hospital. Identical logistic regression analysis was done taking into account for each matched design to select an appropriate effect estimate and confidence interval (CI) controlling for initial vital signs in emergency department, the need for urgent surgery, intensive care unit admission and mechanical ventilation. Unadjusted mortality for HT compared to GT was 7.7% and 5.3% respectively (p > 0.05). The adjusted rates were 4.0% for HT and 7.6% for GT (p < 0.05). In a PS well-matched dataset, HT was associated with a 2.69-fold increase in odds of survival compared to GT patients [adjusted OR (AOR) = 2.69; 95% C.I. = 1.21 to 5.97]. In a rural setting, we demonstrated improved survival associated with HT compared to GT for scene transportation of adult trauma patients to a verified level II trauma center using an advanced methodologic approach, which included adjustment for transport distance. The implication of survival benefit to rural population is discussed
Reilly, Patrick M; Schwab, C William; Kauder, Donald R; Dabrowski, G Paul; Gracias, Vicente; Gupta, Rajan; Pryor, John P; Braslow, Benjamin M; Kim, Patrick; Wiebe, Douglas J
As the malpractice and financial environment has changed, injured patients evaluated by the trauma team and discharged from the emergency department (ED) are now commonplace. The evaluation, care, and disposition of this population has become a significant workload component but is not reported to accrediting organizations and is relatively invisible to hospital administrators. Our objective was to quantify and begin to qualify the evolving picture of the trauma ED discharge population as a work component of trauma service function in an urban, Level I trauma center with an aeromedical program. Trauma registry (contacts, mechanism, transport, injuries, and disposition) and hospital databases (ED closure, occupancy rates) were queried for a 5-year period (1999-2003). Trend analysis provided statistical comparisons for questions of interest. During the 5-year study period, the total number of trauma contacts rose by 18.1% (2,220 in 1999 vs. 2,622 in 2003; trend p < 0.05). This increase in total contacts was not a manifestation of an increase in admissions (1,672 in 1999 vs. 1,544 in 2003) but rather a reflection of a marked increase in patients seen primarily by the trauma team and discharged from the ED (473 in 1999 vs. 1,000 in 2003; trend p < 0.05). These ED discharge patients were increasingly transported by helicopter (12.3% in 1999 vs. 29.2% in 2003; trend p < 0.05) and less frequently from urban areas (57.1% in 1999 vs. 48.1% in 2003; trend p < 0.05) over the course of the study period. Average injury severity of this group increased over the study period (Injury Severity Score of 2.7 +/- 0.1 in 1999 vs. 3.3 +/- 0.1 in 2003; trend p < 0.05). ED length of stay for this group increased 19.8% over the study period (trend p < 0.05), averaging nearly 5 hours in 2003. The total number, relative percentage, and injury severity of patients evaluated by the trauma team and discharged from the ED has significantly increased over the last 5 years, representing nearly 5
McCauley, Lindsay M; Webb, Brandon J; Sorensen, Jeffrey; Dean, Nathan C
Successful treatment of life-threatening community-acquired pneumonia requires appropriate empiric antibiotic coverage. But using conventional diagnostic techniques, a microbiological diagnosis is often not achieved. The diagnostic usefulness of tracheal aspirate at the time of intubation in patients with severe pneumonia has not been well studied. The purpose of this study was to evaluate the use of tracheal aspirate culture in identifying pneumonia pathogens. We identified all patients older than 18 years of age with International Classification of Disease, Ninth Revision codes and radiographic evidence of pneumonia seen in the emergency departments at 2 university-affiliated Utah hospitals from December 2009 to November 2010 and from December 2011 to November 2012. Patients intubated within 24 hours of arrival were then identified electronically. Postintubation orders instructed respiratory therapists to obtain tracheal aspirate for culture. All culture results were reviewed individually and defined as positive if a pneumonia pathogen was identified. Results of other microbiology studies were obtained from the electronic medical record. Of 2,011 patients with pneumonia, 94 were intubated and 84 had a tracheal aspirate obtained. Of these 84 patients, 47 (56%) had a pulmonary pathogen identified by tracheal aspirate culture, 80 also had blood cultures, and 71 underwent Pneumococcal and Legionella urinary antigen testing. A microbiological diagnosis was made in 55 patients (65.5%) by any diagnostic method. In 39% of patients (32 of 82), the tracheal aspirate culture was the only positive test, resulting in a unique microbiological diagnosis in patients who would have otherwise been classified as "culture negative." Tracheal aspirate cultures obtained as part of routine care identified a plausible pneumonia pathogen in more than one-half of emergency department adult patients with severe pneumonia requiring intubation. Tracheal aspirate culture offers important
Michetti, Christopher P; Prentice, Heather A; Rodriguez, Jennifer; Newcomb, Anna
We studied trauma-specific conditions precluding semiupright positioning and other nonmodifiable risk factors for their influence on ventilator-associated pneumonia (VAP). We performed a retrospective study at a Level I trauma center from 2008 to 2012 on ICU patients aged ≥15, who were intubated for more than 2 days. Using backward logistic regression, a composite of 4 factors (open abdomen, acute spinal cord injury, spine fracture, spine surgery) that preclude semiupright positioning (supine composite) and other variables were analyzed. In total, 77 of 374 (21%) patients had VAP. Abbreviated Injury Score head/neck greater than 2 (odds ratio [OR] 2.79, P = .006), esophageal obturator airway (OR 4.25, P = .015), red cell/plasma transfusion in the first 2 intensive care unit days (OR 2.59, P = .003), and 11 or more ventilator days (OR 17.38, P < .0001) were significant VAP risk factors, whereas supine composite, scene vs emergency department airway intervention, brain injury, and coma were not. Factors that may temporarily preclude semiupright positioning in intubated trauma patients were not associated with a higher risk for VAP. Copyright © 2016 Elsevier Inc. All rights reserved.
Wölfl, C G; Gliwitzky, B; Wentzensen, A
Standardised management improves treatment results in seriously injured patients. For conditions like stroke or acute coronary syndrome (ACS) there are set treatment pathways which have been established for prehospital and primary hospital care. The treatment of critical trauma patients, however, follows varying procedures in both the prehospital and primary hospital phases. From an analysis of the trauma register of the German Society for Trauma Surgery (DGU), we know that a seriously injured patient remains on the road for 70 min on average before transferral to hospital. This requires improvement. With the 2003 introduction of the ATLS programme in Germany, the initial clinical phase could be improved upon simply by means of standardised training. PHTLS und ATLS complement one another. PHTLS und ATLS represent training concepts which teach standardised, priority-based prehospital and hospital trauma management. The aim is to make an initial rapid and accurate assessment of the patient's condition, thereby identifying the"critical" patient. The concepts also make priority-based treatment possible and facilitate decision-making as to whether patients can receive further on-the-spot treatment or whether immediate transport is necessary. The procedure is identical in the shock room. The primary consideration is to prevent secondary damage, not to lose track of time and to ensure consistent quality of care. The courses teach systematic knowledge, techniques, skills and conduct in diagnosis and therapy. The courses are oriented to all medical specialities associated with trauma care. With the support of the German Society for Trauma Surgery (DGU) and the German Society for Anesthesiology and Intensive Medicine (DGAI), the German Professional Organisation of Rescue Services (DBRD) has adopted the PHTLS course system on licence from the National Association of Emergency Medical Technicians (NAEMT) and the American College of Surgeons (ACS) and has been offering it in
Stevenson, A G M; Graham, C A; Hall, R; Korsah, P; McGuffie, A C
Background Tracheal intubation is the accepted gold standard for emergency department (ED) airway management. It may be performed by both anaesthetists and emergency physicians (EPs), with or without drugs. Objective To characterise intubation practice in a busy district general hospital ED in Scotland over 40 months between 2003 and 2006. Setting Crosshouse Hospital, a 450‐bed district general hospital serving a mixed urban and rural population; annual ED census 58 000 patients. Methods Prospective observational study using data collection sheets prepared by the Scottish Trauma Audit Group. Proformas were completed at the time of intubation and checked by investigators. Rapid‐sequence induction (RSI) was defined as the co‐administration of an induction agent and suxamethonium. Results 234 intubations over 40 months, with a mean of 6 per month. EPs attempted 108 intubations (46%). Six patients in cardiac arrest on arrival were intubated without drugs. 29 patients were intubated after a gas induction or non‐RSI drug administration. RSI was performed on 199 patients. Patients with trauma constituted 75 (38%) of the RSI group. 29 RSIs (15%) were immediate (required on arrival at the ED) and 154 (77%) were urgent (required within 30 min of arrival at the ED). EPs attempted RSI in 88 (44%) patients and successfully intubated 85 (97%). Anaesthetists attempted RSI in 111 (56%) patients and successfully intubated 108 (97%). Anaesthetists had a higher proportion of good views at first laryngoscopy and there was a trend to a higher rate of successful intubation at the first attempt for anaesthetists. Complication rates were comparable for the two specialties. Conclusions Tracheal intubations using RSI in the ED are performed by EPs almost as often as by anaesthetists in this district hospital. Overall success and complication rates are comparable for the two specialties. Laryngoscopy training and the need to achieve intubation at the first (optimum) attempt
Stevenson, A G M; Graham, C A; Hall, R; Korsah, P; McGuffie, A C
Tracheal intubation is the accepted gold standard for emergency department (ED) airway management. It may be performed by both anaesthetists and emergency physicians (EPs), with or without drugs. To characterise intubation practice in a busy district general hospital ED in Scotland over 40 months between 2003 and 2006. Crosshouse Hospital, a 450-bed district general hospital serving a mixed urban and rural population; annual ED census 58,000 patients. Prospective observational study using data collection sheets prepared by the Scottish Trauma Audit Group. Proformas were completed at the time of intubation and checked by investigators. Rapid-sequence induction (RSI) was defined as the co-administration of an induction agent and suxamethonium. 234 intubations over 40 months, with a mean of 6 per month. EPs attempted 108 intubations (46%). Six patients in cardiac arrest on arrival were intubated without drugs. 29 patients were intubated after a gas induction or non-RSI drug administration. RSI was performed on 199 patients. Patients with trauma constituted 75 (38%) of the RSI group. 29 RSIs (15%) were immediate (required on arrival at the ED) and 154 (77%) were urgent (required within 30 min of arrival at the ED). EPs attempted RSI in 88 (44%) patients and successfully intubated 85 (97%). Anaesthetists attempted RSI in 111 (56%) patients and successfully intubated 108 (97%). Anaesthetists had a higher proportion of good views at first laryngoscopy and there was a trend to a higher rate of successful intubation at the first attempt for anaesthetists. Complication rates were comparable for the two specialties. Tracheal intubations using RSI in the ED are performed by EPs almost as often as by anaesthetists in this district hospital. Overall success and complication rates are comparable for the two specialties. Laryngoscopy training and the need to achieve intubation at the first (optimum) attempt needs to be emphasised in EP airway training.
Kelly, Brendan J; Imai, Ize; Bittinger, Kyle; Laughlin, Alice; Fuchs, Barry D; Bushman, Frederic D; Collman, Ronald G
Lower respiratory tract infection (LRTI) is a major contributor to respiratory failure requiring intubation and mechanical ventilation. LRTI also occurs during mechanical ventilation, increasing the morbidity and mortality of intubated patients. We sought to understand the dynamics of respiratory tract microbiota following intubation and the relationship between microbial community structure and infection. We enrolled a cohort of 15 subjects with respiratory failure requiring intubation and mechanical ventilation from the medical intensive care unit at an academic medical center. Oropharyngeal (OP) and deep endotracheal (ET) secretions were sampled within 24 h of intubation and every 48-72 h thereafter. Bacterial community profiling was carried out by purifying DNA, PCR amplification of 16S ribosomal RNA (rRNA) gene sequences, deep sequencing, and bioinformatic community analysis. We compared enrolled subjects to a cohort of healthy subjects who had lower respiratory tract sampling by bronchoscopy. In contrast to the diverse upper respiratory tract and lower respiratory tract microbiota found in healthy controls, critically ill subjects had lower initial diversity at both sites. Diversity further diminished over time on the ventilator. In several subjects, the bacterial community was dominated by a single taxon over multiple time points. The clinical diagnosis of LRTI ascertained by chart review correlated with low community diversity and dominance of a single taxon. Dominant taxa matched clinical bacterial cultures where cultures were obtained and positive. In several cases, dominant taxa included bacteria not detected by culture, including Ureaplasma parvum and Enterococcus faecalis. Longitudinal analysis of respiratory tract microbiota in critically ill patients provides insight into the pathogenesis and diagnosis of LRTI. 16S rRNA gene sequencing of endotracheal aspirate samples holds promise for expanded pathogen identification.
Elizondo, Eduardo; Navarro, Francisco; Pérez-Romo, Alfredo; Ortega, Concepción; Muñoz, Heberto; Cicero, Raúl
We performed a retrospective chart review to evaluate the indications for endotracheal intubation via flexible fiberoptic bronchoscopy in patients who were scheduled for surgery or who were hospitalized in the intensive care unit of our 1100-bed, tertiary care university hospital. We reviewed 9201 clinical records of anesthetic procedures during which endotracheal intubation had been performed from January to December 2002. We identified 66 patients who had been intubated with flexible fiberoptic bronchoscopy. On preanesthetic examination, 61 of these patients had been found to be poor candidates for conventional laryngoscopic intubation-51 because of abnormal head and neck anatomy and 10 because of reduced visual access to the airway (Mallampati class IV). The remaining 5 patients were intubated via flexible fiberoptic bronchoscopy after conventional intubation had failed during emergency surgery. Our study emphasizes (1) the importance of the preanesthetic examination of surgical patients, to identify those in whom conventional intubation would likely be problematic, and (2) the need to have fiberoptic bronchoscopes and an anesthesiologist or bronchoscopist skilled in their use available in operating suites and intensive care units.
Cushing, M; Shaz, B H
Massive transfusion is an essential part of resuscitation efforts in acute trauma patients. The goal is to quickly correct trauma-induced coagulopathy and replace red blood cell (RBC) mass with the minimal number as well as the appropriate choice of blood components to minimize the possible adverse effects of transfusions. Early trauma induced coagulopathy (ETIC) is present in about 20% of patients upon hospital admission and predicts for decreased survival. The mechanism of ETIC is still being elucidated; however, most theories of ETIC's pathophysiology justify the early use of plasma. Most massive transfusion protocol (MTP) ratios deliver blood products in a ratio of 1:1:1 for RBCs:plasma:platelets, which is supported by the majority of the literature demonstrating improved patient survival with higher ratios (>1 plasma and platelet for every 2 RBCs transfused). Indeed, formula-driven MTPs allow trauma services to react quickly to ETIC and provide coagulation factors and platelets in these ratios without having to wait for the results of coagulation assays while the patient's coagulopathy worsens. New MTPs are being created which are adjusted according to an individual's coagulation laboratory values based on point-of-care laboratory tests, such as thromboelastography. When creating an MTP, product wastage due to inappropriate activation and improper product storage should be considered and closely monitored. Another area of discussion regarding transfusion in trauma includes the potential association of prolonged storage of RBCs and adverse outcomes, which has yet to be confirmed. Significant progress has been made in the transfusion management of trauma patients, but further studies are required to optimize patient care and outcomes.
Gofrit, O N; Leibovici, D; Shemer, J; Henig, A; Shapira, S C
Intubating the subconscious, struggling patient in a pre-hospital setting can be a difficult task even in experienced hands. We performed a clinical prospective study to evaluate the applicability of ketamine for induction of anaesthesia before intubation in the field. Ketamine was distributed to all air medical rescue teams--trained reserve army volunteers from various medical specialties. Lectures and literature concerning the use of ketamine for anaesthesia induction before intubation were given. The physicians were instructed to administer ketamine, in a dose of 2 mg/kg intravenously, if a single intubation attempt failed. Following the administration of ketamine, a questionnaire was filled in by the physician. Analysis of the data was performed after 24 months. During the study period, intubation was indicated in 161 injured patients evacuated by air in Israel. In 29 patients (18 per cent) the first intubation attempt had failed and they were given ketamine. The reasons for failure of the first intubation attempt were restlessness or trismus in 23 patients and traumatic distortion of the upper airway anatomical landmarks in six. Following ketamine administration, intubation was successful in 19 patients (65.5 per cent) in all of whom the indication for ketamine administration was restlessness or trismus. All patients with upper airway anatomy distortion were given a cricothyroidotomy. There were no complications attributed to ketamine. All patients reached hospital alive. This preliminary study suggests that the use of ketamine in this pre-hospital setting is safe. The drug is effective in cases where the primary reason for failure to intubate is restlessness or trismus. The drug is not effective in cases of anatomical damage to the upper airway. In these cases, cricothyroidotomy should probably be performed as early as possible.
Wu, Simon D; Yilmaz, Meltem; Tamul, Paul C; Meeks, Joshua J; Nadler, Robert B
Obesity is associated with adverse outcomes with certain urologic procedures and may make patient positioning more difficult. We describe our technique of awake intubation and prone patient self-positioning before percutaneous nephrolithotomy (PCNL), and review the literature regarding prone positioning in obese patients and the impact of obesity on PCNL. Patient preparation begins with detailed preoperative counseling regarding the procedure. Premedication with a sedative and antisialagogue is followed by airway topicalization to suppress gag reflex and pain. Fiberoptic bronchoscope intubation is then carried out. The patient then positions himself/herself comfortably before induction of general anesthesia. We have successfully performed awake intubation and patient prone self-positioning followed by PCNL, most recently in a 58-year-old (body mass index 51.3 kg/m(2)) man with a history of gastric bypass, diabetes mellitus, and hypertension, without added morbidity. Adverse effect on patient cardiopulmonary dynamics can be minimized in the prone position. The technique of awake intubation with prone patient self-positioning can be helpful for positioning morbidly obese patients before PCNL and has been safe and effective in properly selected patients. Efficacy of PCNL should not be impacted by obesity or prone positioning and morbidity minimized provided that surgical and anesthesia teams understand and safeguard against potential complications.
Hess, M M; Boucher, B A; Laizure, S C; Stevens, R C; Sanders, P L; Janning, S W; Croce, M A; Fabian, T C
To characterize the pharmacokinetic profile of trimethoprim-sulfamethoxazole (TMP-SMX) in trauma patients and to compare these parameter estimates with those obtained in nontrauma patients. Open-label, multidose, pharmacokinetic study. Trauma intensive care unit of a level 1 trauma center located within a regional medical center. Fifteen adult trauma patients with serious gram-negative infections. All patients were studied on day 1 of treatment, nine on day 3, three on day 5, and two on day 7. One patient was discontinued from the study because of a possible drug-induced rash. Study patients received TMP 4 mg/kg and SMX 20 mg/kg intravenously every 12 hours. Serial blood sampling was performed up to 4 times per patient between treatment days 1 and 7. Serum was assayed for TMP-SMX using high-performance liquid chromatography. A one-compartment model was fit to the data using maximum likelihood estimation. Mean (SD) baseline parameter estimates for TMP were volume 2.1 (0.65) L/kg, half-life 9.7 (3.0) hours, and clearance 2.6 (0.80) ml/min/kg. Estimates for SMX were volume 0.51 (0.10) L/kg, half-life 7.8 (2.0) hours, and clearance 0.80 (0.29) ml/min/kg. Both volume (p < 0.01) and clearance (p < 0.001) for SMX were significantly higher and half-life (p < 0.05) significantly shorter than previously reported estimates in nontrauma patients. No significant differences in TMP parameter estimates were found. Neither TMP nor SMX clearance was significantly correlated with estimated creatinine clearance (p > 0.05). The results indicate that the pharmacokinetics of SMX in trauma patients differ significantly from nontrauma patients, which may result in lower than expected concentrations using standard dosing guidelines.
Eyigor, Can; Cagiran, Esra; Balcioglu, Taner; Uyar, Meltem
This is a prospective, randomized, single-blind study. We aimed to compare the tracheal intubation conditions and hemodynamic responses either remifentanil or a combination of remifentanil and lidocaine with sevoflurane induction in the absence of neuromuscular blocking agents. Fifty intellectually disabled, American Society of Anesthesiologists I-II patients who underwent tooth extraction under outpatient general anesthesia were included in this study. Patients were randomized to receive either 2 μg kg(-1) remifentanil (Group 1, n=25) or a combination of 2 μg kg(-1) remifentanil and 1 mg kg(-1) lidocaine (Group 2, n=25). To evaluate intubation conditions, Helbo-Hansen scoring system was used. In patients who scored 2 points or less in all scorings, intubation conditions were considered acceptable, however if any of the scores was greater than 2, intubation conditions were regarded unacceptable. Mean arterial pressure, heart rate and peripheral oxygen saturation (SpO2) were recorded at baseline, after opioid administration, before intubation, and at 1, 3, and 5 min after intubation. Acceptable intubation parameters were achieved in 24 patients in Group 1 (96%) and in 23 patients in Group 2 (92%). In intra-group comparisons, the heart rate and mean arterial pressure values at all-time points in both groups showed a significant decrease compared to baseline values (p=0.000) CONCLUSION: By the addition of 2 μg/kg remifentanil during sevoflurane induction, successful tracheal intubation can be accomplished without using muscle relaxants in intellectually disabled patients who undergo outpatient dental extraction. Also worth noting, the addition of 1mg/kg lidocaine to 2 μg/kg remifentanil does not provide any additional improvement in the intubation parameters. Copyright © 2013 Sociedade Brasileira de Anestesiologia. Published by Elsevier Editora Ltda. All rights reserved.
Eyigor, Can; Cagiran, Esra; Balcioglu, Taner; Uyar, Meltem
This is a prospective, randomized, single-blind study. We aimed to compare the tracheal intubation conditions and hemodynamic responses either remifentanil or a combination of remifentanil and lidocaine with sevoflurane induction in the absence of neuromuscular blocking agents. Fifty intellectually disabled, American Society of Anesthesiologists I-II patients who underwent tooth extraction under outpatient general anesthesia were included in this study. Patients were randomized to receive either 2μg/kg remifentanil (Group 1, n=25) or a combination of 2μg/kg remifentanil and 1mg/kg lidocaine (Group 2, n=25). To evaluate intubation conditions, Helbo-Hansen scoring system was used. In patients who scored 2 points or less in all scorings, intubation conditions were considered acceptable, however if any of the scores was greater than 2, intubation conditions were regarded unacceptable. Mean arterial pressure, heart rate and peripheral oxygen saturation (SpO2) were recorded at baseline, after opioid administration, before intubation, and at 1, 3, and 5 min after intubation. Acceptable intubation parameters were achieved in 24 patients in Group 1 (96%) and in 23 patients in Group 2 (92%). In intra-group comparisons, the heart rate and mean arterial pressure values at all-time points in both groups showed a significant decrease compared to baseline values (p=0.000) CONCLUSION: By the addition of 2μg/kg remifentanil during sevoflurane induction, successful tracheal intubation can be accomplished without using muscle relaxants in intellectually disabled patients who undergo outpatient dental extraction. Also worth noting, the addition of 1mg/kg lidocaine to 2μg/kg remifentanil does not provide any additional improvement in the intubation parameters. Copyright © 2013 Sociedade Brasileira de Anestesiologia. Publicado por Elsevier Editora Ltda. All rights reserved.
Bernhard, M; Matthes, G; Kanz, K G; Waydhas, C; Fischbacher, M; Fischer, M; Böttiger, B W
Patients with multiple trauma presenting with apnea or a gasping breathing pattern (respiratory rate <6/min) require prehospital endotracheal intubation (ETI) and ventilation. Additional indications are hypoxia (S(p)O(2)<90% despite oxygen insufflation and after exclusion of tension pneumothorax), severe traumatic brain injury [Glasgow Coma Scale (GCS)<9], trauma-associated hemodynamic instability [systolic blood pressure (SBP)<90 mmHg] and severe chest trauma with respiratory insufficiency (respiratory rate >29/min). The induction of anesthesia after preoxygenation is conducted as rapid sequence induction (analgesic, hypnotic drug, neuromuscular blocking agent). With the availability of ketamine as a viable alternative, the use of etomidate is not encouraged due to its side effects on adrenal function. An electrocardiogram (ECG), blood pressure measurement and pulse oximetry are needed to monitor the emergency anesthesia and the secured airway. Capnography is absolutely mandatory to confirm correct placement of the endotracheal tube and to monitor tube dislocations as well as ventilation and oxygenation in the prehospital and hospital setting. Because airway management is often complicated in trauma patients, alternative devices and a fiber-optic endoscope need to be available within the hospital. Use of these alternative measures for airway management and ventilation should be considered at the latest after a maximum of three unsuccessful intubation attempts. Emergency medical service (EMS) physicians should to be trained in emergency anesthesia, ETI and alternative methods of airway management on a regular basis. Within hospitals ETI, emergency anesthesia and ventilation are to be conducted by trained and experienced anesthesiologists. When a difficult airway or induction of anesthesia is expected, endotracheal intubation should be supervised or conducted by an anesthesiologist. Normoventilation should be the goal of mechanical ventilation. After arrival in the
Dale, Craig; Angus, Jan E; Sinuff, Tasnim; Mykhalovskiy, Eric
The aim of this critical ethnographic literature review was to explore the evolution of nursing discourse in oral hygiene for intubated and mechanically ventilated patients. The online databases CINAHL and MEDLINE were searched for nurse-authored English language articles published between 1960 and 2011 in peer-reviewed journals. Articles that did not discuss oral problems or related care for intubated adult patients were excluded. Articles that met the inclusion criteria were chronologically reviewed to trace changes in language and focus over time. A total of 469 articles were identified, and 84 papers met all of the inclusion criteria. These articles presented an increasingly scientific and evaluative nursing discourse. Oral care originally focused on patient comfort within the literature; now it is emphasized as an infection control practice for the prevention of ventilator-associated pneumonia (VAP). Despite concern for its neglected application, the literature does not sufficiently address mouth care's practical accomplishment. Mouth care for orally intubated patients is both a science and practice. However, the nursing literature now emphasises a scientific discourse of infection prevention. Inattention to the social and technical complexities of practice may inhibit how nurses learn, discuss and effectively perform this critical aspect of patient care. Copyright © 2012 Elsevier Ltd. All rights reserved.
Miller, Kelsey A; Kimia, Amir; Monuteaux, Michael C; Nagler, Joshua
Correct positioning of the endotracheal tube (ETT) during emergent pediatric intubations can be challenging, and incorrect placement may be associated with higher rates of complications. The aims of this study are to: 1) assess the prevalence of clinically undetected misplaced ETTs after intubation in the pediatric emergency department; 2) identify predictors of ETT misplacement; and 3) evaluate for any association between intubation-related complications and ETT position. In this retrospective cross-sectional study, the primary outcome was rate of unrecognized low or high ETTs detected on confirmatory chest radiographs. The secondary outcome was frequency of complications (i.e., hypoxemia, difficult ventilation, atelectasis, pneumothorax, pneumomediastinum, and aspiration) associated with misplaced ETTs. Multivariable analyses were used to evaluate the associations between patient and procedural characteristics and misplaced ETTs and between ETT position and complications. Seventy-seven of 201 (38.3%) intubations performed in the emergency department resulted in clinically unrecognized misplaced ETTs. Of the misplaced tubes, 45 of 77 (58%) were identified as low and 32 (42%) were high. In multivariable analyses, female sex and decreasing age were associated with increased risk of low tube placement (odds ratio for female sex, 2.4 [95% confidence interval, 1.1-5.1]; odds ratio of decreasing age, 1.16 [95% confidence interval, 1.0-1.3]). Low tube misplacement was associated with an increased risk of intubation-related complications compared to both correct and high tube placement (p < 0.05, Chi-square). Clinically unrecognized ETT misplacement occurs frequently in the pediatric emergency department, with low placement being most common, particularly in girls and younger children. Measures to improve clinical or radiographic recognition of incorrect tube position should be considered. Copyright © 2016 Elsevier Inc. All rights reserved.
Holcomb, John B; Spinella, Philip C
Injury is rapidly becoming the leading cause of death worldwide, and uncontrolled hemorrhage is the leading cause of potentially preventable death. In addition to crystalloid and/or colloid based resuscitation, severely injured trauma patients are routinely transfused RBCs, plasma, platelets, and in some centers either cryoprecipitate or fibrinogen concentrates or whole blood. Optimal timing and quantity of these products in the treatment of hypothermic, coagulopathic and acidotic trauma patients is unclear. The immediate availability of these components is important, as most hemorrhagic deaths occur within the first 3-6h of patient arrival. While there are strongly held opinions and longstanding traditions in their use, there are little data within which to logically guide resuscitation therapy. Many current recommendations are based on euvolemic elective surgery patients and incorporate laboratory data parameters not widely available in the first few minutes after patient arrival. Finally, blood components themselves have evolved over the last 30 years, with great attention paid to product safety and inventory management, yet there are surprisingly limited clinical outcome data describing the long term effects of these changes, or how the components have improved clinical outcomes compared to whole blood therapy. When focused on survival of the rapidly bleeding trauma patient, it is unclear if current component therapy is equivalent to whole blood transfusion. In fact data from the current war in Iraq and Afghanistan suggest otherwise. All of these factors have contributed to the current situation, whereby blood component therapy is highly variable and not driven by long term patient outcomes. This review will address the issues raised above and describe recent trauma patient outcome data utilizing predetermined plasma:platelet:RBC transfusion ratios and an ongoing prospective observational trauma transfusion study. Copyright 2009 The International Association
Böhmer, Andreas B; Poels, Marcel; Kleinbrahm, Kathrin; Lefering, Rolf; Paffrath, Thomas; Bouillon, Bertil; Defosse, Jerome Michel; Gerbershagen, Mark U; Wappler, Frank; Joppich, Robin
Clinical guidelines have been standardized for pre- and in-hospital trauma management in the last decades. Therefore, it is known that prehospital management has changed significantly. Furthermore, in-hospital course may be altered to reduce complications and length of stay (LOS). However, the development of trauma patient in-hospital management as well as LOS in the intensive care unit (ICU) has not been investigated systematically over a long-term period in Germany. Aim of our study is to examine the changes in in-hospital management and LOS in the ICU in moderately and severely injured patients. Patients documented in the TraumaRegister DGU® (TR-DGU) of the German Trauma Society from 2000 to 2011 and admitted to ICU were included in this study. Demographic data, the pattern of injury, injury severity, duration of mechanical ventilation, LOS in the ICU, hospital LOS, and discharge destination were evaluated. The mean values and the standard deviations are shown. The constant variables were calculated with changes over time analyzed by linear regression analysis, and categorical variables were calculated with the chi-square test. A total of 18,048 patients were analyzed. The rate of patients being intubated at the time of ICU admission decreased from 86.8 % in 2000 to 60.0 % in 2011 (p < 0.001). The time of mechanical ventilation decreased from 7.5 ± 10.5 to 4.7 ± 8.7 days. The intensive care unit LOS was reduced from 11.7 ± 12.8 to 9.0 ± 11.3 days and the length of hospital stay from 27.9 ± 28.7 to 21.1 ± 20.4 days (both p < 0.01). The ICU LOS remained stable in the subgroup of mechanically ventilated patients (12.7 ± 13.2 day in 2000, 12,6 ± 12.9 in 2011, p = 0.6), whereas it was reduced in non-mechanically ventilated patients (5.5 ± 6.8 days in 2000, 3.6 ± 4.5 days in 2011; p < 0.001). The reduction LOS in the analyzed dataset is mainly explained by the relevantly reduced rate of
Halpern, Casey H; Milby, Andrew H; Guo, Wensheng; Schuster, James M; Gracias, Vicente H; Stein, Sherman C
Meta-analytic costeffectiveness analysis. Our goal was to compare the results of different management strategies for trauma patients in whom the cervical spine was not clinically evaluable due to impaired consciousness, endotracheal intubation, or painful distracting injuries. We performed a structured literature review related to cervical spine trauma, radiographic clearance techniques (plain radiography, flexion/extension, CT, and MRI), and complications associated with semirigid collar use. Meta-analytic techniques were used to pool data from multiple sources to calculate pooled mean estimates of sensitivities and specificities of imaging techniques for cervical spinal clearance, rates of complications from various clearance strategies and from empirical use of semirigid collars. A decision analysis model was used to compare outcomes and costs among these strategies. Slightly more than 7.5% of patients who are clinically unevaluable have cervical spine injuries, and 42% of these injuries are associated with spinal instability. Sensitivity of plain radiography or fluoroscopy for spinal clearance was 57% (95% CI: 57%-60%). Sensitivities for CT and MRI alone were 83% (82%-84%) and 87% (84%-89%), respectively. Complications associated with collar use ranged from 1.3% (2 days) to 7.1% (10 days) but were usually minor and short-lived. Quadriplegia resulting from spinal instability missed by a clearance test had enormous impacts on longevity, quality of life, and costs. These impacts overshadowed the effects of prolonged collar application, even when the incidence of quadriplegia was extremely low. As currently used, neuroimaging studies for cervical spinal clearance in clinically unevaluable patients are not cost-effective compared with empirical immobilization in a semirigid collar.
Li, Hui; Wang, Wu; Lu, Ya-Ping; Wang, Yan; Chen, Li-Hua; Lei, Li-Pei; Fang, Xiang-Ming
There is an unmet need for a reliable method of airway management for patients in the lateral position. This prospective randomized controlled two-center study was designed to evaluate the feasibility of intubation using a flexible fiberoptic bronchoscope in the lateral position during surgery. Seventy-two patients scheduled for elective nonobstetric surgery in the lateral decubitus position requiring tracheal intubation under general anesthesia at Lishui Central Hospital of Zhejiang Province and Jiaxing First Hospital of Zhejiang Province from April 1, 2015, to September 30, 2015, were enrolled in this study. Patients were randomly assigned to the supine position group (Group S, n = 38) and the lateral position group (Group L, n = 34). Experienced anesthetists performed tracheal intubation with a fiberoptic bronchoscope after general anesthesia. The time required for intubation, intubation success rates, and hemodynamic changes was recorded. Between-group differences were assessed using the Student's t-test, Mann-Whitney U-test, or Chi-square test. The median total time to tracheal intubation was significantly longer in Group S (140.0 [135.8, 150.0] s) compared to Group L (33.0 [24.0, 38.8] s) (P < 0.01). The first-attempt intubation success rate was significantly higher in Group L (97%) compared to Group S (16%). Hemodynamic changes immediately after intubation were more exaggerated in Group S compared to Group L (P = 0.02). Endotracheal intubation with a flexible fiberoptic bronchoscope may be an effective and timesaving technique for patients in the lateral position. Chinese Clinical Trial Register, ChiCTR-IIR-16007814; http://www.chictr.org.cn/showproj.aspx?proj=13183.
Li, Hui; Wang, Wu; Lu, Ya-Ping; Wang, Yan; Chen, Li-Hua; Lei, Li-Pei; Fang, Xiang-Ming
Background: There is an unmet need for a reliable method of airway management for patients in the lateral position. This prospective randomized controlled two-center study was designed to evaluate the feasibility of intubation using a flexible fiberoptic bronchoscope in the lateral position during surgery. Methods: Seventy-two patients scheduled for elective nonobstetric surgery in the lateral decubitus position requiring tracheal intubation under general anesthesia at Lishui Central Hospital of Zhejiang Province and Jiaxing First Hospital of Zhejiang Province from April 1, 2015, to September 30, 2015, were enrolled in this study. Patients were randomly assigned to the supine position group (Group S, n = 38) and the lateral position group (Group L, n = 34). Experienced anesthetists performed tracheal intubation with a fiberoptic bronchoscope after general anesthesia. The time required for intubation, intubation success rates, and hemodynamic changes was recorded. Between-group differences were assessed using the Student's t-test, Mann–Whitney U-test, or Chi-square test. Results: The median total time to tracheal intubation was significantly longer in Group S (140.0 [135.8, 150.0] s) compared to Group L (33.0 [24.0, 38.8] s) (P < 0.01). The first-attempt intubation success rate was significantly higher in Group L (97%) compared to Group S (16%). Hemodynamic changes immediately after intubation were more exaggerated in Group S compared to Group L (P = 0.02). Conclusion: Endotracheal intubation with a flexible fiberoptic bronchoscope may be an effective and timesaving technique for patients in the lateral position. Trial Registration: Chinese Clinical Trial Register, ChiCTR-IIR-16007814; http://www.chictr.org.cn/showproj.aspx?proj=13183. PMID:27569229
Hyde, Glendon A; Savage, Stephanie A; Zarzaur, Ben L; Hart-Hyde, Jensen E; Schaefer, Candace B; Croce, Martin A; Fabian, Timothy C
Patients suffering traumatic brain and chest wall injuries are often difficult to liberate from the ventilator yet best timing of tracheostomy remains ill-defined. While prior studies have addressed early versus late tracheostomy, they generally suffer from the use of historical controls, which cannot account for variations in management over time. Propensity scoring can be utilized to identify controls from the same patient population, minimizing impact of confounding variables. The purpose of this study was to determine outcomes associated with early versus late tracheostomy by application of propensity scoring. Patients requiring intubation within 48h and receiving tracheostomy from January 2010 to June 2012 were identified. Early tracheostomy (ET) was a tracheostomy performed by the fifth hospital day. ET patients were matched to late tracheostomy patients (LT, tracheostomy after day 5) using propensity scoring and compared for multiple outcomes. Cost for services was calculated using average daily billing rates at our institution. One hundred and six patients were included, 53 each in the ET (mean day tracheostomy=4) and the LT (mean day tracheostomy=10) cohorts. The average age was 47 years and 94% suffered blunt injury, with an average NISS of 23.7. Patients in the ET group had significantly shorter TICU LOS (21.4 days vs. 28.6 days, p<0.0001) and significantly fewer ventilator days (16.7 days vs. 21.9, p<0.0001) compared to the LT group. ET patients also had significantly less VAP (34% vs. 64.2%, p=0.0019). In the current era of increased health-care costs, early tracheostomy significantly decreased both pulmonary morbidity and critical care resource utilization. This translates to an appreciable cost savings, at minimum $52,173 per patient and a potential total savings of $2.8million/year for the entire LT cohort. For trauma patients requiring prolonged ventilator support, early tracheostomy should be performed. Copyright © 2014 Elsevier Ltd. All rights
Dash, Sulochana; Balasubramanian, Sreelatha
Quality and safety in anaesthesia is usually monitored by analysis of perioperative mortality-morbidity and are influenced by anaesthetic and non-anaesthetic factors. This study was conducted to analyse the incidence of clinical indicators of quality in endotracheally intubated patients undergoing general abdominal surgeries and obstetric and gynaecological procedures under general anaesthesia and to determine contributing factors for the same. This retrospective study was conducted at our institute over a period of 12 months and 709 case records of patients were reviewed. Patients aged 14 years and more belonging to all ASA groups undergoing abdominal surgeries for general and obstetric and gynaecological causes under General Anaesthesia (GA) with endotracheal intubation posted for both elective and emergency surgeries were included in the study. Demographic details including name, age, sex, hospital number, height, weight, body mass index, type of surgery, nature of surgery, duration, American Society of Anaesthesiologists (ASA) physical status were recorded and presence or absence of clinical indicators of quality (presence of cannot intubate cannot ventilate scenario, occurrence of dental injury, episode of non cardiogenic pulmonary oedema, incidents of residual neuromuscular blockade, existence of aspiration pneumonia, unplanned ICU/HDU admissions, interventions for respiratory/ cardiac arrest, occasions of respiratory distress in the recovery period, occurrence of respiratory arrest within 48 hours and re-intubation) were noted and analysed for all 709 patients. Total 709 patients were analysed in our study. We found that incidence of ICU admission was 1.83% and that of respiratory distress which needed intervention were 0.56%. A total of 0.28% patients needed reintubation. Residual neuromuscular blockade was seen in 0.28% patients. We did not find any case of respiratory and cardiac arrest and also there was no Cannot Ventilate and Cannot Intubate (CVCI
Inal, Mehmet Turan; Memiş, Dilek; Sahin, Sevtap Hekimoglu; Gunday, Isıl
The difficulties with airway management is the main reason for pediatric anesthesia-related morbidity and mortality. To assess the value of modified Mallampati test, Upper-Lip-Bite test, thyromental distance and the ratio of height to thyromental distance to predict difficult intubation in pediatric patients. Prospective analysis. Data were collected from 5 to 11 years old 250 pediatric patients requiring tracheal intubation. The Cormack and Lehane classification was used to evaluate difficult laryngoscopy. Sensitivity, specificity, positive predictive value and AUC values for each test were measured. The sensitivity and specificity of modified Mallampati test were 76.92% and 95.54%, while those for ULBT were 69.23% and 97.32%. The optimal cutoff point for the ratio of height to thyromental distance and thyromental distance for predicting difficult laryngoscopy was 23.5 (sensitivity, 57.69%; specificity, 86.61%) and 5.5cm (sensitivity, 61.54%; specificity, 99.11%). The modified Mallampati was the most sensitive of the tests. The ratio of height to thyromental distance was the least sensitive test. These results suggested that the modified Mallampati and Upper-Lip-Bite tests may be useful in pediatric patients for predicting difficult intubation. Copyright © 2014 Sociedade Brasileira de Anestesiologia. Publicado por Elsevier Editora Ltda. All rights reserved.
Sarkılar, Gamze; Sargın, Mehmet; Sarıtaş, Tuba Berra; Borazan, Hale; Gök, Funda; Kılıçaslan, Alper; Otelcioğlu, Şeref
This study aims to compare the hemodynamic responses to endotracheal intubation performed with direct and video laryngoscope in patients scheduled for cardiac surgery and to assess the airway and laryngoscopic characteristics. One hundred ten patients were equally allocated to either direct Macintosh laryngoscope (n = 55) or indirect Macintosh C-MAC video laryngoscope (n = 55). Systolic, diastolic, and mean arterial pressure, and heart rate were recorded prior to induction anesthesia, and immediately and two minutes after intubation. Airway characteristics (modified Mallampati, thyromental distance, sternomental distance, mouth opening, upper lip bite test, Wilson risk sum score), mask ventilation, laryngoscopic characteristics (Cormack-Lehane, percentage of glottic opening), intubation time, number of attempts, external pressure application, use of stylet and predictors of difficult intubation (modified Mallampati grade 3-4, thyromental distance < 6 cm, upper lip bite test class 3, Wilson risk sum score ≥ 2, Cormack-Lehane grade 3-4) were recorded. Hemodynamic parameters were similar between the groups at all time points of measurement. Airway characteristics and mask ventilation were no significant between the groups. The C-MAC video laryngoscope group had better laryngoscopic view as assessed by Cormack-Lehane and percentage of glottic view, and a longer intubation time. Number of attempts, external pressure, use of stylet, and difficult intubation parameters were similar. Endotracheal intubation performed with direct Macintosh laryngoscope or indirect Macintosh C-MAC video laryngoscope causes similar and stable hemodynamic responses.
Sarkılar, Gamze; Sargın, Mehmet; Sarıtaş, Tuba Berra; Borazan, Hale; Gök, Funda; Kılıçaslan, Alper; Otelcioğlu, Şeref
This study aims to compare the hemodynamic responses to endotracheal intubation performed with direct and video laryngoscope in patients scheduled for cardiac surgery and to assess the airway and laryngoscopic characteristics. One hundred ten patients were equally allocated to either direct Macintosh laryngoscope (n = 55) or indirect Macintosh C-MAC video laryngoscope (n = 55). Systolic, diastolic, and mean arterial pressure, and heart rate were recorded prior to induction anesthesia, and immediately and two minutes after intubation. Airway characteristics (modified Mallampati, thyromental distance, sternomental distance, mouth opening, upper lip bite test, Wilson risk sum score), mask ventilation, laryngoscopic characteristics (Cormack-Lehane, percentage of glottic opening), intubation time, number of attempts, external pressure application, use of stylet and predictors of difficult intubation (modified Mallampati grade 3-4, thyromental distance < 6 cm, upper lip bite test class 3, Wilson risk sum score ≥ 2, Cormack-Lehane grade 3-4) were recorded. Hemodynamic parameters were similar between the groups at all time points of measurement. Airway characteristics and mask ventilation were no significant between the groups. The C-MAC video laryngoscope group had better laryngoscopic view as assessed by Cormack-Lehane and percentage of glottic view, and a longer intubation time. Number of attempts, external pressure, use of stylet, and difficult intubation parameters were similar. Endotracheal intubation performed with direct Macintosh laryngoscope or indirect Macintosh C-MAC video laryngoscope causes similar and stable hemodynamic responses. PMID:26379966
Hansen, Matthew; Loker, William; Warden, Craig
Introduction The association between geographic factors, including transport distance, and pediatric emergency medical services (EMS) run clustering on out-of-hospital pediatric endotracheal intubation is unclear. The objective of this study was to determine if endotracheal intubation procedures are more likely to occur at greater distances from the hospital and near clusters of pediatric calls. Methods This was a retrospective observational study including all EMS runs for patients less than 18 years of age from 2008 to 2014 in a geographically large and diverse Oregon county that includes densely populated urban areas near Portland and remote rural areas. We geocoded scene addresses using the automated address locator created in the cloud-based mapping platform ArcGIS, supplemented with manual address geocoding for remaining cases. We then use the Getis-Ord Gi spatial statistic feature in ArcGIS to map statistically significant spatial clusters (hot spots) of pediatric EMS runs throughout the county. We then superimposed all intubation procedures performed during the study period on maps of pediatric EMS-run hot spots, pediatric population density, fire stations, and hospitals. We also performed multivariable logistic regression to determine if distance traveled to the hospital was associated with intubation after controlling for several confounding variables. Results We identified a total of 7,797 pediatric EMS runs during the study period and 38 endotracheal intubations. In univariate analysis we found that patients who were intubated were similar to those who were not in gender and whether or not they were transported to a children’s hospital. Intubated patients tended to be transported shorter distances and were older than non-intubated patients. Increased distance from the hospital was associated with reduced odds of intubation after controlling for age, sex, scene location, and trauma system entry status in a multivariate logistic regression. The
Hansen, Matthew; Loker, William; Warden, Craig
The association between geographic factors, including transport distance, and pediatric emergency medical services (EMS) run clustering on out-of-hospital pediatric endotracheal intubation is unclear. The objective of this study was to determine if endotracheal intubation procedures are more likely to occur at greater distances from the hospital and near clusters of pediatric calls. This was a retrospective observational study including all EMS runs for patients less than 18 years of age from 2008 to 2014 in a geographically large and diverse Oregon county that includes densely populated urban areas near Portland and remote rural areas. We geocoded scene addresses using the automated address locator created in the cloud-based mapping platform ArcGIS, supplemented with manual address geocoding for remaining cases. We then use the Getis-Ord Gi spatial statistic feature in ArcGIS to map statistically significant spatial clusters (hot spots) of pediatric EMS runs throughout the county. We then superimposed all intubation procedures performed during the study period on maps of pediatric EMS-run hot spots, pediatric population density, fire stations, and hospitals. We also performed multivariable logistic regression to determine if distance traveled to the hospital was associated with intubation after controlling for several confounding variables. We identified a total of 7,797 pediatric EMS runs during the study period and 38 endotracheal intubations. In univariate analysis we found that patients who were intubated were similar to those who were not in gender and whether or not they were transported to a children's hospital. Intubated patients tended to be transported shorter distances and were older than non-intubated patients. Increased distance from the hospital was associated with reduced odds of intubation after controlling for age, sex, scene location, and trauma system entry status in a multivariate logistic regression. The locations of intubations were
Vidya, B; Cariappa, K M; Kamath, Abhay T
Maxillofacial trauma presents a complex problem due to the disruption of normal anatomy. In such cases, we anticipate a difficult oral intubation that may hinder intraoperative IMF. Nasal and skull base fractures do not advocate use of nasotracheal intubation. Hence, other anesthetic techniques should be considered in management of maxillofacial trauma patients with occlusal derangement and nasal deformity. This study evaluates the indications and outcomes of anesthetic management by retromolar, nasal, submental intubation and tracheostomy. Of the 49 maxillofacial trauma cases reviewed, that required intraoperative IMF, 32 underwent nasal intubation, 9 patients had tracheostomy, 5 patients utilized submental approach and 3 underwent retromolar intubation. Among patients who underwent nasal intubation, eight cases needed fiberoptic assistance. In retromolar approach, though no complication was encountered, constant monitoring was mandatory to avoid risk of tube displacement. Consequently, submental intubation required a surgical procedure which could result in a cosmetically acceptable scar. Though invasive, tracheostomy has its benefits for long term ventilation. Intubation of any form performed in a maxillofacial trauma patient is complex and requires both sound judgement and considerable experience.
Vasileiou, Panagiotis V S; Chalkias, Athanasios; Brozou, Vasiliki; Papageorgiou-Brousta, Mary; Kaparos, George; Koutsovasilis, Anastasios; Xanthos, Theodoros; Iacovidou, Nicoletta
Ιnterleukin-6 (IL-6) has been identified as an early biochemical marker of inflammation both in animal and human studies. With this study, we sought to examine the development of local inflammation of the glottic tissues in correlation with the duration of intubation in anesthetized pediatric patients. We measured IL-6 levels in the organic material isolated from the tip of the tube post-extubation in 48 children aged 7 months to 14 years old who were submitted to a total of 72 surgical procedures. A statistically significant positive correlation (ρ = 0.28, p = 0.05) was detected among duration of anesthesia and IL-6 concentration. The odds of having detectable IL-6 levels rose by 36.7 % for every 10 min of anesthetic duration (p = 0.045). In conclusion, the increase of IL-6 in relation to the duration of the intubation indicates an increased risk of inflammation.
Gavrilovska-Brzanov, Aleksandra; Jarallah, Mohhamed Al; Cogliati, Andrea; Mojsova-Mijovska, Maja; Mijuskovic, Dragan; Slaveski, Dimce
Introduction: Cardiac patients are more prone to develop hemodynamic instability on induction of anesthesia and endotracheal intubation. The Airtraq® optical laryngoscope is a single-use rigid video laryngoscope that has been developed to facilitate tracheal intubation. There are limited studies comparing differences in the circulatory responses to Airtraq® and direct Macintosh larynngoscopy in cardiac patients. Aim: The purpose of our study was to evaluate whether there was clinically significant difference between the hemodynamic response to orotracheal intubation guided by either of the two devices (Airtraq® and Macintosh laryngoscopes) in patients who underwent coronary artery bypass grafting surgery. Material and methods: In this clinical study we analyzed the hemodynamic response to endotracheal intubation performed with Airtraq® or Macintosh laryngoscopes in patients who underwent elective coronary artery bypass graft surgery under general anesthesia. Results: We analyzed: blood pressure (systolic, diastolic, mean), heart rate and peripheral oxygen saturation (all notified before induction in anesthesia, immediately after induction, at the time of intubation and thereafter one and five minutes after intubation). We also recorded the maximal values of blood pressure and heart rate, as well as calculated the product of heart rate and systolic blood pressure. There were statistically significant differences in the hemodynamic response between the groups. At the time of intubation, there was significant inter-group difference in heart rate, systolic, diastolic and mean blood pressure. Endotracheal intubation with Macintosh laryngoscope was accompanied by significant increase in blood pressure and heart rate compared to Airtraq® group. Conclusion: The Airtraq® laryngoscope performed better than the Macintosh laryngoscope in terms of hemodynamic to the patient undergoing routine coronary artery bypass graft surgery. PMID:26635435
Kim, Min Jung; Park, Young Sook; Song, You Hong
Objective To identify the associations between the duration of endotracheal intubation and developing post-extubational supraglottic and infraglottic aspiration (PEA) and subsequent aspiration pneumonia. Methods This was a retrospective observational study from January 2009 to November 2014 of all adult patients who had non-neurologic critical illness, required endotracheal intubation and were referred for videofluoroscopic swallowing study. Demographic information, intensive care unit (ICU) admission diagnosis, severity of critical illness, duration of endotracheal intubation, length of stay in ICU, presence of PEA and severity of dysphagia were reviewed. Results Seventy-four patients were enrolled and their PEA frequency was 59%. Patients with PEA had significantly longer endotracheal intubation durations than did those without (median [interquartile range]: 15 [9-21] vs. 10 [6-15] days; p=0.02). In multivariate logistic regression analysis, the endotracheal intubation duration was significantly associated with PEA (odds ratio, 1.09; 95% confidence interval [CI], 1.01-1.18; p=0.04). Spearman correlation analysis of intubation duration and dysphagia severity showed a positive linear association (r=0.282, p=0.02). The areas under the receiver operating characteristic curves (AUCs) of endotracheal intubation duration for developing PEA and aspiration pneumonia were 0.665 (95% CI, 0.542-0.788; p=0.02) and 0.727 (95% CI, 0.614-0.840; p=0.001), respectively. Conclusion In non-neurologic critically ill patients, the duration of endotracheal intubation was independently associated with PEA development. Additionally, the duration was positively correlated with dysphagia severity and may be helpful for identifying patients who require a swallowing evaluation after extubation. PMID:26605174
Sperka, Jana; Hanson, Sheila J; Hoffmann, Raymond G; Dasgupta, Mahua; Meyer, Michael T
Recent Pediatric Advanced Life Support (PALS) guidelines have deemphasized the use of advanced airways in short transport. It is unclear if guideline recommendations have altered practice. We sought to determine if a temporal change exists in the number of prehospital pediatric trauma intubations since the 2005 PALS guidelines update. This is an institutional review board-approved, retrospective, single-center study. Reviewed all pediatric trauma activations where patients younger than 19 years were intubated at the scene, en route or at the level 1 trauma center during 2006 to 2011. Specific complications collected were esophageal intubations, mainstem intubations and need for re-intubations. There were 1012 trauma activations, 1009 pediatric patients, 300 (29.7%) intubated during transport to Children's Hospital of Wisconsin Pediatric Trauma Center (PTC) or upon arrival. Mean age of 9.5 ± 5.9 years. Fifty-seven percent (n = 172) were intubated before PTC, 31.7% (n = 95) field intubations, 25.7% (n = 77) outside facility intubations. 44% (n = 132) at PTC. Age was not a significant variable. There was no difference in the proportion of injured children requiring intubation who were intubated before arrival to the PTC. Those intubated in the field versus a facility had significantly increased mortality (P = 0.0002), longer hospital days (P = 0.0004) including intensive care unit days (P = 0.0003) and ventilator days (P = 0.0003) even when adjusted for illness severity. There was no significant change in the proportion of pretrauma room intubations following the 2005 PALS guidelines even when adjusted for illness or injury severity. Children injured farther from the PTC and more severely injured children were more likely to be intubated before arrival at the PTC.
Hsieh, Ching-Hua; Lai, Wei-Hung; Wu, Shao-Chun; Chen, Yi-Chun; Kuo, Pao-Jen; Hsu, Shiun-Yuan; Hsieh, Hsiao-Yun
Abstract The aim of this study was to investigate and compare the injury characteristics, severity, and outcome between underweight and normal-weight patients hospitalized for the treatment of all kinds of trauma injury. This study was based on a level I trauma center Taiwan. The detailed data of 640 underweight adult trauma patients with a body mass index (BMI) of <18.5 kg/m2 and 6497 normal-weight adult patients (25 > BMI ≥ 18.5 kg/m2) were retrieved from the Trauma Registry System between January 1, 2009, and December 31, 2014. Pearson's chi-square test, Fisher's exact test, and independent Student's t-test were performed to compare the differences. Propensity score matching with logistic regression was used to evaluate the effect of underweight on mortality. Underweight patients presented a different bodily injury pattern and a significantly higher rate of admittance to the intensive care unit (ICU) than did normal-weight patients; however, no significant differences in the Glasgow Coma Scale (GCS) score, injury severity score (ISS), in-hospital mortality, and hospital length of stay were found between the two groups. However, further analysis of the patients stratified by two major injury mechanisms (motorcycle accident and fall injury) revealed that underweight patients had significantly lower GCS scores (13.8 ± 3.0 vs 14.5 ± 2.0, P = 0.020), but higher ISS (10.1 ± 6.9 vs 8.4 ± 5.9, P = 0.005), in-hospital mortality (odds ratio, 4.4; 95% confidence interval, 1.69–11.35; P = 0.006), and ICU admittance rate (24.1% vs 14.3%, P = 0.007) than normal-weight patients in the fall accident group, but not in the motorcycle accident group. However, after propensity score matching, logistic regression analysis of well-matched pairs of patients with either all trauma, motorcycle accident, or fall injury did not show a significant influence of underweight on mortality. Exploratory data analysis revealed that underweight patients
Panic attacks and respiratory disease have been shown to have probable links; which one is the precursor to the other is unknown. However, what is known is that there is a correlation between high serum carbon dioxide and lactate levels, which are suffocation indicators, and panic attacks. Females are at a higher risk of suffering panic attacks than men, as they have been shown to have a lower tolerance of suffocation indicators. The aim of this paper is to review the relevance of panic attacks within the intensive care unit setting, where a significant number of patients with respiratory disease have an oral endotracheal tube, which limits communication and may add to the feeling of panic. Using a reflective model, I revisited the actual scenario and consider the series of events as I reflect in action, and at the conclusion of the situation, I reflect on action. The results show that suffering from panic attacks did not inhibit the patient with weaning from the ventilator. Effective communication between the patient and myself led to recognition of the problem, for the correct treatment to be being given, and enabling subsequent extubation. In conclusion, once the link is made of the likelihood of a patient with respiratory disease being prone to panic attacks, the nurse can communicate with the patient or family to establish whether the patient has a panic disorder. The treatment of a regular benzodiazepine, such as diazepam, and constant reassurance from the nurse can then be given to the patient to minimize the symptoms. Reducing the effects of panic attacks can decrease the distress experienced by the patient and improve the clinical picture to facilitate extubation.
Tang, Chaoliang; Chai, Xiaoqing; Kang, Fang; Huang, Xiang; Hou, Tao; Tang, Fei; Li, Juan
Background. The adverse events induced by intubation and extubation may cause intracranial hemorrhage and increase of intracranial pressure, especially in posterior fossa surgery patients. In this study, we proposed that I-gel combined with tracheal intubation could reduce the stress response of posterior fossa surgery patients. Methods. Sixty-six posterior fossa surgery patients were randomly allocated to receive either tracheal tube intubation (Group TT) or I-gel facilitated endotracheal tube intubation (Group TI). Hemodynamic and respiratory variables, stress and inflammatory response, oxidative stress, anesthesia recovery parameters, and adverse events during emergence were compared. Results. Mean arterial pressure and heart rate were lower in Group TI during intubation and extubation (P < 0.05 versus Group TT). Respiratory variables including peak airway pressure and end-tidal carbon dioxide tension were similar intraoperative, while plasma β-endorphin, cortisol, interleukin-6, tumor necrosis factor-alpha, malondialdehyde concentrations, and blood glucose were significantly lower in Group TI during emergence relative to Group TT. Postoperative bucking and serious hypertensions were seen in Group TT but not in Group TI. Conclusion. Utilization of I-gel combined with endotracheal tube in posterior fossa surgery patients is safe which can yield more stable hemodynamic profile during intubation and emergence and lower inflammatory and oxidative response, leading to uneventful recovery. PMID:26273146
DeRoss, Anthony L; Vane, Dennis W
Trauma is the leading case of death for children in the United States. Effective initial resuscitation of pediatric trauma patients can reduce mortality. Guidelines have been developed to facilitate patient care in a systematic and productive manner. Advances have been made in both diagnostic and therapeutic methods. The evaluation and treatment of trauma patients will continue to engage pediatric surgeons as efforts in trauma prevention become more successful.
Chavan, SG; Gangadharan, S; Gopakumar, AK
Background: The effects of rocuronium at two different doses, that is, 0.6 mg/kg (2 × ED95) and 0.9 mg/kg (3 × ED95), were compared with succinylcholine (2 mg/kg) when used for endotracheal intubation in adult patients for elective surgeries under general anesthesia. Materials and Methods: Ninety patients were divided into three groups of 30 each. Groups A, B received injection rocuronium at 0.6 mg/kg, 0.9 mg/kg respectively and Group C received succinylcholine at 2 mg/kg. Onset of action of relaxant, intubation conditions, time taken to intubate and duration of action were compared. Statistical Analysis Used: To compare the statistical difference in the age, weight, height of the study subjects, onset of action of relaxant, intubation conditions, time taken to intubate, and duration of action analysis of variance and unpaired t-test were used. Results: The onset time was considerably shorter with rocuronium 0.9 mg/kg than 0.6 mg/kg. The onset time of rocuronium 0.9 mg/kg was found to be significantly longer than succinylcholine 2 mg/kg. Time taken to intubate was shortest with succinylcholine 2 mg/kg. The time taken to intubate with the rocuronium 0.9 mg/kg was found to be comparable to that of rocuronium 0.6 mg/kg. Intubation score of rocuronium 0.9 mg/kg was the best (17.75), which was comparable with succinylcholine. However, the intubation score obtained with rocuronium 0.6 mg/kg was inferior. Duration of action was shortest with succinylcholine. The duration of action is prolonged when the dose of rocuronium is increased from 0.6 to 0.9 mg/kg. Conclusion: Rapid sequence induction of anesthesia with propofol and fentanyl, succinylcholine allowed a more rapid endotracheal intubation sequence and created superior intubation conditions than rocuronium. However, the technique of using a large dose of rocuronium to achieve perfect conditions for tracheal intubation may have application whenever succinylcholine is relatively contraindicated. PMID:27833478
Bruder, Eric A; Ball, Ian M; Ridi, Stacy; Pickett, William; Hohl, Corinne
trials in patients undergoing emergency endotracheal intubation for critical illness, including but not limited to trauma, stroke, myocardial infarction, arrhythmia, septic shock, hypovolaemic or haemorrhagic shock, and undifferentiated shock states. We included single (bolus) dose etomidate for emergency airway intervention compared to any other rapid-acting intravenous bolus single-dose induction agent. Refinement of our initial search results by title review, and then by abstract review was carried out by three review authors. Full-text review of potential studies was based on their adherence to our inclusion and exclusion criteria. This was decided by three independent review authors. We reported the decisions regarding inclusion and exclusion in accordance with the PRISMA statement.Electronic database searching yielded 1635 potential titles, and our grey literature search yielded an additional 31 potential titles. Duplicate titles were filtered leaving 1395 titles which underwent review of their titles and abstracts by three review authors. Sixty seven titles were judged to be relevant to our review, however only eight met our inclusion criteria and seven were included in our analysis. We included eight studies in the review and seven in the meta-analysis. Of those seven studies, only two were judged to be at low risk of bias. Overall, no strong evidence exists that etomidate increases mortality in critically ill patients when compared to other bolus dose induction agents (odds ratio (OR) 1.17; 95% confidence interval (CI) 0.86 to 1.60, 6 studies, 772 participants, moderate quality evidence). Due to a large number of participants lost to follow-up, we performed a post hoc sensitivity analysis. This gave a similar result (OR 1.15; 95% CI 0.86 to 1.53). There was evidence that the use of etomidate in critically ill patients was associated with a positive adrenocorticotropic hormone (ACTH) stimulation test, and this difference was more pronounced at between 4 to 6
Cevik, Yunsur; Doğan, Nurettin Özgür; Daş, Murat; Karakayali, Onur; Delice, Orhan; Kavalci, Cemil
The aim of this study was to investigate the factors affecting in-hospital mortality among geriatric trauma patients who presented to the emergency department (ED) following a motor vehicle collision. A retrospective cohort study was carried out in a high-volume tertiary care facility in the central Anatolian Region. Clinical data were extracted from hospital databases for all eligible geriatric patients (either driver, passenger or pedestrian) with entries dated between January 1, 2007, and December 31, 2009. Multivariate logistic regression analysis was used to assess the in-hospital mortality effects of variables including demographic characteristics, trauma mechanisms, injured body parts and various trauma scores. There were 395 geriatric motor vehicle trauma presentations to the ED during the 3-year period. Of these patients, 371 (93.9%) survived, and 24 (6.1%) died in the ED, operating room or intensive care unit. The multivariate logistic regression model included the following variables: heart failure, cranial trauma, abdominal trauma, thoracic trauma, pelvic trauma, Glasgow Coma Score and Injury Severity Score (ISS). These variables were chosen because univariate analysis indicated that they were potential predictors of mortality. The multivariate logistic regression showed that the presence of heart failure (OR: 20.2), cranial trauma (OR: 3.6), abdominal trauma (OR: 26.9), pelvic trauma (OR: 9.9) and ISS (OR: 1.2) were predictors of in-hospital mortality in the study population. In our study, heart failure, cranial trauma, abdominal trauma, pelvic trauma, and ISS were found to be the most important predictors of in-hospital mortality among geriatric motor vehicle trauma patients. © 2013.
Burns, Brian; Habig, Karel; Eason, Hilary; Ware, Sandra
Prehospital rapid sequence intubation (RSI) of critically ill trauma patients is a high-risk procedure that may be associated with an increased rate of severe complications such as failed intubation, failure of oxygenation, hypoxia, hypotension, or need for surgical airway. The objective of this study was to describe the factors associated with difficult intubation in prehospital RSI as defined by more than a single look at laryngoscopy to achieve tracheal intubation. This is an observational study using prospectively collected data. Four hundred forty-three RSIs were performed. Paramedics were the initial laryngoscopist in 290 (65.5%). First-look laryngoscopy resulted in successful tracheal intubation (TI) in 372 (84.0%) (95% confidence interval, 80.3%-87.1%). Intubation was achieved on second look at laryngoscopy in 58 (13.1%). "First-pass" TI was achieved in 394 (88.9%). Overall, successful TI was achieved in 438 (98.9%) (95% confidence interval, 97.4%-99.5%). Complications occurred in 116 (26.2%), with desaturation the commonest in 77 (17.4%). Factors associated with more than 1 look at laryngoscopy before TI included paramedic laryngoscopist and the presence of at least 1 of the following indicators: blood/vomitus in the airway, limited mouth opening, and limited neck movement. Trauma to face/neck, obese body habitus, C-spine precautions, cricoid pressure, midline stabilization, and intubation on the ground did not influence the level of difficulty encountered. Copyright © 2016 Air Medical Journal Associates. Published by Elsevier Inc. All rights reserved.
Jiao, Dechao; Xie, Na; Han, Xinwei; Wu, Gang
To evaluate the feasibility and effectiveness of emergency endotracheal intubation (EEI) under fluoroscopy guidance for patients with acute dyspnea or asphyxia. From October 2011 to October 2014, of 1521 patients with acute dyspnea or asphyxia who required EEI in 6 departments, 43 patients who experienced intubation difficulty or failure were entered into this study. Data on technical success, procedure time, complications, and clinical outcome were collected. The pulse oxygen saturation and Hugh-Jones classification changes were analyzed. Fluoroscopy-guided EEI was technically successful in all patients. Acute dyspnea had resolved in all patients with clinical success rate 100% after the procedure. There were no serious complications during or after the procedure. The pulse oxygen saturation and Hugh-Jones classification showed significant increase after EEI (P < .05). Further treatments, including tracheal stents (n = 21), surgical resection (n = 16), palliative tracheotomy (n = 4), and bronchoscopic treatment (n = 2), were performed 1 to 72 hours after EEI. During a mean follow-up period of 13.2 months, 13 patients had died and 30 patients remained alive without dyspnea. Fluoroscopy-guided EEI is a safe and feasible procedure, and may serve as an alternative treatment option for patients when traditional EEI is unsuccessful. Copyright © 2016 Elsevier Inc. All rights reserved.
Tennyson, Joseph; Ford-Webb, Tucker; Weisberg, Stacy; LeBlanc, Donald
Introduction Endotracheal intubation is a common intervention in critical care patients undergoing helicopter emergency medical services (HEMS) transportation. Measurement of endotracheal tube (ETT) cuff pressures is not common practice in patients referred to our service. Animal studies have demonstrated an association between the pressure of the ETT cuff on the tracheal mucosa and decreased blood flow leading to mucosal ischemia and scarring. Cuff pressures greater than 30 cmH2O impede mucosal capillary blood flow. Multiple prior studies have recommended 30 cmH2O as the maximum safe cuff inflation pressure. This study sought to evaluate the inflation pressures in ETT cuffs of patients presenting to HEMS. Methods We enrolled a convenience sample of patients presenting to UMass Memorial LifeFlight who were intubated by the sending facility or emergency medical services (EMS) agency. Flight crews measured the ETT cuff pressures using a commercially available device. Those patients intubated by the flight crew were excluded from this analysis as the cuff was inflated with the manometer to a standardized pressure. Crews logged the results on a research form, and we analyzed the data using Microsoft Excel and an online statistical analysis tool. Results We analyzed data for 55 patients. There was a mean age of 57 years (range 18–90). The mean ETT cuff pressure was 70 (95% CI= [61–80]) cmH2O. The mean lies 40 cmH2O above the maximum accepted value of 30 cmH2O (p<0.0001). Eighty-four percent (84%) of patients encountered had pressures above the recommended maximum. The most frequently recorded pressure was >120 cmH2O, the maximum pressure on the analog gauge. Conclusion Patients presenting to HEMS after intubation by the referral agency (EMS or hospital) have ETT cuffs inflated to pressures that are, on average, more than double the recommended maximum. These patients are at risk for tracheal mucosal injury and scarring from decreased mucosal capillary blood flow
Tennyson, Joseph; Ford-Webb, Tucker; Weisberg, Stacy; LeBlanc, Donald
Endotracheal intubation is a common intervention in critical care patients undergoing helicopter emergency medical services (HEMS) transportation. Measurement of endotracheal tube (ETT) cuff pressures is not common practice in patients referred to our service. Animal studies have demonstrated an association between the pressure of the ETT cuff on the tracheal mucosa and decreased blood flow leading to mucosal ischemia and scarring. Cuff pressures greater than 30 cmH2O impede mucosal capillary blood flow. Multiple prior studies have recommended 30 cmH2O as the maximum safe cuff inflation pressure. This study sought to evaluate the inflation pressures in ETT cuffs of patients presenting to HEMS. We enrolled a convenience sample of patients presenting to UMass Memorial LifeFlight who were intubated by the sending facility or emergency medical services (EMS) agency. Flight crews measured the ETT cuff pressures using a commercially available device. Those patients intubated by the flight crew were excluded from this analysis as the cuff was inflated with the manometer to a standardized pressure. Crews logged the results on a research form, and we analyzed the data using Microsoft Excel and an online statistical analysis tool. We analyzed data for 55 patients. There was a mean age of 57 years (range 18-90). The mean ETT cuff pressure was 70 (95% CI= [61-80]) cmH2O. The mean lies 40 cmH2O above the maximum accepted value of 30 cmH2O (p<0.0001). Eighty-four percent (84%) of patients encountered had pressures above the recommended maximum. The most frequently recorded pressure was >120 cmH2O, the maximum pressure on the analog gauge. Patients presenting to HEMS after intubation by the referral agency (EMS or hospital) have ETT cuffs inflated to pressures that are, on average, more than double the recommended maximum. These patients are at risk for tracheal mucosal injury and scarring from decreased mucosal capillary blood flow. Hospital and EMS providers should use ETT cuff
Muslim, Muhammad; Bilal, Amer; Salim, Muhammad; Khan, Muhammad Abid; Baseer, Abdul; Ahmed, Manzoor
Penetrating chest trauma is common in this part of the world due to present situation in tribal areas. The first line of management after resuscitation in these patients is tube thoracostomy combined with analgesia and incentive spirometry. After tube thoracostomy following surgery or trauma there are two schools of thought one favours application of continuous low pressure suction to the chest tubes beyond the water seal while other are against it. We studied the application of continuous low pressure suction in patients with penetrating chest trauma. This Randomized clinical controlled trial was conducted in the department of thoracic surgery Post Graduate Medical Institute Lady Reading Hospital Peshawar from July 2007 to March 2008. The objectives of study were to evaluate the effectiveness of continuous low pressure suction in patients with penetrating chest trauma for evacuation of blood, expansion of lung and prevention of clotted Haemothorax. One hundred patients who underwent tube thoracostomy after penetrating chest trauma from fire arm injury or stab wounds were included in the study. Patients with multiple trauma, blunt chest trauma and those intubated for any pulmonary or pleural disease were excluded from the study. After resuscitation, detailed examination and necessary investigations patients were randomized to two groups. Group I included patients who had continuous low pressure suction applied to their chest drains. Group II included those patients whose chest drains were placed on water seal only. Lung expansion development of pneumothorax or clotted Haemothorax, time to removal of chest drain and hospital stay was noted in each group. There were fifty patients in each group. The two groups were not significantly different from each other regarding age, sex, pre-intubation haemoglobin and pre intubation nutritional status. Full lung expansion was achieved in forty six (92%) patients in group I and thirty seven (74%) in group II. Partial lung
Karakuş, Ali; Kekeç, Zeynep; Akçan, Ramazan; Seydaoğlu, Gülşah
In this study, we aimed to determine the effects of trauma severity on cardiac involvement through evaluating the trauma severity score together with diagnostic tests in multiple trauma patients. A trauma score was determined using various trauma severity scales. After obtaining the approval of the ethics committee of the faculty, this prospective study was performed through evaluating 100 multiple trauma patients, aged over 15 years, who applied to our Emergency Department (ED). After determining the trauma severity score using instruments such as the Injury Severity Score (ISS), Glasgow Coma Scale (GCS), and Revised Trauma Score (RTS), the cardiac condition was evaluated using biochemical and radiological diagnostic tests. During the study period, 100 patients were evaluated (78 male, 22 female; mean age: 33.2±15.4; range 15 to 70 years). It was determined that 92 (92%) were blunt trauma cases, and 77 (77%) of them were due to traffic accidents. The majority of cases showed electrocardiogram (ECG) abnormalities (63%) and sinus tachycardia (36%). Abnormal echocardiogram (ECHO) findings, mostly accompanied by ventricular defects (n=24), were determined in 31 of the cases. Nineteen cases with high trauma severity score resulted in death, and 14 of all deaths were secondary to traffic accidents. Trauma scores were found to show a significant difference between the two groups. The ISS trauma scale was determined to be the most effective in terms of indicating heart involvement in patients with multiple traumas. Close follow-up and cardiac monitoring should be applied to patients with high trauma severity scores considering possible cardiac rhythm changes and hemodynamic disturbances due to cardiac involvement.
Greenland, K B; Liu, G; Tan, H; Edwards, M; Irwin, M G
A randomised cross-over study was performed in 34 patients with no evidence of airway difficulties, following induction of general anaesthesia, to compare the efficacy of the Levitan FPS scope (LFPS) and the single-use bougie for tracheal intubation during simulated grade IIIa laryngoscopy. Success rates for intratracheal placement of the device, and the time required for insertion and tracheal intubation were recorded. Both devices were equally successful (31/34 for the LFPS vs 29/34 for the bougie) for insertion into the glottis. The mean insertion time for the LFPS was statistically longer than that for the bougie (4.4-12.5 s) but this difference was not clinically relevant. Intubation times were similar between the two devices. Major problems hindering successful intubation using the LFPS were the presence of a narrow epiglottic-pharyngeal wall space and copious secretions. An inability to maintain the desired shape was the principal cause of failure with the bougie.
Introduction The development of postextubation swallowing dysfunction is well documented in the literature with high prevalence in most studies. However, there are relatively few studies with specific outcomes that focus on the follow-up of these patients until hospital discharge. The purpose of our study was to determine prognostic indicators of dysphagia in ICU patients submitted to prolonged orotracheal intubation (OTI). Methods We conducted a retrospective, observational cohort study from 2010 to 2012 of all patients over 18 years of age admitted to a university hospital ICU who were submitted to prolonged OTI and subsequently received a bedside swallow evaluation (BSE) by a speech pathologist. The prognostic factors analyzed included dysphagia severity rate at the initial swallowing assessment and at hospital discharge, age, time to initiate oral feeding, amount of individual treatment, number of orotracheal intubations, intubation time and length of hospital stay. Results After we excluded patients with neurologic diseases, tracheostomy, esophageal dysphagia and those who were submitted to surgical procedures involving the head and neck, our study sample size was 148 patients. The logistic regression model was used to examine the relationships between independent variables. In the univariate analyses, we found that statistically significant prognostic indicators of dysphagia included dysphagia severity rate at the initial swallowing assessment, time to initiate oral feeding and amount of individual treatment. In the multivariate analysis, we found that dysphagia severity rate at the initial swallowing assessment remained associated with good treatment outcomes. Conclusions Studies of prognostic indicators in different populations with dysphagia can contribute to the design of more effective procedures when evaluating, treating, and monitoring individuals with this type of disorder. Additionally, this study stresses the importance of the initial assessment
Yazdi, Pouya Masroori; Schiodt, Morten
Medication-related osteonecrosis of the jaw (ONJ) is often preceded by dentoalveolar trauma. The aim of this study was to examine the frequency of dentoalveolar trauma precipitated ONJ and compare trauma-precipitated ONJ with spontaneously developing ONJ. This was a retrospective study. All patients were examined according to a standard ONJ chart. Among 149 consecutive ONJ patients from the Copenhagen Cohort, 95 (64%) had a dentoalveolar trauma before referral (trauma group): dental extractions (n = 80); denture-related sore mouth (n = 12); and others (n = 3). The remaining 54 patients had spontaneous ONJ (spontaneous group). The mean time from oral trauma to referral for ONJ was 8 months. This study documented that dentoalveolar trauma precipitated ONJ in the majority of cases. However, even minor trauma, such as intubation and impression tray lesions, precipitated ONJ in a few cases (1%). Besides the occurrence of fistula to the skin and a difference in the male-to-female ratio, we found no significant difference between the spontaneous and trauma groups. Copyright © 2015 Elsevier Inc. All rights reserved.
Lee, Jin Young; Sim, Woo Seog; Kim, Eun Sung; Lee, Sangmin M; Kim, Duk Kyung; Na, Yu Ri; Park, Dahye; Park, Hue Jung
Objective To investigate the incidence of postoperative sore throat (POST) in Korean patients undergoing general anaesthesia with endotracheal intubation and to assess potential risk factors. Methods This prospective study enrolled patients who underwent all types of elective surgical procedures with endotracheal intubation and general anaesthesia. The patients were categorized into group S (those with a POST) or group N (those without a POST). The demographic, clinical and anaesthetic characteristics of each group were compared. Results This study enrolled 207 patients and the overall incidence of POST was 57.5% ( n = 119). Univariate analysis revealed that significantly more patients in group S had a cough at emergence and hoarseness in the postanaesthetic care unit compared with group N. Receiver operating characteristic curve analysis showed that an intracuff pressure ≥17 cmH2O was associated with POST. Multivariate analysis identified an intracuff pressure ≥17 cmH2O and cough at emergence as risk factors for POST. At emergence, as the intracuff pressure over ≥17 cmH2O increased, the incidence of hoarseness increased. Conclusions An intracuff pressure ≥17 cmH2O and a cough at emergence were risk factors for POST in Korean patients. Intracuff monitoring during anaesthesia and a smooth emergence are needed to prevent POST.
Yoo, K Y; Jeong, C W; Jeong, H J; Lee, S H; Na, J H; Kim, S J; Jeong, S T; Lee, J
Dose requirements of thiopental depend on patient characteristics and infusion rate. We determined thiopental dose requirements for induction of anaesthesia, and the effects of remifentanil on cardiovascular and bispectral index (BIS) responses to tracheal intubation in spinal cord-injured (SCI) patients undergoing general anaesthesia. Twenty patients with traumatic complete SCI undergoing elective surgery were enrolled. Twenty patients without SCI served as control. Anaesthesia was induced with thiopental, followed by remifentanil 1 μg/kg and rocuronium 0.8 mg/kg, and maintained with 2% sevoflurane and 50% nitrous oxide in oxygen after tracheal intubation. Thiopental was administered at a rate of 50 mg/15 s until abolition of the eyelash reflex. Thiopental doses, BIS values, systolic arterial blood pressure (SAP), heart rate (HR) and plasma catecholamine concentrations were measured. Total thiopental dose required to abolish the eyelash reflex based on total body weight (BW) (5.26 ± 0.87 vs. 3.91 ± 1.07 mg/kg, P < 0.001) or lean BW (6.56 ± 1.37 vs. 5.24 ± 1.36 mg/kg, P < 0.01) were significantly smaller in the SCI group than in the control. SAP was decreased by induction of anaesthesia with thiopental and remifentanil, and increased by tracheal intubation in both groups. However, the peak SAP after intubation was smaller in the SCI patients. HR increased significantly above baseline values following intubation in both groups with no significant intergroup differences. Hypertension was more frequent in the control group. Norepinephrine concentrations remained unaltered following intubation in both groups. These results suggest that the dose requirements of thiopental for induction of general anaesthesia and subsequent tracheal intubation are reduced in the SCI patients. © 2012 The Authors. Acta Anaesthesiologica Scandinavica © 2012 The Acta Anaesthesiologica Scandinavica Foundation.
Kavakli, Ali Sait; Kavrut Ozturk, Nilgun; Karaveli, Arzu; Onuk, Asuman Arslan; Ozyurek, Lutfi; Inanoglu, Kerem
Nasogastric tube insertion may be difficult in anesthetized and intubated patients with head in the neutral position. Several techniques are available for the successful insertion of nasogastric tube. The primary aim of this study was to investigate the difference in the first attempt success rate of different techniques for insertion of nasogastric tube. Secondary aim was to investigate the difference of the duration of insertion using the selected technique, complications during insertion such as kinking and mucosal bleeding. 200 adult patients, who received general anesthesia for elective abdominal surgeries that required nasogastric tube insertion, were randomized into four groups: Conventional group (Group C), head in the lateral position group (Group L), endotracheal tube assisted group (Group ET) and McGrath video laryngoscope group (Group MG). Success rates, duration of insertion and complications were noted. Success rates of nasogastric tube insertion in first attempt and overall were lower in Group C than Group ET and Group MG. Mean duration and total time for successful insertion of NG tube in first attempt were significantly longer in Group ET. Kinking was higher in Group C. Mucosal bleeding was statistically lower in Group MG. Use of video laryngoscope and endotracheal tube assistance during NG tube insertion compared with conventional technique increase the success rate and reduce the kinking in anesthetized and intubated adult patients. Use of video laryngoscope during nasogastric tube insertion compared to other techniques reduces the mucosal bleeding in anesthetized and intubated adult patients. Copyright © 2016 Sociedade Brasileira de Anestesiologia. Publicado por Elsevier Editora Ltda. All rights reserved.
Silva, Marta João; Aparício, José; Mota, Teresa; Spratley, Jorge; Ribeiro, Augusto
The objective of this study is to report a case of ischemic subglottic damage after a short-time intubation with a large, overinflated endotracheal tube cuff in a child. The study uses individual case report. A 6-year-old boy was admitted to the pediatric intensive care unit after a head trauma intubated with a 5.5-mm inner diameter cuffed endotracheal tube overinflated with 16 ml of air that produced a pressure of more than 120 cm H2O. The endotracheal tube cuff pressure produced by inflation was reduced after 4 h. The child presented postextubation stridor with subglottic edema. Inappropriate handling of tracheal intubation without accurate measurement of endotracheal tube size and intracuff pressures of endotracheal tubes, can cause airway trauma and place patients at risk.
Ko, Byuk Sung; Ahn, Ryeok; Ryoo, Seung Mok; Ahn, Shin; Sohn, Chang Hwan; Seo, Dong Woo; Lim, Kyoung Soo; Kim, Won Young
Emergency endotracheal intubation-related cardiac arrest (CA) is not well documented. This study compares the clinical features and outcomes of intubation-related CA and other causes of inhospital CA. All study patients were consecutive adults (≥18 years) who developed CA in the emergency department between January 2007 and December 2011. Emergent endotracheal intubation-related CA was defined as occurring within 20 minutes after successful intubation. Clinical variables were compared between patients with intubation-related CA and intubation-unrelated CA. The primary outcome was a good neurologic outcome defined as a Cerebral Performance Category score of 1 to 2. The secondary outcome was survival to hospital discharge. Of the 251 patients who developed CA, 41 were excluded due to trauma-related CA or "do-not-resuscitate" protocols, thereby leaving 210 patients. The prevalence of intubation-related CA was 23.3%, and the median duration between successful intubation and CA was 5.0 minutes (interquartile range, 2.0-9.5). Pulseless electrical activity was more commonly noted as the first arrest rhythm in the intubation-related CA group (75.5% vs 59.0%; P = .03) compared with patients with other causes of CA. However, the rates of good neurologic outcomes (14.3% vs 21.1%) and survival to discharge (34.7% vs 35.4%) were not significantly higher in intubation-related CA group (both P > .05). Endotracheal intubation-related CA occurred higher than commonly recognized, and patient outcomes were not better than other causes of CA. These data highlight the importance of efforts to prevent intubation-related CA. However, further prospective larger study will be required to generalize this result. Copyright © 2015 Elsevier Inc. All rights reserved.
Xu, Mao; Li, Xiao-Xi; Guo, Xiang-Yang; Wang, Jun
Background: Airway management is critical in patients with cervical spondylosis, a population with a high incidence of difficult airway. Intubation with Shikani Optical Stylet (SOS) has become increasingly popular in difficult airway. We compared the effects of intubation with SOS versus Macintosh laryngoscope (MLS) in patients undergoing surgery for cervical spondylosis. Methods: A total of 270 patients scheduled for elective surgery for cervical spondylosis of spinal cord and nerve root type from August 2012 to January 2016 were enrolled and randomly allocated to the MLS or SOS group by random numbers. Patients were evaluated for difficult airway preoperatively, and Cormack-Lehane laryngoscopy classification was determined during anesthesia induction. Difficult airway was defined as Cormack-Lehane Grades III–IV. Patients were intubated with the randomly assigned intubation device. The success rate, intubation time, required assistance, immediate complications, and postoperative complaints were recorded. Categorical variables were analyzed by Chi-square test, and continuous variables were analyzed by independent samples t-test or rank sum test. Results: The success rate of intubation among normal airways was 100% in both groups. In patients with difficult airway, the success rates in the MLS and SOS groups were 84.2% and 94.1%, respectively (P = 0.605). Intubation with SOS took longer compared with MLS (normal airway: 25.1 ± 5.8 s vs. 24.5 ± 5.7 s, P = 0.426; difficult airway: 38.5 ± 8.5 s vs. 36.1 ± 8.2 s, P = 0.389). Intubation with SOS required less assistance in patients with difficult airway (5.9% vs. 100%, P < 0.001). The frequency of postoperative sore throat was lower in SOS group versus MLS group in patients with normal airway (22.0% vs. 34.5%, P = 0.034). Conclusions: SOS is a safe and effective airway management device in patients undergoing surgery for cervical spondylosis. Compared with MLS, SOS appears clinically beneficial for intubation
Yang, Shiming; Menne, Ashley; Hu, Peter; Stansbury, Lynn; Gao, Cheng; Dorsey, Nicolas; Chiu, William; Shackelford, Stacy; Mackenzie, Colin
Respiratory rate (RR) is important in many patient care settings; however, direct observation of RR is cumbersome and often inaccurate, and electrocardiogram-derived RR (RRECG) is unreliable. We asked how data derived from the first 15 min of RR recording after trauma center admission using a novel acoustic sensor (RRa) would compare to RRECG and to end-tidal carbon dioxide-based RR ([Formula: see text]) from intubated patients, the "gold standard" in predicting life-saving interventions in unstable trauma patients. In a convenience sample subset of trauma patients admitted to our Level 1 trauma center, enrolled in the ONPOINT study, and monitored with RRECG, some of whom also had [Formula: see text] data, we collected RRa using an adhesive sensor with an integrated acoustic transducer (Masimo RRa™). Using Bland-Altman analysis of area under the receiver operating characteristic (AUROC) curves, we compared the first 15 min of continuous RRa and RRECG to [Formula: see text] and assessed the performance of these three parameters compared to the Revised Trauma Score (RTS) in predicting blood transfusion 3, 6, and 12 h after admission. Of the 1200 patients enrolled in ONPOINT from December 2011 to May 2013, 1191 had RRECG data recorded in the first 15 min, 358 had acoustic monitoring, and 14 of the latter also had [Formula: see text]. The three groups did not differ demographically or in mechanism of injury. RRa showed less bias (0.8 vs. 6.9) and better agreement than RRECG when compared to [Formula: see text]. At [Formula: see text] 10-29 breaths per minute, RRa was more likely to be the same as [Formula: see text] and assign the same RTS. In predicting transfusion, features derived from RRa and RRECG gave AUROCs 0.59-0.66 but with true positive rate 0.70-0.89. RRa monitoring is a non-invasive option to glean valid RR data to assist clinical decision making and could contribute to prediction models in non-intubated unstable trauma patients.
Kelleher, Deirdre C; Waterhouse, Lauren J; Parsons, Samantha E; Fritzeen, Jennifer L; Burd, Randall S; Carter, Elizabeth A
Exposure and environmental control are essential components of the advanced trauma life support primary survey, especially during the resuscitation of pediatric patients. Proper exposure aids in early recognition of injuries in patients unable to communicate their injuries, while warming techniques, such as the use of blankets, assist in maintaining normothermia. The purpose of this study was to identify factors associated with exposure compliance and duration during pediatric trauma resuscitation. All pediatric trauma resuscitations over a 4-month period were reviewed for compliance and time to completion of clothing removal and warm blanket placement. Video review data were then linked with clinical data obtained from the trauma registry. Univariate and multivariate analyses were used to determine the associations of patient characteristics, injury mechanism, and clinical factors on exposure compliance and duration. Of 145 patients, 65 (52%) were never exposed. Lower exposure compliance was associated with increasing age (odds ratio, [OR], 0.90; 95% confidence interval [CI], 0.83-0.98), Glasgow Coma Scale (GCS) score of 14 or greater (OR, 0.16; 95% CI, 0.03-0.76), Injury Severity Score (ISS) of 15 or less (OR, 0.27; 95% CI, 0.09-0.82), and the absence of head injury (OR, 0.26; 95% CI, 0.08-0.87). Among those exposed, the duration of exposure was longer among children with GCS score of less than 14 (4.3 [1.6], p = 0.009), head injuries (3.33 [1.6], p = 0.04), and the need for intubation (8.4 [2.2], p < 0.001). In multivariate analyses, older age and ISS of 15 or less were associated with a decreased odds of exposure (p = 0.009, p = 0.04, respectively), while intubation was associated with increased exposure duration (p = 0.007). Despite the importance of exposure and environmental control during pediatric trauma resuscitation, compliance with these tasks was low, even among severely injured patients. Interventions are needed to promote the proper exposure of
Aitken, Leanne M; Chaboyer, Wendy; Schuetz, Michael; Joyce, Christopher; Macfarlane, Bonnie
To describe the recovery of trauma intensive care patients up to six months posthospital discharge. Injury is a leading cause of preventable mortality and morbidity worldwide, with approximately 10% of hospitalised trauma patients being admitted to intensive care. Intensive care patients experience significant ongoing physical and psychological burden after discharge; however, the patterns of recovery and the subgroups of intensive care patients who experience the greatest burden are not described. This prospective cohort study was conducted in one tertiary referral hospital in south-east Queensland, Australia. Following ethics approval, injured patients who required admission to intensive care provided consent. Participants completed questionnaires prior to hospital discharge (n = 123) and one (n = 93) and six months (n = 88) later. Data included demographic and socioeconomic details, pre-injury health, injury characteristics, acute care factors, postacute factors [self-efficacy, illness perception, perceived social support and psychological status as measured by the Kessler Psychological Distress Scale (K10) and the PTSD Civilian Checklist] and health status (SF-36). All participants required ongoing support from healthcare providers in the six months after discharge from hospital, and approximately half required support services such as accommodation and home modifications. Approximately 20% of participants reported post-traumatic stress symptoms, while approximately half the participants reported psychological distress. Average quality of life scores were significantly below the Australian norms both one and six months postdischarge. Trauma intensive care patients rely on ongoing healthcare professional and social support services. Compromised health-related quality of life and psychological health persists at six months. Effective discharge planning and communication across the care continuum is essential to facilitate access to healthcare providers and other
Kleine-Brueggeney, M; Greif, R; Urwyler, N; Wirthmüller, B; Theiler, L
We compared the Bonfils(™) and SensaScope(™) rigid fibreoptic scopes in 200 patients with a simulated difficult airway randomised to one of the two devices. A cervical collar inhibited neck movement and reduced mouth opening to a mean (SD) of 23 (3) mm. The primary outcome parameter was overall success of tracheal intubation; secondary outcomes included first-attempt success, intubation times, difficulty of intubation, fibreoptic view and side-effects. The mean (95% CI) overall success rate was 88 (80-94)% for the Bonfils and 89 (81-94)% for the SensaScope (p = 0.83). First-attempt intubation success rates were 63 (53-72)% for the Bonfils and 72 (62-81)% for the SensaScope (p = 0.17). Median (IQR [range]) intubation time was significantly shorter with the SensaScope (34 (20-84 [5-240]) s vs. 45 (25-134 [12-230]) s), and fibreoptic view was significantly better with the SensaScope (full view of the glottis in 79% with the SensaScope vs. 61% with the Bonfils). This might be explained by its steerable tip and the S-formed shape, contributing to better manoeuvrability. There were no differences in the difficulty of intubation or side-effects. © 2016 The Association of Anaesthetists of Great Britain and Ireland.
Kurtipek, Omer; Isik, Berrin; Arslan, Mustafa; Unal, Yusuf; Kizil, Yusuf; Kemaloglu, Yusuf
Background and Aim: Obstructive sleep apnea (OSA) syndrome is predisposed to the development of upper airway obstruction during sleep, and it poses considerable problem for anesthetic management. Difficult intubation (DI) is an important problem for management of anesthesia. In this clinical research, we aim to investigate the relationship between DI and prediction criteria of DI in cases with OSA. Materials and Methods: We studied 40 [OSA (Group O, n = 20) and non-OSA, (Group C, n = 20)] ASA I-II, adult patients scheduled tonsillectomy under general anesthesia. Same anesthetic protocol was used in two groups. Intubation difficulties were assessed by Mallampati grading, Wilson sum score, Laryngoscopic grading (Cormack and Lehane), a line joining the angle of the mouth and tragus of the ear with the horizontal, sternomental distance, and tyromental distance. Demographic properties, time-dependent hemodynamic variables, doses of reversal agent, anesthesia and operation times, and recovery parameters were recorded. Results: Significant difference was detected between groups in terms of BMI, Mallampati grading, Wilson weight scores, Laryngoscopic grading, sternomental distance, tyromental distance, doses of reversal agent, and recovery parameters. Conclusion: OSA patient's DI ratio is higher than that of non-OSA patients. BMI Mallampati grading, Wilson weight scores, Laryngoscopic grading, sternomental distance, and tyromental distance evaluation might be predictors for DI in patients with OSA. PMID:23798919
Yıldırım, İlker; İnal, Mehmet Turan; Memiş, Dilek; Turan, F Nesrin
Pregnancy induced anatomical and physiological changes in the airway makes airway management difficult in obstetric patients, thus the preoperative evaluation of the airway is important for obstetric patients. The first aim was determine the effectiveness of the modified mallampati test, the interincisor, sternomental, thyromental distances, the upper limb bite tests and the second aim was to access the effectiveness of the combination of the upper limb bite test with the other tests in obstetric patients. Cross-sectional study. Two hundred and fifty pregnant women scheluded for caesarean section were analyzed. Age, height and weight of the patients were all collected. Preoperative airway evaluation was done by using modified mallampati test. The interincisor, sternomental and thyromental distances and the upper limb bite test was performed. The laryngoscopy difficulty was evaluated by Results:No statistically significant difference was found between age, height and weight (p>0.05). The modified mallampati test, interincisor, sternomental, and thyromental distances revealed a lower number than the number of easy intubations determined by the Cormack-Lehane classification and a higher number than the case number of difficult intubations (p<0.05). The sensitivity and the specificity of the modified mallampati test, the upper limb bite test, the interincisor distance test, the sternomental and thyromental distance tests were found as 73.08, 57.69, 84.62, 80.77, 88.46 and 90.62, 99.11, 83.04, 84.37 and 87.05. When the combinations were examined, the sensitivity and the specificity of the combination of the upper limb bite test with the modified mallampati test were found as 57.69 and 100. When the upper limb bite test was combined with the the interincisor distance, the sensitivity and the specificity were detected as 46.15 and 100. We found 93.75 and 95.30 values as the sensitivity and specificity of the combination of the upper limb bite test with the thyromental
Asghar, Ali; Shamim, Faisal; Aman, Asiyah
Craniofacial abnormalities are associated with mandibular hypoplasia, reduced mandibular space with overcrowding of soft tissues and maxillary hypoplasia. Decreased mouth opening and limitation in jaw protrusion are independent predictors of difficult airway in such patients. The relative difficult problem becomes even graver in the paediatric age group because of their small mouth opening and un-cooperativeness. A child with severe temporomandibular joint (TMJ) ankylosis presented with negligible mouth opening and required surgical correction under general anaesthesia. Successful intubation was performed with endotracheal tube size 5.5 mm using an adult 4.3 mm fiberoptic bronchoscope under inhalational as well as topical anaesthesia.
Suzuki, Hiroto; Nakajima, Waka; Aoyagi, Mitsuo; Takahashi, Minori; Kuzuta, Toshimichi; Osaki, Mami
We experienced the airway management of a morbidly obese patient in prone position utilizing PENTAX-Airwayscope (AWS) which is a novel airway device for endotracheal intubation. A 29-year-old man, who was 150 kg in weight and 51.9 kg x m(-2) in body mass index, was scheduled for the discectomy for lumbar disc herniation. After the topical anesthesia with lidocaine spray, the patient lay on his stomach by himself on the table. Following the induction of general anesthesia with ketamine and dexmedetomidine in prone position, an anatomically curved blade (INTLOCK) was inserted to his oral cavity first, then the body of AWS was attached. With the patient breathing spontaneously, we successfully inserted the reinforced endotracheal tube. After the maintenance of anesthesia with continuous infusion of dexmedetomidine, ketamin and remifentanil, the patient awoke clearly without pain and endotracheal tube was removed safely in the prone position. Although the prone position is not the standard position for endotracheal intubation under general anesthesia, our technique could be performed in emergency situations.
Yersin, Bertrand; Carron, Pierre-Nicolas; Pasquier, Mathieu; Zingg, Tobias
In elderly patients, a blunt trauma of the chest is associated with a significant risk of complications and mortality. The number of ribs fractures (≥ 4), the presence of bilateral rib fractures, of a pulmonary contusion, of existent comorbidities or acute extra-thoracic traumatic lesions, and lastly the severity of thoracic pain, are indeed important risk factors of complications and mortality. Their presence may require hospitalization of the patient. When complications do occur, they are represented by alveolar hypoventilation, pulmonary atelectasia and broncho-pulmonary infections. When hospitalization is required, it may allow for the specific treatment of thoracic pain, including locoregional anesthesia techniques.
Karcz, Marcin K; Papadakos, Peter J
Trauma patients are a diverse population with heterogeneous needs for ventilatory support. This requirement depends mainly on the severity of their ventilatory dysfunction, degree of deterioration in gaseous exchange, any associated injuries, and the individual feasibility of potentially using a noninvasive ventilation approach. Noninvasive ventilation may reduce the need to intubate patients with trauma-related hypoxemia. It is well-known that these patients are at increased risk to develop hypoxemic respiratory failure which may or may not be associated with hypercapnia. Hypoxemia in these patients is due to ventilation perfusion mismatching and right to left shunt because of lung contusion, atelectasis, an inability to clear secretions as well as pneumothorax and/or hemothorax, all of which are common in trauma patients. Noninvasive ventilation has been tried in these patients in order to avoid the complications related to endotracheal intubation, mainly ventilator-associated pneumonia. The potential usefulness of noninvasive ventilation in the ventilatory management of trauma patients, though reported in various studies, has not been sufficiently investigated on a large scale. According to the British Thoracic Society guidelines, the indications and efficacy of noninvasive ventilation treatment in respiratory distress induced by trauma have thus far been inconsistent and merely received a low grade recommendation. In this review paper, we analyse and compare the results of various studies in which noninvasive ventilation was applied and discuss the role and efficacy of this ventilator modality in trauma. PMID:25685722
Fabricius-Bjerre, Andreas; Overgaard, Anders; Winther-Olesen, Marie; Lönn, Lars; Secher, Niels H; Nielsen, Henning B
Brain activation reduces balance between cerebral consumption of oxygen versus carbohydrate as expressed by the so-called cerebral oxygen-carbohydrate-index (OCI). We evaluated whether preparation for surgery, anaesthesia including tracheal intubation and surgery affect OCI. In patients undergoing aortic surgery, arterial to internal jugular venous (a-v) concentration differences for oxygen versus lactate and glucose were determined from before anaesthesia to when the patient left the recovery room. Intravenous anaesthesia was supplemented with thoracic epidural anaesthesia for open aortic surgery (n = 5) and infiltration with bupivacaine for endovascular procedures (n = 14). The a-v difference for O2 decreased throughout anaesthesia and in the recovery room (1.6 ± 1.9 versus 3.2 ± 0.8 mmol l(-1), mean ± SD), and while a-v glucose decreased during surgery and into the recovery (0.4 ± 0.2 versus 0.7 ± 0.2 mmol l(-1) , P<0.05), a-v lactate did not change significantly (0.03 ± 0.16 versus -0.03 ± 0.09 mmol l(-1)). Thus, OCI decreased from 5.2 ± 1.8 before induction of anaesthesia to 3.2 ± 1.0 following tracheal intubation (P<0.05) because of the decrease in a-v O2 with a recovery for OCI to 4.6 ± 1.4 during surgery and to 5.6 ± 1.7 in the recovery room. In conclusion, preparation for surgery and tracheal intubation decrease OCI that recovers during surgery under the influence of sensory blockade. © 2014 Scandinavian Society of Clinical Physiology and Nuclear Medicine. Published by John Wiley & Sons Ltd.
Park, Yong-Hee; Lee, Seung-Hyuk; Lee, Oh Haeng; Kang, Hyun; Shin, Hwa-Yong; Baek, Chong-Wha; Jung, Yong Hun; Woo, Young Cheol
Abstract Background: Intravenous oxycodone has been used as an adjunct to anesthetic agents. This study aimed to assess the optimal dose of intravenous oxycodone for the attenuation of the hemodynamic responses to laryngoscopy and endotracheal intubation. Methods: A prospective, randomized, double-blind study was conducted. Ninety-five patients were randomly divided into 5 groups based on the oxycodone dose: 0, 0.05, 0.1, 0.15, 0.2 mg/kg. After administering the assigned dose of intravenous oxycodone, anesthesia was induced with thiopental. Heart rate (HR) and blood pressure (BP) were measured at baseline, before intubation, and 1, 2, and 3 minutes after intubation. The percentage increase of BP was calculated as (highest BP after intubation − baseline BP)/baseline BP × 100 (%). The percentage increase of HR was calculated in same formula as above. Hypertension was defined as a 15% increase of systolic BP from baseline, and probit analysis was conducted. Results: Hemodynamic data from 86 patients were analyzed. The percentage increase of mean arterial pressure after intubation in groups 0.05, 0.1, 0.15, and 0.2 was significantly different from that in the control (P < 0.001). For HR, the percentage increase was lower than control group when oxycodone was same or more than 0.1 mg/kg (P < 0.05). Using probit analysis, the 95% effective dose (ED95) for preventing hypertension was 0.159 mg/kg (95% confidence interval [CI], 0.122–0.243). In addition, ED50 was 0.020 mg/kg (95% CI, −0.037 to 0.049). However, oxycodone was not effective for maintaining the HR in our study dosage. There were no significant differences in the incidence of hypotension during induction between groups. Conclusions: Using 0.1 mg/kg of intravenous oxycodone is sufficient to attenuate the increase of BP and HR during induction period in healthy patients. The ED95, which was 0.159 mg/kg, can be useful to adjust the dosage of IV oxycodone for maintain stable BP
Amani, Hamed; Lozano, Daniel D; Blome-Eberwein, Sigrid
Home oxygen therapy use has steadily increased for the past 30 years. A majority of these patients suffer from chronic obstructive pulmonary disease secondary to smoking. Although warned of the danger of smoking while on oxygen, patients continue to do so, potentially resulting in cutaneous burns and suspected inhalation injury. Those suspected of inhalation injury are intubated for airway control. In the English literature, there is a paucity of data discussing the need for intubation. To date, this is the largest study to determine whether intubated patients had inhalation injury as observed by bronchoscopy and whether intubation was necessary. All patient's charts who sustained burns while on home oxygen therapy from May 2000 to May 2010 were retrospectively reviewed (n = 86). Data collected were age, sex, TBSA, ventilator days, length of stay (LOS), and presence or absence of inhalation. Of those patients intubated, a subset analysis was performed to determine whether intubation in the "Field" or "Outside Hospital" correlated with inhalation injury compared with intubation in our Emergency Department. Eighty-six patients (mean age 64 years, mean %TBSA 2.6) were included. Before transfer to the burn unit, 32 patients (37%) were intubated and 52 patients (61%) were not intubated. Of the 32 intubated patients, bronchoscopy confirmed inhalation injury in 12 patients (39%). No significant difference was seen in %TBSA between intubated vs nonintubated patients (3.5 vs 2.0, respectively). However, there was a difference in LOS between the two groups (12.7 vs 2.8, respectively). No difference was found in incidence of inhalation injury between patients intubated in the "Field/Outside Hospital" compared with patients intubated in our Emergency Department (39% and 37.5%, respectively). Between the subgroups, no difference was found in %TBSA, ventilator days, or LOS. One patient admitted for airway observation required intubation and one patient failed extubation
Magalhães, Edno; Oliveira Marques, Felipe; Sousa Govêia, Cátia; Araújo Ladeira, Luis Cláudio; Lagares, Jader
Although the incidence of difficult laryngoscopy is similar in obese and non-obese patients, there are more reports of difficult intubation in obese individuals. Alternatives for the diagnosis and prediction of difficult intubation in the preoperative period may help reduce anesthetic complications in obese patients. The aim of this study was to identify predictors for the diagnosis of difficult airway in obese patients, correlating with the clinical methods of pre-anesthetic evaluation and polysomnography. We also compared the incidence of difficult facemask ventilation and difficult laryngoscopy between obese and non-obese patients, identifying the most prevalent predictors. Observational, prospective and comparative study, with 88 adult patients undergoing general anesthesia. In the preoperative period, we evaluated a questionnaire on the clinical predictors of the obstructive sleep apnea syndrome (OSAS) and anatomical parameters. During anesthesia, we evaluated difficult facemask ventilation and laryngoscopy. Descriptive statistics and correlation test were used for analysis. Patients were allocated into two groups: obese group (n=43) and non-obese group (n=45). Physical status, prevalence of snoring, hypertension, diabetes mellitus, neck circumference, and Mallampati index were higher in the obese group. Obese patients had a higher incidence of difficult facemask ventilation and laryngoscopy. There was no correlation between anatomical or clinical variable and difficult facemask ventilation in both groups. In obese patients, the diagnosis of OSAS showed strong correlation with difficult laryngoscopy. The clinical and polysomnographic diagnosis of OSA proved useful in the preoperative diagnosis of difficult laryngoscopy. Obese patients are more prone to difficult facemask ventilation and laryngoscopy. Copyright © 2013 Elsevier Editora Ltda. All rights reserved.
Ahammed, Sk Mahiuddin; Das, Kshaunish; Sarkar, R; Dasgupta, J; Bandopadhyay, S; Dhali, G K
Patient's posture change is commonly employed by a colonoscopist to achieve complete examination. We studied whether patient's posture (left-lateral decubitus vs supine) influenced the success rate of ileal intubation. In this prospective open-label randomized study performed in the Endoscopy Suite of a tertiary-care center, all adult outpatients referred for colonoscopy, in whom cecal intubation was achieved and who satisfied predefined inclusion criteria, were randomized to undergo ileal intubation in either of the above two postures. Colonoscopy (EC-201 WL, Fujinon) was performed after overnight poly-ethylene-glycol preparation, under conscious sedation and continuous pulse-oxymetry monitoring. After confirming cecal intubation, patients were randomized for ileal intubation. Success was defined by visualization of ileal mucosa or villi (confirmed by digital photography) and was attempted until limited by pain and/or time of ≥ 6 min. Of 320 eligible patients, 217 patients (150 males) were randomized, 106 to left-lateral decubitus and 111 to supine posture. At baseline, the two groups were evenly matched. Successful ileal intubation was achieved in 145 (66.8 %) patients overall, significantly higher in the supine posture (74.8 % versus 58.5 %; P = 0.014). On multivariate analysis, supine posture (P = 0.02), average/good right-colon preparation (P < 0.01), non-thin-lipped ileocecal (IC) valve (P < 0.001) and younger age (P = 0.02) were independent predictors of success. Positive ileal findings were recorded in 13 (9 %) patients. Ileoscopy is more successful in supine than in left-lateral decubitus posture. Age, bowel preparation and type of IC valve also determine success.
Mahshidfar, Babak; Sameti, Azadeh; Abbasi, Saeed; Farsi, Davood; Mofidi, Mani; Hafezimoghadam, Peyman; Rahimzadeh, Popak; Rezai, Mahdi
Aims: To evaluate the effect of intravenous (IV) acetaminophen on reducing the need for morphine sulfate in intubated patients admitted to the Intensive Care Unit (ICU). Settings and Design: Current study was done as a clinical trial on the patients supported by mechanical ventilator. Subjects and Methods: Behavioral pain scale (BPS) scoring system was used to measure pain in the patients. All of the patients received 1 g, IV acetaminophen, every 6 h during the 1st and 3rd days of admission and placebo during the 2nd and 4th days. Total dose of morphine sulfate needed, its complications, and the BPS scores at the end of every 6 h interval were compared. Results: Totally forty patients were enrolled. The mean pain scores were significantly lower in the 2nd and 4th days (4.33 and 3.66, respectively; mean: 4.0) in which the patients had received just morphine sulfate compared to the 1st and 3rd days (7.36 and 3.93, respectively; mean: 5.65) in which the patients had received acetaminophen in addition to morphine sulfate too (P < 0.001). Cumulative dose of morphine sulfate used, was significantly higher in the 1st and 3rd days (8.92 and 3.15 mg, respectively; 12.07 mg in total) compared to the 2nd and 4th days (6.47 mg and 3.22 mg, respectively; 9.7 mg in total) (P = 0.035). Conclusion: In our study, IV acetaminophen had no effect on decreasing the BPSs and need of morphine sulfate in intubated patients admitted to ICU. PMID:27630458
Sugiura, Soichiro; Seki, Sumihiko; Hidaka, Kohji; Masuoka, Miharu; Tsuchida, Hideaki
The ultra-short-acting beta1-selective blocker, landiolol, is widely used in Japan. We investigated the effects of landiolol on intubation-induced adrenergic response in 88 patients. General anesthesia was induced and maintained with target-controlled infusion of propofol at an effect-site concentration of 5 microg/mL. Muscle relaxation was obtained with 0.1 mg/kg vecuronium, and endotracheal intubation was performed 4 min after vecuronium injection. We first investigated the optimal time point for landiolol to be administered before intubation in 43 normotensive patients. Then we examined whether landiolol was as effective as fentanyl to prevent tachycardia after intubation in 45 hypertensive patients. Landiolol at 0.1 mg/kg was most effective against intubation-induced tachycardia when infused 4 min before intubation in normotensive patients. However, 0.2 mg/kg landiolol was necessary to prevent tachycardia after intubation in hypertensive patients. Landiolol had no significant effects on arterial blood pressure or bispectral index at any dose throughout the study period. In contrast, 2 mug/kg fentanyl frequently caused hypotension just before and 5 min after intubation. Low doses of landiolol can effectively prevent tachycardia after intubation without significant effects on arterial blood pressure.
Gupta, Deepak; Rusin, Konstantin
In regards to peri-anesthetic morbidity considerations, morbidly obese patients often have full stomach for extended periods secondary to delayed gastric emptying. Additionally, they may have difficulty lying supine because of multiple reasons. The purpose of the study was to compare endotracheal intubation of morbidly obese patients placed in semi-erect position with the rapid sequence induction in the supine position using GlideScope video laryngoscopy. A prospective randomized study was conducted in ASA I-III patients aged 18-65 years who were scheduled for bariatric surgery. Group A (Study Group): General anesthesia was induced in the semi-erect position, and endotracheal intubation was performed by the investigator positioned in front of the patient. The GlideScope blade was held in the right hand of the investigator during intubation and endotracheal tube with rigid stylet was inserted using the left hand. Group B (Control Group): General anesthesia was induced and patient's trachea intubated in the standard supine position. 39 patients underwent endotracheal intubation in semi-erect position (Study Group) and 37 patients underwent endotracheal intubation in supine position (Control Group). No differences were observed in the intubation parameters or patient safety. Intubation times required to secure patients' airways were not significantly insignificant (p = 0.42) between the two groups; desaturation episodes occurred 50% less frequently (though insignificant p = 0.42) in the semierect group. This is the first prospective study demonstrating endotracheal intubation with GlideScope in the semi-erect position as comparable to standard supine position intubation. Moreover, gravity-directed and aligned biomechanics in the semi-erect position may be ergonomically more efficient for intubating morbidly obese patients.
Cierniak, Marcin; Sobczak, Renata; Timler, Dariusz; Wieczorek, Andrzej; Borkowski, Bartosz; Gaszyński, Tomasz
Abstract The intubation difficulties in obese patients are not a new problem. They may result from an accumulation of fat in the oral cavity and cheeks. A thick tongue is also a significant factor. The literature reports that some tests to determine the intubation difficulties in obese people may be unreliable. The observed predictors of difficult intubation were the thyromental and sternomental distance and the intubation difficulty scale: FRONT score. The aim of this study was to assess the degree of difficult intubation in obese patients by the parameters such as the thyromental and sternomental distance. The authors also tried to evaluate the frequency of the guidewire usage and the number of intubation attempts in obese patients in the research sample. The study included the group of 153 patients intubated in prehospital conditions. The research was conducted in 3 clinical centers receiving patients from prehospital care. Among the members of the research sample, obese patients with body mass index >35 were selected and evaluated for various predictors of intubation difficulties. Quantitative analysis of differences in the incidence of the variables was assessed using the chi-squared test for P < 0.05. Analyses were performed in STATISTICA.Complications such as postintubation hematomas were more frequent in obese patients of the research sample. The frequency of the guidewire usage observed in that group was also higher. As anticipated by the adopted predictors, most of the obese patients were classified as difficult to intubate. There is a correlation between the occurrence of injuries and the prevalence of obesity in the research sample and the same dependency has been demonstrated in the issue concerning the use of the guidewire. Although the majority of predictors indicated patients with intubation difficulties, many predictors could show falsely positive results. The greater amount of intubation attempts was observed in obese patients. Further studies
Cierniak, Marcin; Sobczak, Renata; Timler, Dariusz; Wieczorek, Andrzej; Borkowski, Bartosz; Gaszyński, Tomasz
The intubation difficulties in obese patients are not a new problem. They may result from an accumulation of fat in the oral cavity and cheeks. A thick tongue is also a significant factor. The literature reports that some tests to determine the intubation difficulties in obese people may be unreliable. The observed predictors of difficult intubation were the thyromental and sternomental distance and the intubation difficulty scale: FRONT score.The aim of this study was to assess the degree of difficult intubation in obese patients by the parameters such as the thyromental and sternomental distance. The authors also tried to evaluate the frequency of the guidewire usage and the number of intubation attempts in obese patients in the research sample.The study included the group of 153 patients intubated in prehospital conditions. The research was conducted in 3 clinical centers receiving patients from prehospital care. Among the members of the research sample, obese patients with body mass index >35 were selected and evaluated for various predictors of intubation difficulties. Quantitative analysis of differences in the incidence of the variables was assessed using the chi-squared test for P < 0.05. Analyses were performed in STATISTICA.Complications such as postintubation hematomas were more frequent in obese patients of the research sample. The frequency of the guidewire usage observed in that group was also higher. As anticipated by the adopted predictors, most of the obese patients were classified as difficult to intubate.There is a correlation between the occurrence of injuries and the prevalence of obesity in the research sample and the same dependency has been demonstrated in the issue concerning the use of the guidewire. Although the majority of predictors indicated patients with intubation difficulties, many predictors could show falsely positive results. The greater amount of intubation attempts was observed in obese patients. Further studies devoted to
Gawande, Ninad B; Tumram, Nilesh Keshav; Dongre, Anand Paikuji
Modern clinical management of the patients sustaining traumatic injuries and thermal burns has resulted in their longer survival, but the clinical and pathological effects of these traumatic injuries over the myocardium have been largely neglected. It is speculated that certain factors such as the inflammatory and degenerative lesions of the heart, prolonged clinical course, and the subsequent stress and strain may play role in hastening the death. In the present study, 125 hospitalized cases of traumatic injuries and thermal burns brought for medicolegal autopsy were examined, with the purpose to find out the incidence, its significance, and the extent of the myocardial lesions due to stress and strain following trauma. About 20% patients had myocardial lesions recognized at gross and histological examination at autopsy. A myocardial lesion does develop in the cases of traumatic injuries and thermal burns. No significant sex difference is seen in the cases showing positive myocardial lesions. However, a relationship exists between these myocardial lesions and the after-effects developing in the cases of trauma. These myocardial lesions seen in the cases of traumatic injuries can be termed as early ischemic or anoxic lesions in the absence of any specific coronary pathology. The intensity of myocardial lesions increases with increase in the survival period of the patient. The findings in the study support the concept of human stress cardiomyopathy and demonstrate the potential significance of stress in precipitating death.
Cheng, Wei-Chun; Jimmy-Ong; Lee, Chia-Ling; Lan, Cing-Hong; Chen, Tsung-Ying; Lai, Hsien-Yong
The Airway Scope (AWS) provides better glottic view than the conventional direct laryngoscopy in tracheal intubation. With it, the endotracheal tube can be more easily inserted into the tracheal lumen easily. We hereby presented a 24-year-old ankylosing spondylitis (AS) patient wearing a halo vest who was successfully intubated for undergoing cervical spine surgery involving C1 and C2 under general anesthesia. Pre-operative airway assessment revealed that he was a case of difficult intubation. An AWS was used for oral tracheal intubation which was achieved smoothly in the first attempt. AWS can be an alternative device for airway management in a patient wearing halo vest.
Asahi, Yoshinao; Fujii, Ryosuke; Usui, Naoko; Kagamiuchi, Hajime; Omichi, Shiro; Kotani, Junichiro
Disabled patients may face respiratory problems during general anesthesia because of head and neck anomalies. We describe a case of dental treatment under general anesthesia using a laryngeal mask airway in a disabled patient who faced difficulty in endotracheal intubation on several occasions, 5 of which resulted in dental injuries.
Asahi, Yoshinao; Fujii, Ryosuke; Usui, Naoko; Kagamiuchi, Hajime; Omichi, Shiro; Kotani, Junichiro
Disabled patients may face respiratory problems during general anesthesia because of head and neck anomalies. We describe a case of dental treatment under general anesthesia using a laryngeal mask airway in a disabled patient who faced difficulty in endotracheal intubation on several occasions, 5 of which resulted in dental injuries. PMID:25849470
Cho, Hyun-Jun; Kim, Hae-Kyu; Cho, Ah-Reum; Oh, Narae
Background A nasogastric tube (NGT) is commonly inserted into patients undergoing abdominal surgery to decompress the stomach during or after surgery. However, for anatomic reasons, the insertion of NGTs into anesthetized and intubated patients may be challenging. We hypothesized that the use of a tube exchanger for NGT insertion could increase the success rate and reduce complications. Methods One hundred adult patients, aged 20–70 years, who were scheduled for gastrointestinal surgeries with general anesthesia and NGT insertion were enrolled in our study. The patients were randomly allocated to the tube-exchanger group or the control group. The number of attempts, the time required for successful NGT insertion, and the complications were noted for each patient. Results In the tube-exchanger group, the success rate of NGT insertion on the first attempt was 92%, which is significantly higher than 68%, the rate in the control group (P = 0.007). The time required for successful NGT insertion in the tube-exchanger group was 18.5 ± 8.2 seconds, which is significantly shorter than the control group, 75.1 ± 9.8 seconds (P < 0.001). Complications such as laryngeal bleeding and the kinking and knotting of the NGT occurred less often in the tube-exchanger group. Conclusions There were many advantages in using a tube-exchanger as a guide to inserting NGTs in anesthetized and intubated patients. Compared to the conventional technique, the use of a tube-exchanger resulted in a higher the success rate of insertion on the first attempt, a shorter procedure time, and fewer complications. PMID:27924196
Kim, Hyae-Jin; Lee, Hyeon Jeong; Cho, Hyun-Jun; Kim, Hae-Kyu; Cho, Ah-Reum; Oh, Narae
A nasogastric tube (NGT) is commonly inserted into patients undergoing abdominal surgery to decompress the stomach during or after surgery. However, for anatomic reasons, the insertion of NGTs into anesthetized and intubated patients may be challenging. We hypothesized that the use of a tube exchanger for NGT insertion could increase the success rate and reduce complications. One hundred adult patients, aged 20-70 years, who were scheduled for gastrointestinal surgeries with general anesthesia and NGT insertion were enrolled in our study. The patients were randomly allocated to the tube-exchanger group or the control group. The number of attempts, the time required for successful NGT insertion, and the complications were noted for each patient. In the tube-exchanger group, the success rate of NGT insertion on the first attempt was 92%, which is significantly higher than 68%, the rate in the control group (P = 0.007). The time required for successful NGT insertion in the tube-exchanger group was 18.5 ± 8.2 seconds, which is significantly shorter than the control group, 75.1 ± 9.8 seconds (P < 0.001). Complications such as laryngeal bleeding and the kinking and knotting of the NGT occurred less often in the tube-exchanger group. There were many advantages in using a tube-exchanger as a guide to inserting NGTs in anesthetized and intubated patients. Compared to the conventional technique, the use of a tube-exchanger resulted in a higher the success rate of insertion on the first attempt, a shorter procedure time, and fewer complications.
Prekker, Matthew E.; Kwok, Heemun; Shin, Jenny; Carlbom, David; Grabinsky, Andreas; Rea, Thomas D.
Objective Endotracheal intubation success rates in the prehospital setting are variable. Our objective was to describe the challenges encountered and corrective actions taken during the process of endotracheal intubation by paramedics. Design Analysis of prehospital airway management using a prospective registry that was linked to an emergency medical services (EMS) administrative database. Setting EMS system serving King County, Washington, 2006-2011. Paramedics in this system have the capability to administer neuromuscular blocking agents to facilitate intubation (i.e. rapid sequence intubation). Patients A total of 7,523 patients >12 years old in whom paramedics attempted prehospital endotracheal intubation. Interventions None Measurements and Main Results An intubation attempt was defined as the introduction of the laryngoscope into the patient's mouth, and the attempt concluded when the laryngoscope was removed from the mouth. Endotracheal intubation was successful on the first attempt in 77% and ultimately successful in 99% of patients (7,433 of 7,523). Paramedics used a rapid sequence intubation strategy on 54% of first attempts. Among the subset with a failed first attempt (N=1,715), bodily fluids obstructing the laryngeal view (50%), obesity (28%), patient positioning (17%), and facial or spinal trauma (6%) were identified as challenges to intubation. A variety of adjustments were made to achieve intubation success, including upper airway suctioning (used in 43% of attempts resulting in success), patient repositioning (38%), rescue bougie use (19%), operator change (16%), and rescue rapid sequence intubation (6%). Surgical cricothyrotomy (0.4%, N=27) and bag-valve-mask ventilation (0.8%, N=60) were rarely performed by paramedics as final rescue airway strategies. Conclusions Airway management in the prehospital setting has substantial challenges. Success can require a collection of adjustments that involve equipment, personnel, and medication often in a
Müller, F S; Meyer, O W; Chocano-Bedoya, P; Schietzel, S; Gagesch, M; Freystaetter, G; Neuhaus, V; Simmen, H-P; Langhans, W; Bischoff-Ferrari, H A
Malnutrition is an established risk factor for adverse clinical outcomes. Our aim was to assess nutritional status among geriatric trauma patients. We enrolled 169 consecutive patients (⩾70 years) admitted to the Geriatric Traumatology Centre (University Hospital Zurich, Switzerland). On admission to acute care, nutritional status was assessed with the mini nutritional assessment (score<17=malnourished (M), ⩽23.5=at risk of malnutrition (ARM), >23.5=normal). At the same examination, we assessed mental (Geriatric Depression Scale; GDS) and cognitive function (Mini-Mental State Examination; MMSE), frailty status (Fried Scale), and number of comorbidities and medications. Further, discharge destination was documented. All analyses were adjusted for age and gender. A total of 7.1% of patients were malnourished and 49.1% were ARM. Patients with reduced mental health (GDS⩾5: 30.5 vs 11.5%; P=0.004), impaired cognitive function (MMSE⩽26: 23.6±0.5 vs 26.0±0.6; P=0.004), prevalent frailty (32.5 vs 8%; P<0.001), more comorbidities (2.3±0.1 vs 1.3±0.2; P<0.0001) and medications (5.6±0.3 vs 3.4±0.4; P<0.0001) were more likely to have an impaired nutritional status (M+ARM). Further, M+ARM patients were twice as likely to be discharged to destinations different to home (odds ratio=2.08; confidence interval 1.07-4.05). In this consecutive sample of geriatric trauma patients, 56.2% had an M+ARM upon admission to acute care, which was associated with indicators of worse physical, mental and cognitive health and predicted a more than twofold greater odds of being discharged to a destination other than home.
Sheta, Saad A.; Abdelhalim, Ashraf A.; ElZoughari, Ismail A.; AlZahrani, Tariq A.; Al-Saeed, Abdulhamid H.
Objectives: To evaluate Parker Flex-It stylet as an alternative to GlideRite Rigid stylet to aid tracheal intubation with the Glidescope. Methods: This prospective randomized trial was conducted at King Abdulaziz University Hospital, College of Medicine, King Saud University, Riyadh, Saudi Arabia between May and December 2014. Sixty American Society of Anesthesiologists I-II patients were randomly assigned to one of 2 equal groups receiving intubation by Glidescope using either GlideRite Rigid stylet (Group GS) or Parker Flex-It stylet (Group PS). The total intubation time, ease of intubation, incidences of successful intubation at first attempt, number of intubation attempts, use of optimization maneuvers, and possible complications were recorded. Results: No significant differences between both groups regarding the total intubation time (p=0.08) was observed. Intubation was significantly easier in group PS compared with group GS as measured by visual analogue scale (p=0.001) with no significant differences between the groups regarding the rate of successful tracheal intubation from first attempt (p=0.524). However, the number of attempts at intubation and usage of external laryngeal manipulation were similar in both groups (p>0.05). The incidence of sore throat, dysphagia, hoarseness, and trauma were significantly higher in group GS (p<0.05). Conclusion: Parker Flex-It stylet is as effective as GlideRite Rigid stylet when used by experienced operators in patients with normal airways using Glidescope; however, it is easier and less traumatic. PMID:26620987
Proctor, Kenneth G; Atapattu, Suresh A; Duncan, Robert C
Heart rate variability (HRV) changes often reflect autonomic dysfunction with high sensitivity, but the specificity is also low. There are several different methods for measuring HRV, but interpretation is often complex, and the units are not interchangeable. For these reasons, HRV monitoring is not routinely used in many clinical situations. We hypothesized that the specificity of HRV as a screening tool for trauma patients could be improved by controlling some of the confounding influences using multiple logistic regression. A prospective observational trial with waiver of consent was performed in 243 healthy student volunteers and 257 trauma patients, in the resuscitation bay and intensive care units of a Level I trauma center, who received computed axial tomography (CT) scans of the head as part of the initial work up. Electrocardiogram results were recorded for 5 minutes. HRV was defined by SD of normal R-R intervals (SDNN5) and by root mean square of successive differences of R-R intervals (RMSSD5). A head CT scan was considered positive (+) if there were abnormalities in the parenchyma (diffuse axonal injury or contusion), vasculature (intraparenchymal, subdural, or epidural hemorrhage), and/or structural or bony components (fractures of the face or cranium). In volunteers, SDNN5 was 73 +/- 15 (M +/- SD) milliseconds, compared with 42 +/- 22, 31 +/- 19, 28 +/- 17, and 12 +/- 8 milliseconds in, CT(-) patients with no sedation (n = 82), CT(-) with sedation (n = 60), CT(+) with no sedation (n = 55), and CT(+) with sedation (n = 60), respectively. The differences between trauma, sedation, and CT categories were significant (all p < 0.001). RMSSD5 differences were similar and also highly significant (all p < 0.001). For both SDNN5 and RMSSD5, in each category, there was wide overlap in the range of values, and strong inverse correlations with heart rate (all p < 0.001). Using multiple logistic regression in a subset with no missing data (n = 194), an index was
Prekker, Matthew E; Kwok, Heemun; Shin, Jenny; Carlbom, David; Grabinsky, Andreas; Rea, Thomas D
Endotracheal intubation success rates in the prehospital setting are variable. Our objective was to describe the challenges encountered and corrective actions taken during the process of endotracheal intubation by paramedics. Analysis of prehospital airway management using a prospective registry that was linked to an emergency medical services administrative database. Emergency medical services system serving King County, Washington, 2006-2011. Paramedics in this system have the capability to administer neuromuscular blocking agents to facilitate intubation (i.e., rapid sequence intubation). A total of 7,523 patients more than 12 years old in whom paramedics attempted prehospital endotracheal intubation. None. An intubation attempt was defined as the introduction of the laryngoscope into the patient's mouth, and the attempt concluded when the laryngoscope was removed from the mouth. Endotracheal intubation was successful on the first attempt in 77% and ultimately successful in 99% of patients (7,433 of 7,523). Paramedics used a rapid sequence intubation strategy on 54% of first attempts. Among the subset with a failed first attempt (n = 1,715), bodily fluids obstructing the laryngeal view (50%), obesity (28%), patient positioning (17%), and facial or spinal trauma (6%) were identified as challenges to intubation. A variety of adjustments were made to achieve intubation success, including upper airway suctioning (used in 43% of attempts resulting in success), patient repositioning (38%), rescue bougie use (19%), operator change (16%), and rescue rapid sequence intubation (6%). Surgical cricothyrotomy (0.4%, n = 27) and bag-valve-mask ventilation (0.8%, n = 60) were rarely performed by paramedics as final rescue airway strategies. Airway management in the prehospital setting has substantial challenges. Success can require a collection of adjustments that involve equipment, personnel, and medication often in a simultaneous fashion.
Life trauma is highly correlated with an increased risk of mortality from chronic disease. Trauma-informed care (TIC) is an evidence-based approach to deliver healthcare in a way that recognizes and responds to the long-term health effects of the experience of trauma in patients' lives. Four essential features and six defining concepts delineate a TIC approach to healthcare. Nurses can realize the benefits and learn the tenets of TIC to deliver superior care to patients with chronic illness.
Otuzoğlu, Münevver; Karahan, Azize
Communication with non-speaking patients in intensive care unit is stress for both nurse and patients. Semi-experimental study that took place at a University Hospital was to develop illustrated material for patient communication and determine its effectiveness. The study sample consisted of 90 intubated patients at the Adult Cardiovascular Intensive Care Unit who had undergone open heart surgery. The patients were divided into the intervention and control groups. Data analysis was with descriptive statistics and the χ(2) test. The illustrated communication material was stated to be helpful by 77.8% and partially helpful by 22.2% of the intervention group patients regarding the communication between the health-care staff and the patients. Control group patients had more difficulties communicating with the health-care staff. Illustrated communication material was an effective method in communicating with intubated patients. © 2013 Wiley Publishing Asia Pty Ltd.
Wang, Jun; Wang, Zhi-Ping; Wang, Hao-Xing; Shao, Mu-Qing; Mu, Hui-Jun
Endotracheal intubation elicits a hemodynamic response associated with increased heart rate and blood pressure that is influenced by the angiotensin-converting enzyme (ACE) insertion (I)/deletion (D) genetic polymorphism which may be of importance also for the pressure response to anesthesia. A total of 337 patients underwent abdominal surgery in general anesthesia and 16% were D/D-homozygotes, 45% were I/D heterozygotes and 39% of the patients were I/I homozygotes. Before surgery most patients were in treatment for arterial hypertension. Systolic and diastolic pressure, heart rate and concentrations of catecholamines in blood were determined before and after induction of anesthesia and for up to 10 minutes following endotracheal intubation. Anesthesia decreased blood pressure and for patients presenting ID and DD, blood pressure and heart rate reached similar levels but compared to II-homozygotes, D-carriers demonstrated significantly higher levels for systolic pressure and heart rate before and after intubation (p < 0.05). The blood levels of catercholamines were similar in the three genotype groups. The incidence of ECG-determined myocardial ischemia was higher in D-allele carriers compared to I-allele homozygotes (DD 22%, ID 25% vs. II 5%). In response to anesthesia and intubation and independent of sympathetic nervous activity, D-allele carriers for ACE polymorphism increased blood pressure response and higher risk for development of cardiovascular complications compared to patients homozygous for the I-allele.
Hayat, Umar; Lee, Peter J; Ullah, Hamid; Sarvepalli, Shashank; Lopez, Rocio; Vargo, John J
Prophylactic endotracheal intubation (PEI) is often advocated to mitigate the risk of cardiopulmonary adverse events in patients presenting with brisk upper GI bleeding (UGIB). However, the benefit of such a measure remains controversial. Our study aimed to compare the incidence of cardiopulmonary unplanned events between critically ill patients with brisk UGIB who underwent endotracheal intubation versus those who did not. Patients aged 18 years or older who presented at Cleveland Clinic between 2011 and 2014 with hematemesis and/or patients with melena with consequential hypovolemic shock were included. The primary outcome was a composite of several cardiopulmonary unplanned events (pneumonia, pulmonary edema, acute respiratory distress syndrome, persistent shock/hypotension after the procedure, arrhythmia, myocardial infarction, and cardiac arrest) occurring within 48 hours of the endoscopic procedure. Propensity score matching was used to match each patient 1:1 in variables that could influence the decision to intubate. These included Glasgow Blatchford Score, Charleston Comorbidity Index, and Acute Physiology and Chronic Health Evaluation scores. Two hundred patients were included in the final analysis. The baseline characteristics, comorbidity scores, and prognostic scores were similar between the 2 groups. The overall cardiopulmonary unplanned event rates were significantly higher in the intubated group compared with the nonintubated group (20% vs 6%, P = .008), which remained significant (P = .012) after adjusting for the presence of esophageal varices. PEI before an EGD for brisk UGIB in critically ill patients is associated with an increased risk of unplanned cardiopulmonary events. The benefits and risks of intubation should be carefully weighed when considering airway protection before an EGD in this group of patients. Copyright © 2017 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.
Ucgun, Irfan; Metintas, Muzaffer; Moral, Hale; Alatas, Fusun; Yildirim, Huseyin; Erginel, Sinan
Mortality rate, the possible factors affecting mortality and intubation in patients with acute exacerbation of chronic obstructive pulmonary diseases (COPD) and hypercapnic respiratory failure (RF) are yet unclear. To identify the possible factors affecting mortality and intubation in COPD patients. A prospective study using data obtained over the first 24h of respiratory intensive care unit (RICU) admission. Consecutive admissions of 656 patients were monitored and 151 of them who had acute exacerbation of COPD and hypercapnic RF were enrolled. University hospital, Department of Chest Diseases, RICU. Mean age was 65.1 years. The mean APACHE II score was 23.7. Eighty-seven patients (57.6%) received mechanical ventilation (MV) via an endotracheal tube for more than 24 h. Twenty-two patients received non-invasive ventilation (NIV). Fifty patients died (33.1%) in hospital during the study period. The mortality rate was 52.9% in patients in need of MV. In the multivariate analysis, the need for intubation, inadequate metabolic compensation for respiratory acidosis, and low (=bad) Glasgow Coma Score (GCS) were determined as independent factors associated with mortality. The low GCS (OR: 0.61; CI: 0.48-0.78) and high APACHE II score (OR: 1.24; CI: 1.11-1.38) were determined as factors associated with intubation. The most important predictors related to hospital mortality were the need for invasive ventilation and complications to MV. Adequate metabolic compensation for respiratory acidosis at admittance is associated with better survival. A high APACHE II score and loss of consciousness (low GCS) were independent predictors of a need to intubate patients.
Daly, Emma; Miles, Anna; Scott, Samantha; Gillham, Michael
This retrospective audit set out to identify referral rates, swallowing characteristics, and risk factors for dysphagia and silent aspiration in at-risk patients after cardiac surgery. Dysphagia and silent aspiration are associated with poorer outcomes post cardiac surgery. One hundred ninety patients who survived cardiac surgery and received more than 48 hours of intubation were included. Preoperative, perioperative, and postoperative information was collected. Forty-one patients (22%) were referred to speech-language pathology for a swallowing assessment. Twenty-four of these patients (13%) underwent instrumental swallowing assessment, and silent aspiration was observed in 17 (70% of patients diagnosed as having dysphagia via instrumental assessment). Multilogistic analysis revealed previous stroke (P < .05), postoperative stroke (P < .001), and tracheostomy (P < .001) independently associated with dysphagia. The odds ratio for being diagnosed as having pneumonia, if a patient was diagnosed as having dysphagia, was 3.3. Patients identified with dysphagia after cardiac surgery had a high incidence of silent aspiration and increased risk of pneumonia. However, referral rates were low in this at-risk patient group. Early identification and ongoing assessment and appropriate management of dysphagic patients by a speech-language pathologist are strongly recommended. Copyright © 2015 Elsevier Inc. All rights reserved.
Moore, Jaime E; Hu, Amanda; Rutt, Amy; Green, Parmis; Hawkshaw, Mary; Sataloff, Robert T
Vocal fold injury is a well-know complication of intubation, with rates reported as high as 69%. Laryngology textbooks recommend the use of a small endotracheal tube (ETT) to help avoid these complications and optimize visualization. Case reports have suggested that the rigid stylet can lead to laryngeal injury. Given the additional risks, intubation without the stylet is our preferred practice. There is limited documentation in the literature regarding this viewpoint. Our study investigated the feasibility of and potential barriers to intubation using 5.0 ETT without a stylet. Prospective study. Consecutive adult patients undergoing laryngeal surgery were recruited for intubation with a 5.0 ETT without a stylet. Demographic data, specialty and training level of the intubator, and factors that would predict a difficult intubation were recorded. Descriptive statistical analysis was performed. Findings of the participants (n = 67) included average American Society of Anesthesiologists (ASA) physical status classification (2.2), average Mallampati score (1.7), average Cormack-Lehane grade (1.5), and average body mass index (28.0). Five patients (7.4%) required intubation using a stylet, and one of these five participants was intubated initially with a stylet. Of these five participants, 80% required use of a GlideScope (P < .001), and they had significantly higher ASA classification (P = .047) and number of intubation attempts (P = .042). One patient sustained an oropharyngeal injury during intubation with a stylet. No participants had laryngeal injury. Most patients can be intubated successfully using a 5.0 ETT without a stylet. There were no cases of laryngeal trauma with this technique. 2b. © 2014 The American Laryngological, Rhinological and Otological Society, Inc.
Shukeri, Wan Fadzlina Wan Muhd; Hassan, Wan Mohd Nazaruddin Wan; Nadarajan, Chandran
Accidental endobronchial intubation is a frequent complication in critically ill patients requiring tracheal intubation (TI). If such complication occurs, it is more often the right main bronchus that is intubated due to anatomical reasons. Left main bronchus (LMB) intubation is rare. Here, we report a case with auscultatory, bronchoscopic, and radiographic evidence of accidental LMB intubation in a pregnant woman with dengue shock syndrome. We highlight this case to increase awareness about this possible-but-rare complication of TI. PMID:27275080
Zeckey, C; Wendt, K; Mommsen, P; Winkelmann, M; Frömke, C; Weidemann, J; Stübig, T; Krettek, C; Hildebrand, F
Chest trauma is a relevant risk factor for mortality after multiple trauma. Kinetic therapy (KT) represents a potential treatment option in order to restore pulmonary function. Decision criteria for performing kinetic therapy are not fully elucidated. The purpose of this study was to investigate the decision making process to initiate kinetic therapy in a well defined multiple trauma cohort. A retrospective analysis (2000-2009) of polytrauma patients (age > 16 years, ISS ⩾ 16) with severe chest trauma (AIS(Chest) ⩾ 3) was performed. Patients with AIS(Head) ⩾ 3 were excluded. Patients receiving either kinetic (KT+) or lung protective ventilation strategy (KT-) were compared. Chest trauma was classified according to the AIS(Chest), Pulmonary Contusion Score (PCS), Wagner Jamieson Score and Thoracic Trauma Severity Score (TTS). There were multiple outcome parameters investigated included mortality, posttraumatic complications and clinical data. A multivariate regression analysis was performed. Two hundred and eighty-three patients were included (KT+: n=160; KT-: n=123). AIS(Chest), age and gender were comparable in both groups. There were significant higher values of the ISS, PCS, Wagner Jamieson Score and TTS in group KT+. The incidence of posttraumatic complications and mortality was increased compared to group KT- (p< 0.05). Despite that, kinetic therapy failed to be an independent risk factor for mortality in multivariate logistic regression analysis. Kinetic therapy is an option in severely injured patients with severe chest trauma. Decision making is not only based on anatomical aspects such as the AIS(Chest), but on overall injury severity, pulmonary contusions and physiological deterioration. It could be assumed that the increased mortality in patients receiving KT is primarily caused by these factors and does not reflect an independent adverse effect of KT. Furthermore, KT was not shown to be an independent risk factor for mortality.
Rogers, Frederick B; Shackford, Steven R; Horst, Michael A; Miller, Jo Ann; Wu, Daniel; Bradburn, Eric; Rogers, Amelia; Krasne, Margaret
This study aimed to determine the relative "weight" of risk factors known to be associated with venous thromboembolism (VTE) for patients with trauma based on injuries and comorbidities. A retrospective review of 16,608 consecutive admissions to a trauma center was performed. Patients were separated into those who developed VTE (n = 141) versus those who did not (16,467). Univariate analysis was performed for each risk factor reported in the trauma literature. Risk factors that were shown to be significant (p < 0.05) by univariate analysis underwent multivariate analysis to develop odds ratios for VTE. The Trauma Embolic Scoring System (TESS) was derived from the multivariate coefficients. The resulting TESS was compared with a data set from the National Trauma Data Bank (2002-2006) to determine its ability to predict VTE. The multivariate analysis demonstrated that age, Injury Severity Score, obesity, ventilator use for more than 3 days, and lower-extremity trauma were significant predictors of VTE in our patient population. The TESS was from 0 to 14, with the best prediction for those patients with a score of more than 6 (sensitivity, 81.6%; specificity, 84%). Overall, the model had excellent discrimination in predicting VTE with a receiver operating characteristic curve of 0.89. The VTE rates for TESS in the National Trauma Data Bank data set were similar for all integers except for 3 and 4, in which the VTE rates were significantly higher (3, 0.2% vs. 0.6%; 4, 0.4% vs. 1.0%). The TESS provides an objective measure of classifying VTE risk for patients with trauma. The TESS could allow informed decision making regarding prophylaxis strategies in patients with trauma.
Self, Michael; Mangram, Alicia; Dunn, Ernest
We sought to evaluate the outcomes of trauma patients admitted to medical services rather than to the general trauma team, particularly those elderly patients with isolated injuries of a specialty nature. Over the 2-year retrospective study period, 3017 trauma patients were admitted. The trauma service directed care in 2740 (90.8%) of this group versus the 277 (9.2%) admitted to medical services (MS). The patients in each group were then classified according to age younger than 55 years or older than 55 years (elderly). Of the 277 patients admitted to the MS, 177 (63.8%) were elderly compared with only 13 per cent of the trauma service group. Smaller proportions (16.9%) of the elderly medical patients were admitted to the intensive care unit as compared with the trauma group (22.1%). There was a higher morbidity rate, 41.9 per cent, in the trauma service group as compared with the MS group, 20 per cent. No patients on the MS underwent a laparotomy for intraabdominal injuries nor were there any missed injuries of a general surgical nature. Allowing elderly trauma patients with isolated specialty injuries to be managed by the MS is not associated with increased morbidity or mortality.
Childhood traumas are associated with suicidal behavior but this aspect has not been examined in relation to schizophrenia. In this study, 50 chronic schizophrenic patients who had attempted suicide were compared with 50 chronic schizophrenic patients who had never attempted suicide for their scores on the 34-item Childhood Trauma Questionnaire…
Rajan, Sunil; Surendran, Jayasankar; Paul, Jerry; Kumar, Lakshmi
Background and Aims: Obese individuals are predisposed to difficult airway and intubation. They usually yield confusing or misleading auscultatory findings. We aimed to assess the rapidity and efficacy of ultrasonographic (USG) sliding lung sign for confirming endotracheal intubation in normal as well as overweight and obese surgical patients. Methods: This prospective, observational study was performed in forty surgical patients. Twenty patients with body mass index (BMI) <25 were recruited to Group A, whereas twenty patients with BMI ≥25 constituted Group B. Following induction and intubation, appearance of end-tidal carbon dioxide waveform was used to confirm endotracheal intubation. Presence of breath sounds bilaterally was sought by auscultation, and time taken for auscultatory confirmation was noted. The USG confirmation of air entry to the lung field as indicated by lung sliding was sought, and the time taken was noted. Chi-square test, independent t-test and paired t-test were used as applicable. Results: Auscultatory confirmation was more rapid in Group A as compared to Group B (9.34 ± 2.43 s vs. 14.35 ± 5.53 s, P = 0.001). However, there was no significant difference in USG confirmation time in both the groups (8.57 ± 2.05 s vs. 8.61 ± 1.66 s). Four patients in Group B had doubtful breath sounds against none in Group A. There was no doubtful lung slide with USG in both groups. One case of endobronchial intubation in Group B was diagnosed with USG which was doubtful by auscultation. Conclusion: Ultrasound directed confirmation of endotracheal tube placement in overweight and obese patients is superior in speed and accuracy in comparison to the standard auscultatory method. PMID:28405036
Rajan, Sunil; Surendran, Jayasankar; Paul, Jerry; Kumar, Lakshmi
Obese individuals are predisposed to difficult airway and intubation. They usually yield confusing or misleading auscultatory findings. We aimed to assess the rapidity and efficacy of ultrasonographic (USG) sliding lung sign for confirming endotracheal intubation in normal as well as overweight and obese surgical patients. This prospective, observational study was performed in forty surgical patients. Twenty patients with body mass index (BMI) <25 were recruited to Group A, whereas twenty patients with BMI ≥25 constituted Group B. Following induction and intubation, appearance of end-tidal carbon dioxide waveform was used to confirm endotracheal intubation. Presence of breath sounds bilaterally was sought by auscultation, and time taken for auscultatory confirmation was noted. The USG confirmation of air entry to the lung field as indicated by lung sliding was sought, and the time taken was noted. Chi-square test, independent t-test and paired t-test were used as applicable. Auscultatory confirmation was more rapid in Group A as compared to Group B (9.34 ± 2.43 s vs. 14.35 ± 5.53 s, P = 0.001). However, there was no significant difference in USG confirmation time in both the groups (8.57 ± 2.05 s vs. 8.61 ± 1.66 s). Four patients in Group B had doubtful breath sounds against none in Group A. There was no doubtful lung slide with USG in both groups. One case of endobronchial intubation in Group B was diagnosed with USG which was doubtful by auscultation. Ultrasound directed confirmation of endotracheal tube placement in overweight and obese patients is superior in speed and accuracy in comparison to the standard auscultatory method.
Arslan, Z I; Yildiz, T; Baykara, Z N; Solak, M; Toker, K
The aim of this study was to evaluate the effectiveness of the Airtraq and CTrach in lean patients with simulated cervical spine injury after application of a rigid cervical collar. Eighty-six consenting adult patients of ASA physical status 1 or 2, who required elective tracheal intubation were included in this study in a randomised manner. Anaesthesia was induced using 1 microg kg(-1) fentanyl, 3 mg kg(-1) propofol and 0.6 mg kg(-1) rocuronium, following which a rigid cervical collar was applied. Comparison was then made between tracheal intubation techniques using either the AirTraq or CTrach device. The mean (SD) time to see the glottis was shorter with the Airtraq than the CTrach (11.9 (6.8) vs 37.6 (16.7)s, respectively; p < 0.001). The mean (SD) time taken for tracheal intubation was also shorter with the Airtraq than the CTrach (25.6 (13.5) and 66.3 (29.3)s, respectively; p < 0.001). There was less mucosal damage in the Airtraq group (p = 0.008). Our findings demonstrate that use of the Airtraq device shortened the tracheal intubation time and reduced the mucosal damage when compared with the CTrach in patients who require cervical spine immobilisation.
The i-gel Supraglottic Airway as a Conduit for Fibreoptic Tracheal Intubation - A Randomized Comparison with the Single-use Intubating Laryngeal Mask Airway and CTrach Laryngeal Mask in Patients with Predicted Difficult Laryngoscopy.
Michálek, Pavel; Donaldson, Will; McAleavey, Francis; Abraham, Alexander; Mathers, Rachel J; Telford, Claire
Fibreoptic intubation through a supraglottic airway is an alternative plan for airway management in difficult or failed laryngoscopy. The aim of this study was to compare three supraglottic airways as conduits in patients with at least one predictor for difficult laryngoscopy. The i-gel was compared with the single-use intubating laryngeal mask airway (sILMA) and CTrach laryngeal mask in 120 adult patients scheduled for elective surgeries under general anaesthesia using a prospective, randomized and single-blinded design. Primary outcome was success rate of tracheal intubation through the device, while secondary outcomes were times required for device insertion and tracheal tube placement, fibreoptic scores and the incidence of perioperative complications and postoperative complaints. The success rates showed no statistical difference between devices (i-gel 100%, CTrach 97.5%, ILMA 95%). Insertion time was shortest for the i-gel (12.4 s) compared with ILMA (19.3 s) and CTrach (24.4 s). Intubation time was shorter in the i-gel group (29.4 s) in comparison with the CTrach (39.8 s, p<0.05) and sILMA (51.9 s, p<0.001) groups. Best fibreoptic scores were observed also in the i-gel group. In total, 24 patients (20%) presented with difficult laryngoscopy. The i-gel showed significantly shorter times for insertion and fibreoptic intubation than the other two devices in this group. No difference was observed in the incidence of postoperative complaints. The i-gel is a suitable alternative to the sILMA and CTrach for fibrescope-guided tracheal intubation. Shorter insertion and intubation times with the i-gel may provide advantage in case of difficult oxygenation.
Said, Tarek; Chaari, Anis; Hakim, Karim Abdel; Hamama, Dalia; Casey, William Francis
Objective: To assess the usefulness of the full outline of unresponsiveness (FOUR) score in predicting extubation failure in critically ill intubated patients admitted with disturbed level of conscious in comparison with the Glasgow coma scale (GCS). Patients and Methods: All intubated critically ill patients with a disturbed level of consciousness were assessed using both the FOUR score and the GCS. The FOUR score and the GCS were compared regarding their predictive value for successful extubation at 14 days after intubation as a primary outcome measure. The 28-day mortality and the neurological outcome at 3 months were used as secondary outcome measures. Results: Eighty-six patients were included in the study. Median age was 63 (50–77) years. Sex–ratio (M/F) was 1.46. On admission, median GCS was 7 (3–10) while median FOUR score was 8.5 (2.3–11). A GCS ≤ 7 predicted the extubation failure at 14 days after intubation with a sensitivity of 88.5% and specificity of 68.3%, whereas a FOUR score <10 predicted the same outcome with a sensitivity of 80.8% and a specificity of 81.7%. The areas under the curves was significantly higher with the FOUR score than with GCS (respectively 0.867 confidence interval [CI]: 95% [0790–0.944] and 0.832 CI: 95% [0.741–0.923]; P = 0.014). When calculated before extubation, FOUR score <12 predicted extubation failure with a sensitivity of 92.3% and a specificity of 85%, whereas a GCS <12 predicted the same outcome with a sensitivity of 73% and a specificity of 61.7%. Both scores had similar accuracy for predicting 28-day mortality and neurological outcome at 3 months. Conclusion: The FOUR score is superior to the GCS for the prediction of successful extubation of intubated critically ill patients. PMID:28149821
Menahem, Benjamin; Lim, Chetana; Lahat, Eylon; Salloum, Chady; Osseis, Michael; Lacaze, Laurence; Compagnon, Philippe; Pascal, Gerard
Background The management of pancreatic trauma is complex. The aim of this study was to report our experience in the management of pancreatic trauma. Methods All patients hospitalized between 2005 and 2013 for pancreatic trauma were included. Traumatic injuries of the pancreas were classified according to the American Association for Surgery of Trauma (AAST) in five grades. Mortality and morbidity were analyzed. Results A total of 30 patients were analyzed (mean age: 38±17 years). Nineteen (63%) patients had a blunt trauma and 12 (40%) had pancreatic injury ≥ grade 3. Fifteen patients underwent exploratory laparotomy and the other 15 patients had nonoperative management (NOM). Four (13%) patients had a partial pancreatectomy [distal pancreatectomy (n=3) and pancreaticoduodenectomy (n=1)]. Overall, in hospital mortality was 20% (n=6). Postoperative mortality was 27% (n=4/15). Mortality of NOM group was 13% (n=2/15) in both cases death was due to severe head injury. Among the patients who underwent NOM, three patients had injury ≥ grade 3, one patient had a stent placement in the pancreatic duct and two patients underwent endoscopic drainage of a pancreatic pseudocyst. Conclusions Operative management of pancreatic trauma leads to a higher mortality. This must not be necessarily related to the pancreas injury alone but also to the associated injuries including liver, spleen and vascular trauma which may cause impaired outcome more than pancreas injury. PMID:28124001
Farach, Sandra M; Danielson, Paul D; Amankwah, Ernest K; Chandler, Nicole M
Pediatric trauma patients presenting with stable, isolated injuries are often admitted to the trauma service for initial management. The purpose of this study was to evaluate admission patterns in trauma patients with isolated injuries and compare outcomes based on admitting service. The institutional trauma registry was retrospectively reviewed for patients presenting from January 2007-December 2012. A total of 3417 patients were admitted to a surgical service and further reviewed. Patients with isolated injuries were further stratified by admission to the general trauma service (GTS, n = 738) versus admission to the subspecialty surgical trauma service (STS, n = 2251). When compared to patients admitted to GTS, patients admitted to STS with isolated injuries were significantly younger, were more likely to present with injury severity scores ranging from 9-14, Glasgow coma scale ≥ 13, had shorter emergency room length of stay, were more likely to undergo surgery within 24 h, and had fewer computed tomography scans performed. There were no missed injuries in patients with isolated injuries admitted to STS (with 5% having a GTS consult) compared with one missed injury in those admitted to GTS. Patients with isolated injuries admitted to an STS were found to have significantly lower complication rates (0.6% versus 2.2%, P < 0.01). Pediatric trauma patients presenting with stable, isolated injuries may be efficiently and safely managed by nontrauma services without an increase in missed injuries or complications. Copyright © 2015 Elsevier Inc. All rights reserved.
Coppola, Silvia; Froio, Sara; Chiumello, Davide
Fluid resuscitation in trauma patients could reduce organ failure, until blood components are available and hemorrhage is controlled. However, the ideal fluid resuscitation strategy in trauma patients remains a debated topic. Different types of trauma can require different types of fluids and different volume of infusion. There are few randomized controlled trials investigating the efficacy of fluids in trauma patients. There is no evidence that any type of fluids can improve short-term and long-term outcome in these patients. The main clinical evidence emphasizes that a restrictive fluid resuscitation before surgery improves outcome in patients with penetrating trauma. Fluid management of blunt trauma patients, in particular with coexisting brain injury, remains unclear. In order to focus on the state of the art about this topic, we review the current literature and guidelines. Recent studies have underlined that the correct fluid resuscitation strategy can depend on the type of trauma condition: penetrating, blunt, brain injury or a combination of them. Of course, further studies are needed to investigate the impact of a specific fluid strategy on different type and severity of trauma.
Bailly, Arthur; Le Thuaut, Aurelie; Boisrame-Helms, Julie; Kamel, Toufik; Mercier, Emmanuelle; Ricard, Jean Damien; Lemiale, Virginie; Champigneulle, Benoit; Reignier, Jean
Introduction Critically ill patients with acute respiratory, neurological or cardiovascular failure requiring invasive mechanical ventilation are at high risk of difficult intubation and have organ dysfunctions associated with complications of intubation and anaesthesia such as hypotension and hypoxaemia. The complication rate increases with the number of intubation attempts. Videolaryngoscopy improves elective endotracheal intubation. McGRATH MAC is the lightest videolaryngoscope and the most similar to the Macintosh laryngoscope. The primary goal of this trial was to determine whether videolaryngoscopy increased the frequency of successful first-pass intubation in critically ill patients, compared to direct view Macintosh laryngoscopy. Methods and analysis MACMAN is a multicentre, open-label, randomised controlled superiority trial. Consecutive patients requiring intubation are randomly allocated to either the McGRATH MAC videolaryngoscope or the Macintosh laryngoscope, with stratification by centre and operator experience. The expected frequency of successful first-pass intubation is 65% in the Macintosh group and 80% in the videolaryngoscope group. With α set at 5%, to achieve 90% power for detecting this difference, 185 patients are needed in each group (370 in all). The primary outcome is the proportion of patients with successful first-pass orotracheal intubation, compared between the two groups using a generalised mixed model to take the stratification factors into account. Ethics and dissemination The study project has been approved by the appropriate ethics committee (CPP Ouest 2, # 2014-A00674-43). Informed consent is not required, as both laryngoscopy methods are considered standard care in France; information is provided before study inclusion. If videolaryngoscopy proves superior to Macintosh laryngoscopy, its use will become standard practice, thereby decreasing first-pass intubation failure rates and, potentially, the frequency of intubation
McLellan, Barry A.; Ali, Jameel; Towers, Mark J.; Sharkey, P. William
Objectives To examine the accuracy of standard trauma-room chest x-ray films in assessing blunt abdominal trauma and to determine the significance of missed injuries under these circumstances. Design A retrospective review. Setting A regional trauma unit in a tertiary-care institution. Patients Multiply injured trauma patients admitted between January 1988 and December 1990 who died within 24 hours of injury and in whom an autopsy was done. Intervention Standard radiography of the chest. Main Outcome Measures Chest injuries diagnosed and recorded by the trauma room team from standard anteroposterior x-ray films compared with the findings at autopsy and with review of the films by a staff radiologist initially having no knowledge of the injuries and later, if injuries remained undetected, having knowledge of the autopsy findings. Results Thirty-seven patients met the study criteria, and their cases were reviewed. In 11 cases, significant injuries were noted at autopsy and not by the trauma-room team, and in 7 cases these injuries were also missed by the reviewing radiologist. Injuries missed by the team were: multiple rib fractures (11 cases), sternal fractures (3 cases), diaphragmatic tear (2 cases) and intimal aortic tear (1 case). In five cases, chest tubes were not inserted despite the presence (undiagnosed) of multiple rib fractures and need for intubation and positive-pressure ventilation. Conclusions Significant blunt abdominal trauma, potentially requiring operative management or chest-tube insertion, may be missed on the initial anteroposterior chest x-ray film. Caution must therefore be exercised in interpreting these films in the trauma resuscitation room. PMID:8599789
Ditchek, Jordan J.; Kiffin, Chauniqua; Carrillo, Eddy H.
We present two separate cases of young male patients with congenital kidney anomalies (horseshoe and crossed fused renal ectopia) identified following blunt abdominal trauma. Despite being rare, ectopic and fusion anomalies of the kidneys are occasionally noted in a trauma patient during imaging or upon exploration of the abdomen. Incidental renal findings may influence the management of traumatic injuries to preserve and protect the patient's renal function. Renal anomalies may be asymptomatic or present with hematuria, flank or abdominal pain, hypotension, or shock, even following minor blunt trauma or low velocity impact. It is important for the trauma clinician to recognize that this group of congenital anomalies may contribute to unusual symptoms such as gross hematuria after minor trauma, are readily identifiable during CT imaging, and may affect operative management. These patients should be informed of their anatomical findings and encouraged to return for long-term follow-up. PMID:27895945
Getto, Leila P; Marco, Debra; Papas, Mia A; Fort, Charles W; Fredette, Jenna
The environment in the Emergency Department (ED) is chaotic, and physicians are expected to perform procedures amongst distractions. Our aim was to prospectively determine the effects of various levels of noise distraction on the success and time to successful intubation of a simulator. Forty-five Emergency Medicine, Emergency Medicine/Internal Medicine, and Emergency Medicine/Family Medicine Residents were studied in background noise environments of <50 decibels (noise level 1), 60-70 decibels (noise level 2), and of >70 decibels (noise level 3). Residents attempted three intubations on a simulator in succession, with three randomized noise levels. Time, in seconds, to intubation was measured in each of the successful intubations. Generalized linear models were employed to examine associations between noise level and time to intubation by attempt. Time to intubation decreased with each attempt (median = 25.9, 17.9, 14.4 for attempt numbers 1, 2, and 3, respectively). Decibel noise level was not associated with time to intubation (p > 0.6) or success rate (p > 0.1). Attempt number did not modify the association between noise and time to intubation (p-for-interaction = 0.16). Noise level did not have an effect on time to intubation or intubation success rate, suggesting that noise levels in the ED do not affect provider ability to perform procedures. However, knowing that increased noise levels increase stress and impair the ability to communicate with team members, further study needs to be done to definitively conclude that noise does not affect provider performance in the ED setting. Copyright © 2016 Elsevier Inc. All rights reserved.
Pargger, H; Studer, W; Rüttimann, U
In trauma patients it is mandatory to establish the exact reason for their hypotension. If hypovolaemia is most probably responsible for the hypotension, fluid resuscitation should be initiated. The therapy of choice is infusion of sugarless, isotonic crystalloids with a physiologic serum electrolyte composition. In patients with brain injuries a decrease in serum osmolality is not advisable and hypertonic fluids may therefore be considered. Human albumin preparations are no longer indicated, but synthetic colloids may be an adjunct to a pure crystalloid regime. Hydroxyethyl starch preparations with a molecular weight in the mean range are reasonable choices considering the individual advantages and disadvantages of the various colloids. Larger blood losses must be treated with blood components such as packed red cells, fresh frozen plasma and thrombocyte concentrates as indicated. There are no widely accepted values for laboratory or monitoring parameters in starting or stopping a given fluid therapy; these values are unquestionably influenced, among other things, by the patient history and the pattern of the injuries. Initial resuscitation (when to start, who should administer the fluid and how much) also remains a focus of heated controversy.
Videolaryngoscopes improve the view of the entry to the larynx in morbidly obese patients. Super obesity is one of the risk factors for difficult mask ventilation as well as difficult intubation. Super obese patients should be intubated awake either with a fiber-optic scope or with a videolaryngoscope. The glottic view during video-intubation in super obese patients using different devices was compared. The McGrath MAC (MGM) was used in all patients and then compared to the King Vision (KV) in three patients, the APA videolaryngoscope in two patients and the Airtraq Avant with a video camera in four patients. The pictures were of the same patient for two used devices. All obtained images were analyzed using the Percentage of Glottic Opening (POGO) scale. The POGO score for the MGM was better than for the KV and the APA but comparable to the Airtraq device. The images were processed electronically, and the best view of the laryngeal inlet that was obtained by the evaluated devices in the same patient was superimposed onto the other one and then compared.
Videolaryngoscopes improve the view of the entry to the larynx in morbidly obese patients. Super obesity is one of the risk factors for difficult mask ventilation as well as difficult intubation. Super obese patients should be intubated awake either with a fiber-optic scope or with a videolaryngoscope. The glottic view during video-intubation in super obese patients using different devices was compared. The McGrath MAC (MGM) was used in all patients and then compared to the King Vision (KV) in three patients, the APA videolaryngoscope in two patients and the Airtraq Avant with a video camera in four patients. The pictures were of the same patient for two used devices. All obtained images were analyzed using the Percentage of Glottic Opening (POGO) scale. The POGO score for the MGM was better than for the KV and the APA but comparable to the Airtraq device. The images were processed electronically, and the best view of the laryngeal inlet that was obtained by the evaluated devices in the same patient was superimposed onto the other one and then compared. PMID:27956835
O'Hara, Nathan N.; Mugarura, Rodney; Slobogean, Gerard P.; Bouchard, Maryse
The disability adjusted life years (DALYs) associated with injuries have increased by 34% from 1990 to 2010, making it the 10th leading cause of disability worldwide, with most of the burden affecting low-income countries. Although disability from injuries is often preventable, limited access to essential surgical services contributes to these increasing DALY rates. Similar to many other low- and middle-income countries (LMIC), Uganda is plagued by a growing volume of traumatic injuries. The aim of this study is to explore the orthopaedic trauma patient's experience in accessing medical care in Uganda and what affects the injury might have on the socioeconomic status for the patient and their dependents. We also evaluate the factors that impact an individual's ability to access an appropriate treatment facility for their traumatic injury. Semi-structured interviews were conducted with patients 18 year of age or older admitted with a fractured tibia or femur at Mulago National Referral Hospital in Kampala, Uganda. As limited literature exists on the socioeconomic impacts of disability from trauma, we designed a descriptive qualitative case study, using thematic analysis, to extract unique information for which little has been previously been documented. This methodology is subject to less bias than other qualitative methods as it imposes fewer preconceptions. Data analysis of the patient interviews (n = 35) produced over one hundred codes, nine sub-themes and three overarching themes. The three overarching categories revealed by the data were: 1) the importance of social supports; 2) the impact of and on economic resources; and 3) navigating the healthcare system. Limited resources to fund the treatment of orthopaedic trauma patients in Uganda leads to reliance of patients on their friends, family, and hospital connections, and a tremendous economic burden that falls on the patient and their dependents. PMID:25360815
Goldstein, Ellen; Athale, Ninad; Sciolla, Andrés F; Catz, Sheryl L
Exposure to traumatic events is common in primary care patients, yet health care professionals may be hesitant to assess and address the impact of childhood trauma in their patients. To assess patient preferences for discussing traumatic experiences and posttraumatic stress disorder (PTSD) with clinicians in underserved, predominantly Latino primary care patients. Cross-sectional study. We evaluated patients with a questionnaire assessing comfort to discuss trauma exposure and symptoms using the Adverse Childhood Experiences (ACE) Study questionnaire and the Primary Care-PTSD screen. The questionnaire also assessed patients' confidence in their clinicians' ability to help with trauma-related issues. Surveys were collected at an integrated medical and behavioral health care clinic. Of 178 adult patients asked, 152 (83%) agreed to participate. Among participants, 37% screened positive for PTSD, 42% reported 4 or more ACEs, and 26% had elevated scores on both measures. Primary Care-PTSD and ACE scores were strongly positively correlated (r = 0.57, p < 0.001). Most patients agreed they were comfortable being asked about trauma directly or through screening questionnaires and did not oppose the inclusion of trauma-related information in their medical record. In addition, most patients perceived their clinician as comfortable asking questions about childhood trauma and able to address trauma-related problems. Screening is acceptable to most primary care patients regardless of trauma exposure or positive PTSD screening. Findings may aid primary care clinicians to consider screening regularly for ACEs and PTSD to better serve the health care needs of trauma-exposed patients.
Mosquera, Victor X; Marini, Milagros; Muñiz, Javier; Lopez-Perez, José M; Gulías, Daniel; Cuenca, José J
The objective of this study is to report the clinical and radiological characteristics and early and long-term survival of a series of acute traumatic aortic injuries (ATAI) in crush trauma patients, and to compare such data with our last 30 years experience managing ATAI in deceleration non-crush trauma patients. From January 1980 to December 2010, 5 consecutive ATAI in crush trauma and 69 in non-crush trauma patients were admitted at our institution. ISS, RTS and TRISS scores were similar in both groups. Overall in-hospital mortality was 24.3%. There was no in-hospital mortality in crush patients and 26.1% in non-crush patients (p=0.32). All aortic-related complications occurred in non-crush patients. Median follow-up was 129 months (range 3-350 months). Non-crush group survival was 76.8% at 1 year, 73.6% at 5 years, and 71.2%% at 10 years. There was no mortality during follow-up in the crush group. Mean (SD) peak creatine phosphokinase was significantly higher in crush group than in non-crush group: 7598 (3690) IU/L vs. 3645 (2506) IU/L; p=0.041. Incidence of acute renal injury was higher in crush trauma patients (100% vs. 36.2%; p=0.018). Low-severity injuries were more common in crush trauma patients (100% in crush patients vs. 43.5% in non-crush patients, p=0.04). Aortic injuries in crush thoracic trauma patients seem to present in a different clinical scenario from aortic injuries in high-speed thoracic trauma thus requiring distinct considerations. When planning the initial management of aortic injuries in crush trauma, the increased risk of rhabdomiolysis and subsequent acute renal failure, as well as a tendency to develop lower-risk aortic wall injuries, must be considered. Copyright © 2011 Elsevier Ltd. All rights reserved.
Daniel, Subashini R; Morita, Shane Y; Yu, Mihae; Dzierba, Alex
There are no published reports identifying an inadequate ventilatory response to metabolic acidosis as a predictor of impending respiratory failure. Metabolic acidosis should induce a respiratory alkalosis in which the partial pressure of carbon dioxide (Paco2) is (1.5 [HCO3-] + 8) +/- 2. This study examined the relation between inadequate ventilatory compensation and intubation among trauma patients. A retrospective chart review was performed for trauma patients admitted between January 1999 and December 2000. Age, gender, Injury Severity Score and combined Trauma and Injury Severity Score, chest injury, history of cardiac or pulmonary disease, partial pressure of oxygen (Pao2), Paco2, Glasgow Coma Score, respiratory rate, systolic blood pressure, base deficit, and ability to compensate were analyzed with respect to intubation and need for ventilator support. Of 140 patients with metabolic acidosis, 45 ultimately were intubated. The mean Paco2 for the unintubated patients was 34 +/- 7 mm Hg, as compared with 41 +/- 11 mm Hg for the intubated patients (p < 0.001). Only injury severity and ability to compensate for metabolic acidosis were independent predictors of intubation. Patients with inadequate compensation were 4.2 times more likely to require intubation when control was used for the Injury Severity Score (95% confidence interval, 1.8-9.7; p < 0.001). Inability to mount an adequate hyperventilatory response to metabolic acidosis is associated with an increased likelihood of respiratory failure and a need for ventilatory support. Recognition of this relation should lead to closer monitoring of patients with this condition, and could help to avert unforeseen crisis intubations. This observation needs to be validated in a prospective study.
Brodsky, Jay B; Lemmens, Harry J M; Brock-Utne, John G; Vierra, Mark; Saidman, Lawrence J
The tracheas of obese patients may be more difficult to intubate than those of normal-weight patients. We studied 100 morbidly obese patients (body mass index >40 kg/m(2)) to identify which factors complicate direct laryngoscopy and tracheal intubation. Preoperative measurements (height, weight, neck circumference, width of mouth opening, sternomental distance, and thyromental distance) and Mallampati score were recorded. The view during direct laryngoscopy was graded, and the number of attempts at tracheal intubation was recorded. Neither absolute obesity nor body mass index was associated with intubation difficulties. Large neck circumference and high Mallampati score were the only predictors of potential intubation problems. Because in all but one patient the trachea was intubated successfully by direct laryngoscopy, the neck circumference that requires an intervention such as fiberoptic bronchoscopy to establish an airway remains unknown. We conclude that obesity alone is not predictive of tracheal intubation difficulties. In 100 morbidly obese patients, neither obesity nor body mass index predicted problems with tracheal intubation. However, a high Mallampati score (greater-than-or-equal to 3) and large neck circumference may increase the potential for difficult laryngoscopy and intubation.
Siddhartha, B S Vijay; Sharma, N G Anish; Kamble, Shashank; Shankaranarayana, P
Insertion of a nasogastric tube (NGT) in an anesthetized, comatose intubated patient is not always as easy as in a conscious, cooperative patient. Various techniques have been tried with varying success. The aim of this randomized study was to compare and evaluate the two techniques of NGT insertion with the conventional technique of insertion with respect to success rate, time taken for insertion and adverse effects. Patients admitted for laparoscopic hysterectomy were chosen and then were divided into three equal groups of forty each, by randomized technique. Group C included patients in whom conventional method was used to insert NGT. Group R where reverse Sellick's technique was used. Group F where neck flexion with lateral pressure was used. Both the techniques were better than the conventional method. Among both the techniques, reverse Sellick's technique was the best method but not without adverse effects. The required insertion time was very less and success in the first attempt was more in the group where reverse Sellick's was used. Modified techniques of NGT insertion were better than the conventional method. Further studies after eliminating major limitations are required to really find a superior technique.
Krobbuaban, B; Diregpoke, S; Kumkeaw, S
Preoperative evaluation is important in the detection of patients at risk for difficult tracheal intubation. Thyromental distance (TMD) is often used for these purposes, but its value as an indicator for difficult intubation is questionable, as it varies with patient size and body proportions. The purpose of the present study was to evaluate and compare the accuracies of the ratio of patient's height to TMD (ratio of height to TMD = RHTMD) and TMD alone in the prediction of difficult tracheal intubation in Thai patients. The authors collected data on 382 consecutive patients scheduled to receive general anesthesia requiring endotracheal intubation for elective surgery. Thyromental distance and RHTMD were evaluated preoperatively. Difficult intubation was defined in the present study by Cormack and Lehane grade 3 or 4. The optimal predictive value was chosen using a receiver operating characteristic (ROC) curve. The areas under the ROC curves (AUC) of TMD and RHTMD were compared to determine the performance of the different predictive tests used. The sensitivity, specificity, and positive and negative predictive values of each of the predictive tests were calculated according to standard formulae. Difficult intubation occurred in 42 patients (10.9 %). The predictive advantage of RHTMD has a similar specificity with improved sensitivity in comparison with TMD. The AUC of RHTMD was significantly greater than the AUC of TMD (p = 0.00). The authors concluded that RHTMD had better accuracy in predicting difficult intubation than TMD.
Attarde, Viren Bhaskar; Kotekar, Nalini; Shetty, Sarika M
Background and Aims: Air-Q intubating laryngeal mask airway (ILA) is used as a supraglottic airway device and as a conduit for endotracheal intubation. This study aims to assess the efficacy of the Air-Q ILA regarding ease of insertion, adequacy of ventilation, rate of successful intubation, haemodynamic response and airway morbidity. Methods: Sixty patients presenting for elective surgery at our Medical College Hospital were selected. Following adequate premedication, baseline vital parameters, pulse rate and blood pressure were recorded. Air-Q size 3.5 for patients 50-70 kg and size 4.5 for 70-100 kg was selected. After achieving adequate intubating conditions, Air-Q ILA was introduced. Confirming adequate ventilation, appropriate sized endotracheal tube was advanced through the Air-Q blindly to intubate the trachea. Placement of the endotracheal tube in trachea was confirmed. Results: Air-Q ILA was successfully inserted in 88.3% of patients in first attempt and 11.7% patients in second attempt. Ventilation was adequate in 100% of patients. Intubation was successful in 76.7% of patients with Air-Q ILA. 23.3% of patients were intubated by direct laryngoscopy following failure with two attempts using Air-Q ILA. Post-intubation the change in heart rate was statistically significant (P < 0.0001). 10% of patients were noted to have a sore throat and 5% of patients had mild airway trauma. Conclusion: Air-Q ILA is a reliable device as a supraglottic airway ensuring adequate ventilation as well as a conduit for endotracheal intubation. It benefits the patient by avoiding the stress of direct laryngoscopy and is also superior alternative device for use in a difficult airway. PMID:27212722
Goldstein, Ellen; Athale, Ninad; Sciolla, Andrés F; Catz, Sheryl L
Context: Exposure to traumatic events is common in primary care patients, yet health care professionals may be hesitant to assess and address the impact of childhood trauma in their patients. Objective: To assess patient preferences for discussing traumatic experiences and posttraumatic stress disorder (PTSD) with clinicians in underserved, predominantly Latino primary care patients. Design: Cross-sectional study. Main Outcome Measure: We evaluated patients with a questionnaire assessing comfort to discuss trauma exposure and symptoms using the Adverse Childhood Experiences (ACE) Study questionnaire and the Primary Care-PTSD screen. The questionnaire also assessed patients’ confidence in their clinicians’ ability to help with trauma-related issues. Surveys were collected at an integrated medical and behavioral health care clinic. Results: Of 178 adult patients asked, 152 (83%) agreed to participate. Among participants, 37% screened positive for PTSD, 42% reported 4 or more ACEs, and 26% had elevated scores on both measures. Primary Care-PTSD and ACE scores were strongly positively correlated (r = 0.57, p < 0.001). Most patients agreed they were comfortable being asked about trauma directly or through screening questionnaires and did not oppose the inclusion of trauma-related information in their medical record. In addition, most patients perceived their clinician as comfortable asking questions about childhood trauma and able to address trauma-related problems. Conclusion: Screening is acceptable to most primary care patients regardless of trauma exposure or positive PTSD screening. Findings may aid primary care clinicians to consider screening regularly for ACEs and PTSD to better serve the health care needs of trauma-exposed patients. PMID:28333604
Mador, Brett; Nascimento, Bartolomeu; Hollands, Simon; Rizoli, Sandro
Trauma resuscitation has undergone a paradigm shift with new emphasis on the early use of blood products and increased proportions of plasma and platelets. However, it is unclear how this strategy is applied or how effective it is in the elderly population. The study aim is to identify differences in transfusion practices and the coagulopathy of trauma in the elderly. Data was prospectively collected on all consecutive patients that met trauma activation criteria at a Level I trauma centre. Data fields included patient demographics, co-morbidities, injury and resuscitation data, laboratory values, thromboelastography (TEG) results, and outcome measures. Elderly patients were defined as those 55 and older. Propensity-score matched analysis was completed for patients receiving blood product transfusion. Patients were matched by gender, mechanism, injury severity score (ISS), head injury, and time from injury. Total of 628 patients were included, of which 142 (23%) were elderly. Elderly patients were more likely to be female (41% vs. 24%), suffer blunt mechanism of trauma (96% vs. 80%), have higher ISS scores (mean 25.4 vs. 21.6) and mortality (19% vs. 8%). Elderly patients were significantly more likely to receive a blood transfusion (42% vs. 30%), specifically for red cells and plasma. Propensity-matched analysis resulted in no difference in red cell transfusion or mortality. Despite the broad similarities between the matched cohorts, trauma coagulopathy as measured by TEG was less commonly observed in the elderly. Our results suggest that elderly trauma patients are more likely to receive blood products when admitted to a trauma centre, though this may be attributed to under-triage. The results also suggest an altered coagulopathic response to traumatic injury which is partially influenced by increased anticoagulant and antiplatelet medication use in the geriatric population. It is not clear whether the acute coagulopathy of trauma is equivalent in geriatric
Kosmos, C A
This case study reinforces key principles in caring for multiply injured trauma victims. The Primary Survey is a tool developed to allow those caring for trauma patients to prioritize injuries. Those injuries identified in the Primary Survey will be the most life threatening.
Laeeq, K.; Cheung, S.; Phillips, B.
Blunt trauma resulting in rib fractures can be associated with hemothorax, pneumothorax, pulmonary contusions or less frequently chest and abdominal wall hematomas. Our case describes the first report of hemoperitoneum secondary to intercostal arterial bleeding from blunt trauma in a patient on anticoagulation. PMID:28108633
Du, Xiaojun; Mao, Songsong; Cui, Jianxiu; Ma, Jue; Zhang, Guangyan; Zheng, Yong; Zhou, Haiyu; Xie, Liang; Zhang, Dongkun; Shi, Ruiqing
Background The aim of the present study was to determine the safety and feasibility of the use of laryngeal mask airway (LMA) for non-endotracheal intubated anesthesia for patients with pectus excavatum (PE) undergoing thoracoscopic Nuss procedure. Methods Between July 2015 and December 2015, 30 selected patients with PE were planned to undergo a thoracoscopic Nuss procedure using LMA for non-endotracheal intubated anesthesia in the Guangdong General Hospital. The clinical data were analyzed to evaluate the safety and feasibility of this technique. Results Of the 30 selected patients, two were female, the mean age was 16.04±5.09 years and the average Haller index was 3.37±0.88. A total of 27 cases (90%) succeeded at the first attempt, one patient required conversion to an endotracheal tube (ETT) because of continuous air leak. The peripheral O2 saturation (SpO2), end-tidal carbon dioxide (EtCO2) values, heart rate (HR), and mean arterial blood pressure (MAP) remained stable throughout the procedure in all cases. All of the 30 patients were successfully corrected without requiring conversion to an open surgery. Two patients experienced postoperative nausea and one reported a sore throat. Neither gastro-esophageal reflux nor in-hospital mortality occurred. Conclusions The use of LMA for non-endotracheal intubated anesthesia for selected patients with PE undergoing thoracoscopic Nuss procedure is clinically safe and technically feasible. PMID:27621860
Sonneborn, R; Espinoza, R; Geni, R; Rodríguez, A; Power, E; Plaza de los Reyes, M
Ten to fifteen million wounded and 700,000 deaths each year, around the world, are the consequences of accidents, according to the World Health Organization. In Chile 2,269 deaths occur each year due to accidents. The successful treatment of these patients requires a schematized initial management, that is taught in the Advanced Trauma Life Support Course. To review the results of trauma treatment using this model at Hospital del Trabajador in Santiago. A retrospective review of patients with trauma treated between 1984 and 1994. The severity of trauma was classified according to the Injury Severity Score. Five hundred eighty eight patients (60 female) aged 35.4 +/- 14 years old were treated in the period. Vehicular accidents accounted for 62% of trauma. The most frequently injured corporal segments were limbs and pelvis in 79%, head and neck in 66% and thorax in 44%. There were 2.45 lesions per patient. Mortality was 8% and, among survivors, 79% had a complete recovery and were reintegrated to their usual activities. Fifteen percent of patients were severely injured. Among these, mortality was 28% and 43% of survivors had some sequel. Head injuries had a predominant role in mortality and post traumatic disabilities. These results confirm the efficacy of Advanced Trauma Life Support system in the treatment of patients with multiple trauma.
Lanitis, Sophocles; Zacharioudakis, Constantinos; Zafeiriadou, Paraskevi; Armoutides, Vasileios; Karaliotas, Charilaos; Sgourakis, George
During the initial assessment of trauma patients they usually undergo a Focused Assessment with Sonography for Trauma (FAST) in which there are occasionally incidental findings of other surgical conditions. In this audit we discuss the incidence, demographics, and implications of these findings and we propose a management algorithm. Within 2 years we managed 6041 trauma patients in the emergency department based on the Advanced Trauma Life Support protocols, 95 per cent of which underwent a FAST ultrasound. Incidental findings were reported in 468 patients (7.8%), whereas in a further 11.2 per cent of these patients there was a second finding. The mean age of these patients was 57.55 years (15-105), and most of them were men (51.1%). The vast majority of the findings were related to the liver and biliary tree (52.1%) followed by the urinary track (27.1% + 8%). In multivariate analysis only the age was a significant factor associated with incidental findings (P < 0.001) whereas in univariate analysis both the gender [men (54.1%) vs women (45.9), P = 0.013] and the mechanism of trauma (P < 0.001) were as important as the age (P < 0.001). The patients who had incidental findings were 15 years older than the rest. The detection of unknown surgical conditions in FAST may lead to managerial and possible medico-legal issues rendering the development of a proper algorithm mandatory.
Paydar, Shahram; Sabetian, Golnar; Khalili, Hosseinali; Fallahi, Javad; Tahami, Mohammad; Ziaian, Bizhan; Abbasi, Hamid Reza; Bolandparvaz, Shahram; Ghaffarpasand, Fariborz; Ghahramani, Zahra
Deep vein thrombosis (DVT) and pulmonary embolism (PTE) are known as venous thromboembolism (VTE). DVT occurs when a thrombus (a blood clot) forms in deep veins of the body, usually in the lower extremities. It can cause swelling or leg pain, but sometimes may occur with no symptoms. Awareness of DVT is the best way to prevent the VTE. Patients with trauma are at increased risk of DVT and subsequent PE because of coagulopathy in patients with multiple trauma, DVT prophylaxis is essential but the VTE prophylaxis strategy is controversial for the trauma patients. The risk factors for VTE includes pelvic and lower extremity fractures, and head injury. PMID:27162921
Childhood traumas are associated with suicidal behavior but this aspect has not been examined in relation to schizophrenia. In this study, 50 chronic schizophrenic patients who had attempted suicide were compared with 50 chronic schizophrenic patients who had never attempted suicide for their scores on the 34-item Childhood Trauma Questionnaire (CTQ). It was found that schizophrenics who had attempted suicide reported significantly higher CTQ scores for emotional abuse, physical abuse, sexual abuse, emotional neglect, and physical neglect than schizophrenics who had never attempted suicide. Therefore, childhood trauma may be a risk factor predisposing schizophrenic patients to attempt suicide.
Bhowate, Rahul; Dubey, Alok
A case of palatal perforation occurring in 7-year-old girl with IDDM due to nasotracheal intubation is reported. The child, who was not previously diagnosed of IDDM, was brought to hospital in comatose stage and was put on nasotracheal tube for maintaining respiration. This paper highlights the link between IDDM and palatal perforation communicating the nasal cavity due to naso-tracheal intubation.
Bohman, J. Kyle; Kor, Daryl J.; Kashyap, Rahul; Gajic, Ognjen; Festic, Emir; He, Zhaoping
Background: Airway pepsin has been increasingly used as a potentially sensitive and quantifiable biomarker for gastric-to-pulmonary aspiration, despite lack of validation in normal control subjects. This study attempts to define normal levels of airway pepsin in adults and distinguish between pepsin A (exclusive to stomach) and pepsin C (which can be expressed by pneumocytes). Methods: We performed a prospective study of 51 otherwise healthy adult patients undergoing elective extremity orthopedic surgery at a single tertiary-care academic medical center. Lower airway samples were obtained immediately following endotracheal intubation and just prior to extubation. Total pepsin and pepsin A concentrations were directly measured by an enzymatic activity assay, and pepsin C was subsequently derived. Pepsinogen/pepsin C was confirmed by Western blot analyses. Baseline characteristics were secondarily compared. Results: In all, 11 (22%; 95% CI = 9.9%-33%) had detectable airway pepsin concentrations. All 11 positive specimens had pepsin C, without any detectable pepsin A. Pepsinogen/pepsin C was confirmed by Western blot analyses. In a multivariate logistic regression, men were more likely to have airway pepsin (OR, 12.71, P = .029). Conclusions: Enzymatically active pepsin C, but not the gastric-specific pepsin A, is frequently detected in the lower airways of patients who otherwise have no risk for aspiration. This suggests that nonspecific pepsin assays should be used and interpreted with caution as a biomarker of gastropulmonary aspiration, as pepsinogen C potentially expressed from pneumocytes may be detected in airway samples. PMID:23117366
Bohman, J Kyle; Kor, Daryl J; Kashyap, Rahul; Gajic, Ognjen; Festic, Emir; He, Zhaoping; Lee, Augustine S
Airway pepsin has been increasingly used as a potentially sensitive and quantifiable biomarker for gastric-to-pulmonary aspiration, despite lack of validation in normal control subjects. This study attempts to define normal levels of airway pepsin in adults and distinguish between pepsin A (exclusive to stomach) and pepsin C (which can be expressed by pneumocytes). We performed a prospective study of 51 otherwise healthy adult patients undergoing elective extremity orthopedic surgery at a single tertiary-care academic medical center. Lower airway samples were obtained immediately following endotracheal intubation and just prior to extubation. Total pepsin and pepsin A concentrations were directly measured by an enzymatic activity assay, and pepsin C was subsequently derived. Pepsinogen/pepsin C was confirmed by Western blot analyses. Baseline characteristics were secondarily compared. In all, 11 (22%; 95% CI = 9.9%-33%) had detectable airway pepsin concentrations. All 11 positive specimens had pepsin C, without any detectable pepsin A. Pepsinogen/pepsin C was confirmed by Western blot analyses. In a multivariate logistic regression, men were more likely to have airway pepsin (OR, 12.71, P = .029). Enzymatically active pepsin C, but not the gastric-specific pepsin A, is frequently detected in the lower airways of patients who otherwise have no risk for aspiration. This suggests that nonspecific pepsin assays should be used and interpreted with caution as a biomarker of gastropulmonary aspiration, as pepsinogen C potentially expressed from pneumocytes may be detected in airway samples.
Rapsang, Amy Grace; Shyam, Devajit Chowlek
Trauma is a major cause of morbidity and mortality; hence severity scales are important adjuncts to trauma care in order to characterize the nature and extent of injury. Trauma scoring models can assist with triage and help in evaluation and prediction of prognosis in order to organise and improve trauma systems. Given the wide variety of scoring instruments available to assess the injured patient, it is imperative that the choice of the severity score accurately match the application. Even though trauma scores are not the key elements of trauma treatment, they are however, an essential part of improvement in triage decisions and in identifying patients with unexpected outcomes. This article provides the reader with a compendium of trauma severity scales along with their predicted death rate calculation, which can be adopted in order to improve decision making, trauma care, research and in comparative analyses in quality assessment. Copyright © 2013 AEC. Publicado por Elsevier España, S.L.U. All rights reserved.
Traumatic injuries to the scrotum are uncommon but, when they do occur, frequently lead to serious complications. Early complications include testicular infarction, necrosis and abscess formation; in the longer-term trauma may result in testicular atrophy and subfertility. Early surgical intervention in patients with testicular rupture can significantly improve the clinical outcome and reduce the need for delayed orchidectomy. However, clinical examination of the scrotum following trauma is difficult and frequently inaccurate; this may result in incorrect triage of patients for surgical exploration. Scrotal ultrasound can reliably assess scrotal injuries and diagnose testicular rupture with a high level of accuracy. Additionally, ultrasound can provide important information regarding testicular perfusion, which can further inform decisions on surgical management. This article reviews the sonographic findings that may be encountered in patients with scrotal trauma, with an emphasis on blunt trauma. It describes the pivotal role that ultrasound can play in the accurate triage of these patients to surgical or conservative management. PMID:27433221
Hasse, Gwendolyn L
The purpose of this study was to discover unique aspects of caring for adult trauma intensive care unit patients with respect to implementing patient-centered care. The concept of patient-centered care has been discussed since 2000, but the actual implementation is currently becoming the focus of health care. The Institute of Medicine defined patient-centered care as "providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions" in the 2001 Crossing the Quality Chasm report. Discussion and documentation of patient centered-care of the intensive care trauma patient population are limited and yield no results for publication search. This article explores the concept of delivering patient-centered care specifically in a trauma adult intensive care unit.
Rezaei, Sahra; Rezaei, Korosh; Mahboubi, Mohaddese; Jarahzadeh, Mohammad Hossein; Momeni, Ehsan; Bagherinasab, Mostafa; Targhi, Mehrdad Gaffari; Memarzadeh, Mohammad Reza
Background: Intubated patients in Intensive Care Unit (ICU) are not able to take care of their mouth health, so they are at risk of bacterial colonization and dental plaques formation that can lead to systemic diseases such as pneumonia and gingivitis. Aims: In randomized, double-blind clinical study, the efficacy of natural herbal mouthwash containing Salvadora persica ethanol extract and Aloe vera gel was compared with chlorhexidine on gingival index (GI) of intubated patients in ICU. Materials and Methods: Seventy-six intubated patients (18–64 years old with mean age 40.35 ± 13.2) in ICU were admitted to this study. The patients were randomly divided into two groups: (1) Herbal mouthwash and (2) chlorhexidine solution. Before the intervention, the GIs was measured by modified GI device into two groups. The mouth was rinsed by mouthwashes every 2–3 h for 4 days. 2 h after the last intervention, GIs were determined. Results: Along with mechanical methods, herbal mouthwash in reducing GI was statistically significant than that of chlorhexidine (P < 0.05). Conclusion: The results of this study introduce a new botanical extract mouthwash with dominant healing effects on GI (1.5 ± 0.6) higher than that of synthetic mouthwash, chlorhexidine (2.31 ± 0.73). PMID:28298822
Patil, Vinuta V; Subramanya, Bala H; Kiranchand, N; Bhaskar, S Bala; Dammur, Srinivasalu
C-MAC(®) video laryngoscope (VL) with Macintosh blade has been found to improve Cormack-Lehane (C-L) laryngoscopic view as well as intubating conditions for orotracheal intubation. However, studies done on the performance of C-MAC(®) VL for nasotracheal intubation (NTI) are very few in number. Hence, we compared laryngoscopy and intubating conditions between Macintosh direct laryngoscope and C-MAC(®) VL for NTI. Sixty American Society of Anesthesiologists Physical Status I, II patients, aged 8-18 years, posted for tonsillectomy surgeries under general anaesthesia with NTI were randomised, into two groups. Patients in group 1 were intubated using Macintosh direct laryngoscope and group 2 with C-MAC(®) VL. C-L grading, time required for intubation, need for additional manoeuvres and haemodynamic changes during and after intubation were compared between the groups. C-L grade 1 views were obtained in 26 and 29 patients in group 1 and group 2, respectively (86.7% vs. 96.7%). Remaining patients were having C-L grade 2 (13.3% vs. 3.3%). Duration of intubation was less than a minute in group 2 (93.3%). Need for additional manoeuvres (M1-M5) were more in group 1 (97% vs. 77%). M1 (external manipulation) was needed more in group 2 compared to group 1 (53.3% vs. 30%). Magill's forceps alone (M4) and M4 with additional external manipulation (M5) were needed more in group 1 compared to group 2 (60% vs. 16%). The overall performance of C-MAC(®) VL was better when compared to conventional direct Macintosh laryngoscope during NTI in terms of glottis visualisation, intubation time and need for additional manoeuvres.
Patil, Vinuta V; Subramanya, Bala H; Kiranchand, N; Bhaskar, S Bala; Dammur, Srinivasalu
Background and Aims: C-MAC® video laryngoscope (VL) with Macintosh blade has been found to improve Cormack-Lehane (C-L) laryngoscopic view as well as intubating conditions for orotracheal intubation. However, studies done on the performance of C-MAC® VL for nasotracheal intubation (NTI) are very few in number. Hence, we compared laryngoscopy and intubating conditions between Macintosh direct laryngoscope and C-MAC® VL for NTI. Methods: Sixty American Society of Anesthesiologists Physical Status I, II patients, aged 8–18 years, posted for tonsillectomy surgeries under general anaesthesia with NTI were randomised, into two groups. Patients in group 1 were intubated using Macintosh direct laryngoscope and group 2 with C-MAC® VL. C-L grading, time required for intubation, need for additional manoeuvres and haemodynamic changes during and after intubation were compared between the groups. Results: C-L grade 1 views were obtained in 26 and 29 patients in group 1 and group 2, respectively (86.7% vs. 96.7%). Remaining patients were having C-L grade 2 (13.3% vs. 3.3%). Duration of intubation was less than a minute in group 2 (93.3%). Need for additional manoeuvres (M1–M5) were more in group 1 (97% vs. 77%). M1 (external manipulation) was needed more in group 2 compared to group 1 (53.3% vs. 30%). Magill's forceps alone (M4) and M4 with additional external manipulation (M5) were needed more in group 1 compared to group 2 (60% vs. 16%). Conclusion: The overall performance of C-MAC® VL was better when compared to conventional direct Macintosh laryngoscope during NTI in terms of glottis visualisation, intubation time and need for additional manoeuvres. PMID:27761036
segment elevated myocardial infarction (STEMI) patients). An additional 23 prehospital patients were excluded because of missing or incomplete data...tool (J Trauma Acute Care Surgery 2014 Mar;76(3):743-9.), and is among the important findings from this project...Trauma Acute Care Surgery 2014 Mar;76(3):743-9 2) Van Haren RM, Ryan ML, Thorson CM, Namias N, Livingstone AS, Proctor KG: Bilateral near infrared
Rahmani, Farzad; Ebrahimi Bakhtavar, Hanieh; Shahsavari Nia, Kavous; Mohammadi, Neda
Shock as an inadequate tissue perfusion is one of the frequent causes of death in trauma patients. In this context, there are various reasons for hemodynamic instability and shock including hypovolemic (hemorrhagic), obstructive (cardiac tamponade, tension pneumothorax), cardiogenic, neurogenic, and rarely septic. In the present report, a 30-year-old trauma patient with full clinical signs and symptoms of shock referred while had unknown origin; it was finally recognized as anaphylactic shock.
Rahmani, Farzad; Ebrahimi Bakhtavar, Hanieh; Shahsavari Nia, Kavous; Mohammadi, Neda
Shock as an inadequate tissue perfusion is one of the frequent causes of death in trauma patients. In this context, there are various reasons for hemodynamic instability and shock including hypovolemic (hemorrhagic), obstructive (cardiac tamponade, tension pneumothorax), cardiogenic, neurogenic, and rarely septic. In the present report, a 30-year-old trauma patient with full clinical signs and symptoms of shock referred while had unknown origin; it was finally recognized as anaphylactic shock. PMID:26495357
Objective. Tranexamic Acid (TXA) is currently the only drug with prospective clinical evidence supporting its use in bleeding trauma patients. We sought to better understand the barriers preventing its use and elicit suggestions to further its use in trauma patients in the state of Maryland. Methods. This is a cross-sectional study. Results. The overall response rate was 38%. Half of all participants reported being familiar with the CRASH-2 trial and MATTERs study. Half reported being aware of TXA as part of their institution's massive transfusion protocol. The majority of participants felt that TXA would have a significant positive impact on the survival of trauma patients. A majority also felt that the use of TXA would increase if its administration was the responsibility of both trauma surgeons and emergency physicians. Conclusion. Only half of responders reported being aware of TXA as being part of their institution's massive transfusion protocol. Lack of awareness of the clinical data supporting its use is a major barrier. However, most trauma providers and emergency physicians do have a favorable view of TXA and support its incorporation into massive transfusion protocols. We believe that more studies of this kind on both state and national level are needed. PMID:28316839
Hidano, Gumi; Nagata, Osamu; Narushima, Mitsuhiro; Ozaki, Makoto
A 62-year-old woman (148 cm, 48.5 kg) with a history of bronchial asthma underwent an emergency appendectomy. Ten days before the operation she developed symptoms of wheezing while under asthma medication. An endotracheal tube (7 mm) was inserted after the induction of general anesthesia with intravenous injection of fentanyl 100 micrograms, propofol 100 mg and vecuronium 10 mg under Sellick's maneuver. Anesthesia was maintained with 1% sevoflurane with oxygen 6l-min-1 just after intubation, but bilateral lung sound soon became weaker and ventilation difficult. Based on a diagnosis of bronchoconstriction, we started hyperventilation with 3% sevoflurane. Ventilation returned to normal after about 5 minutes. Percutaneous O2 saturation was maintained at 100% during this episode, but the BIS transiently rose to 82. Anesthesia was maintained with 2% sevoflurane and 50% nitrous oxide balanced with oxygen, and 250 mg aminophylline was administered. Upon completion of the operation, the endotracheal tube was removed without any events. The patient gave no sign of awareness during the operation. When severe bronchoconstriction prevents the absorption of anesthetics from the lung alveoli, additional intravenous anesthetics should be administered to maintain stable amnesia.
Fingerhut, A; Boffard, K D
Trauma societies have an influence on the management and outcome of polytrauma. Its contributions include setting up standard definitions, trauma registries, evidence-based medicine guidelines, and the creation of educational tools such as specific courses of trauma care and decision-making. Literature and web-based search of definitions and available information. The history of and accomplishments of trauma societies in the above-mentioned domains are reviewed, including the major trauma registries (Major Trauma Outcome Study, National Trauma Data Bank, The American Pediatric Surgical Association, the American Burn Association trauma, and the German Trauma Society trauma registries). Several learned societies in the field of trauma have created recommendations and/or guidelines concerning polytrauma (the Eastern Association for the Surgery of Trauma, The Society of Critical Care Medicine, and the German Trauma Society, Brain Trauma Foundation, and the Essential Trauma Care (EsTC) Guidelines). Several practical, hands-on courses and scoring systems for improving the quality of management of polytrauma patients have been founded and implemented in the past 35 years, including the Advanced Trauma Life Support (ATLS(®)) Course of the American College of Surgeons, the Definitive Surgical Trauma Care (DSTC(TM)) Course, the National Trauma Management Course (NTMC(TM) Course,) the Advanced Trauma Operative Management (ATOM) Course, and the European Trauma Course (ETC). Trauma and emergency care societies have made an elaborate, substantial contribution by developing trauma registries and creating specific guidelines courses on trauma care and decision-making.
For the German speaking countries, Tscherne's definition of "polytrauma" which represents an injury of at least two body regions with one or a combination being life-threatening is still valid. The timely and adequate management including quick referral of the trauma patient into a designated trauma center may limit secondary injury and may thus improve outcomes already during the prehospital phase of care. The professional treatment of multiple injured trauma patients begins at the scene in the context of a well structured prehospital emergency medical system. The "Primary Survey" is performed by the emergency physician at the scene according to the Prehospital Trauma Life Support (PHTLS)-concept. The overall aim is to rapidly assess and treat life-threatening conditions even in the absence of patient history and diagnosis ("treat-first-what-kills-first"). If no immediate treatment is necessary, a "Secondary Sur- vey" follows with careful and structured body examination and detailed assessment of the trauma mechanism. Massive and life-threatening states of hemorrhage should be addressed immediately even disregarding the ABCDE-scheme. Critical trauma patients should be referred without any delay ("work and go")toTR-DGU® certified trauma centers of the local trauma networks. Due to the difficult pre- hospital environment the number of quality studies in the field is low and, as consequence, the level of evidence for most recommendations is also low. Much information has been obtained from different care systems and the interchangeability of results is limited. The present article provides a synopsis of rec- ommendations for early prehospital care for the severely injured based upon the 2011 updated multi- disciplinary S3-Guideline "Polytrauma/Schwerstverletzten Behandlung", the most recently updated European Trauma guideline and the current PHTLS-algorithms including grades of recommendation whenever possible.
De Boever, J A; Keersmaekers, K
Controversy exists on the aetiological importance and the effect of jaw macrotrauma (fractures excluded) on the occurrence of temporomandibular joint disorders (TMD). The purpose of this study was to assess the incidence of jaw injury in TMD patients and to compare the severity of the symptoms, the clinical characteristics and the treatment outcome in TMD patients with or without a history of trauma to the head and neck region directly linked to the onset of symptoms. The study sample included 400 consecutive TMD clinical patients. In 24.5% of patients the onset of the pain and dysfunction could be linked directly to the trauma, mainly whiplash accidents. No significant differences could be found between the two groups in daily recurrent headache, dizziness, neck pain, joint crepitation and pain in the joints. Maximal mouth opening was less than 20 mm in 14.3% of patients with a history of trauma and in 4.1% of those without such a history. According to the Helkimo dysfunction index (DI), more trauma than non-trauma TMD patients belonged to the severe dysfunction groups (DI 4 and 5) at first examination. The outcome of a conservative treatment procedure (counselling, occlusal splint, physiotherapy, occasionally occlusal therapy and non-steroidal anti-inflammation drugs was not different between the two groups at the 1 year evaluation. The degree of maximal opening was similar: less than 20 mm in 3.7% and 2.2% in trauma and non-trauma patients respectively. Forty percent and 41% respectively were symptom free or had DI = 1. The results suggest that external trauma to the joint or to the jaw in general is an important initiating factor in the aetiology of TMD but also that the prognosis is favourable.
Chou, Hui-Ling; Ruan, Sheng-Yuan; Wu, Huey-Dong
The universal bite block is increasingly used in orotracheally intubated patients. Here, we report a case of pilot tube dysfunction caused by a malpositioned universal bite block in an orotracheally intubated patient. We summarize the key points on identifying and managing a malpositioned universal bite block from this case and literature review.A 74-year-old woman was emergently intubated during an episode of hyperkalemia-related cardiac arrest. A universal bite block was used for fixing the endotracheal tube. After her condition stabilized, ventilator weaning was attempted; however, a positive cuff-leak test result was observed.The cuff-leak test revealed a lack of elasticity of the pilot balloon, which was completely deflated after 2 mL of air was removed. Pilot tube dysfunction was highly suspected. The bite block was slightly pulled out, and 8 mL of air was aspirated from the pilot tube. The patient was successfully extubated without stridor and respiratory distress.Our case highlighted that a malpositioned bite block may obstruct the pilot tube, causing unfavorable consequences. While fixing the bite block on an endotracheal tube, it is crucial to ensure that the takeoff point of the pilot tube is located within the C-notch of the bite block.
Brink, Monique; Deunk, Jaap; van Tongeren, Paul; Blickman, Johan G
The need for prospective studies in trauma radiology emerges as knowledge on the appropriate use of imaging becomes increasingly important in this field. Prospective observational studies enroll patients after research questions are articulated but only observe medical practice and should not compromise or change patient treatment. However, controversy exists regarding the requirement of informed consent from trauma patients in this type of study. This is reflected not only in differences in reporting informed consent in recent scientific publications on trauma radiology but also by the fact that policies regarding this topic vary in different parts of the world. The authors consider whether requesting informed consent is appropriate in prospective observational studies in trauma radiology from practical and different ethical perspectives.
Egea-Guerrero, J J; Freire-Aragón, M D; Serrano-Lázaro, A; Quintana-Díaz, M
Traumatic injuries represent a major health problem all over the world. In recent years we have witnessed profound changes in the paradigm of severe trauma patient resuscitation, new concepts regarding acute coagulopathy in trauma have been proposed, and there has been an expansion of specific commercial products related to hemostasis, among other aspects. New strategies in severe trauma management include the early identification of those injuries that are life threatening and require surgical hemostasis, tolerance of moderate hypotension, rational intravascular volume replacement, prevention of hypothermia, correction of acidosis, optimization of oxygen carriers, and identification of those factors required by the patient (fresh frozen plasma, platelets, tranexamic acid, fibrinogen, cryoprecipitates and prothrombin complex). However, despite such advances, further evidence is required to improve survival rates in severe trauma patients. Copyright © 2014 Elsevier España, S.L.U. y SEMICYUC. All rights reserved.
Hildebrand, Frank; Mommsen, Philipp; Frink, Michael; van Griensven, Martijn; Krettek, Christian
The care of multiple trauma patients has been improved through advances made in preclinical treatment, surgical procedures, and intensive care medicine. However, posttraumatic complications such as systemic inflammatory response syndrome, multiple organ dysfunction syndrome, and sepsis remain a major problem following multiple trauma. Components of the innate immune system and other inflammatory mediators (e.g., procalcitonin) play a pivotal role in the pathophysiology of posttraumatic complications. Studies investigating the genetic predisposition for complications after multiple trauma have provided evidence for a genetic heterogeneity in the posttraumatic immune response. The differences in response to multiple trauma associated with single-nucleotide polymorphisms may contribute to the development of new genetically tailored diagnostic and therapeutic interventions improving outcome in this patient population. In addition, detrimental adverse effects of adjuvant therapy could be avoided in other patients who, by genotype, are predicted not to benefit.
Introduction Advanced Trauma Life Support (ATLS) protocols provide a common approach for trauma resuscitations. This was a quality review assessing compliance with ATLS protocols at a Level I trauma center; specifically whether the presence or absence of a trauma team leader (TTL) influenced adherence. Methods This retrospective study was conducted on adult major trauma patients with acute injuries over a one-year period in a Level I Canadian trauma center. Data were collected from the Alberta Trauma Registry, and adherence to ATLS protocols was determined by chart review. Results The study identified 508 patients with a mean Injury Severity Score of 24.5 (SD 10.7), mean age 39.7 (SD 17.6), 73.8% were male and 91.9% were involved in blunt trauma. The overall compliance rate was 81.8% for primary survey and 75% for secondary survey. The TTL group compared to non-TTL group was more likely to complete the primary survey (90.9% vs. 81.8%, p = 0.003), and the secondary survey (100% vs. 75%, p = 0.004). The TTL group was more likely than the non-TTL group to complete the following tasks: insertion of two large bore IVs (68.2% vs. 57.7%, p = 0.014), digital rectal exam (64.6% vs. 54.7%, p = 0.023), and head to toe exam (77% vs. 67.1%, p = 0.013). Mean times from emergency department arrival to diagnostic imaging were also significantly shorter in the TTL group compared to the non-TTL group, including times to pelvis xray (mean 68min vs. 107min, p = 0.007), CT chest (mean 133min vs. 172min, p = 0.005), and CT abdomen and pelvis (mean 136min vs. 173min, p = 0.013). Readmission rates were not significantly different between the TTL and non-TTL groups (3.5% vs. 4.5%, p = 0.642). Conclusions While many studies have demonstrated the effectiveness of trauma systems on outcomes, few have explored the direct influence of the TTL on ATLS compliance. This study demonstrated that TTL involvement during resuscitations was associated with improved
Nakao, Shunichiro; Kimura, Akio; Hagiwara, Yusuke; Hasegawa, Kohei
Although successful airway management is essential for emergency trauma care, comprehensive studies are limited. We sought to characterise current trauma care practice of airway management in the emergency departments (EDs) in Japan. Analysis of data from a prospective, observational, multicentre registry-the Japanese Emergency Airway Network (JEAN) registry. 13 academic and community EDs from different geographic regions across Japan. 723 trauma patients who underwent emergency intubation from March 2010 through August 2012. ED characteristics, patient and operator demographics, methods of airway management, intubation success or failure at each attempt and adverse events. A total of 723 trauma patients who underwent emergency intubation were eligible for the analysis. Traumatic cardiac arrest comprised 32.6% (95% CI 29.3% to 36.1%) of patients. Rapid sequence intubation (RSI) was the initial method chosen in 23.9% (95% CI 21.0% to 27.2%) of all trauma patients and in 35.5% (95% CI 31.4% to 39.9%) of patients without cardiac arrest. Overall, intubation was successful in ≤3 attempts in 96% of patients (95% CI 94.3% to 97.2%). There was a wide variation in the initial methods of intubation; RSI as the initial method was performed in 0-50.9% of all trauma patients among 12 EDs. Similarly, there was a wide variation in success rates and adverse event rates across the EDs. Success rates varied between 35.5% and 90.5% at the first attempt, and 85.1% and 100% within three attempts across the 12 EDs. In this multicentre prospective study in Japan, we observed a high overall success rate in airway management during trauma care. However, the methods of intubation and success rates were highly variable among hospitals. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
This article presents thromboelastography (TEG) as an important assay to incorporate into anesthesia practice for development of evidence-based therapy of trauma patients receiving blood transfusions. The leading cause of death worldwide results from trauma. Hemorrhage is responsible for 30% to 40% of trauma mortality and accounts for almost 50% of the deaths occurring in the initial 24 hours following the traumatic incident. On admission, 25% to 35% of trauma patients present with coagulopathy, which is associated with a sevenfold increase in morbidity and mortality. The literature supports that routine plasma-based routine coagulation tests, such as prothrombin time, activated partial thromboplastin time, and international normalized ratio, are inadequate for monitoring coagulopathy and guided transfusion therapy in trauma patients. A potential solution is incorporating the use of the TEG assay into the care of trauma patients to render evidence-based therapy for patients requiring massive blood transfusions. Analysis with TEG provides a complete picture of hemostasis, which is far superior to isolated, static conventional tests. The result is a fast, well-designed, and precise diagnosis enabling more cost-effective treatment, improved clinical outcome, accurate use of blood products, and pharmaceutical therapies at the point of care.
Dewhirst, Elisabeth; Tobias, Joseph D; Martin, David P
Aspiration is a significant cause of anesthetic morbidity, occurring most commonly during the induction of anesthesia. For patients with a high likelihood of aspiration, rapid sequence intubation (RSI) techniques may minimize this risk by reducing the time between the loss of protective airway reflexes and the placement of a cuffed endotracheal tube. Although RSI frequently involves the administration of a neuromuscular-blocking agent (NMBA) such as succinylcholine or rocuronium, there are times when the administration of an NMBA is contraindicated or undesirable. We present an 11-year-old boy who presented with vomiting, papilledema, and a history concerning for an undiagnosed neuromuscular disorder. Deep sedation or anesthesia was required during an emergent lumbar puncture to evaluate his symptoms. Rapid sequence intubation was successfully performed with propofol and remifentanil without the use of an NMBA. We highlight the anesthetic considerations in such a clinical scenario and review the literature regarding the combination of remifentanil and propofol for RSI.
Karakus, Osman; Kaya, Cengiz; Ustun, Faik Emre; Koksal, Ersin; Ustun, Yasemin Burcu
Predictive value of preoperative tests in estimating difficult intubation may differ in the laryngeal pathologies. Patients who had undergone direct laryngoscopy (DL) were reviewed, and predictive value of preoperative tests in estimating difficult intubation was investigated. Preoperative, and intraoperative anesthesia record forms, and computerized system of the hospital were screened. A total of 2611 patients were assessed. In 7.4% of the patients, difficult intubations were detected. Difficult intubations were encountered in some of the patients with Mallampati scoring (MS) system Class 4 (50%), Cormack-Lehane classification (CLS) Grade 4 (95.7%), previous knowledge of difficult airway (86.2%), restricted neck movements (cervical ROM) (75.8%), short thyromental distance (TMD) (81.6%), vocal cord mass (49.5%) as indicated in parentheses (p<0.0001). MS had a low sensitivity, while restricted cervical ROM, presence of a vocal cord mass, short thyromental distance, and MS each had a relatively higher positive predictive value. Incidence of difficult intubations increased 6.159 and 1.736-fold with each level of increase in CLS grade and MS class, respectively. When all tests were considered in combination difficult intubation could be classified accurately in 96.3% of the cases. Test results predicting difficult intubations in cases with DL had observedly overlapped with the results provided in the literature for the patient populations in general. Differences in some test results when compared with those of the general population might stem from the concomitant underlying laryngeal pathological conditions in patient populations with difficult intubation. Copyright © 2014 Sociedade Brasileira de Anestesiologia. Publicado por Elsevier Editora Ltda. All rights reserved.
Mitra, Biswadev; Fitzgerald, Mark C; Olaussen, Alexander; Thaveenthiran, Prasanthan; Bade-Boon, Jordan; Martin, Katherine; Smit, De Villiers; Cameron, Peter A
Multiply injured patients represent a particularly demanding subgroup of trauma patients as they require urgent simultaneous clinical assessments using physical examination, ultrasound and invasive monitoring together with critical management, including tracheal intubation, thoracostomies and central venous access. Concurrent access to multiple body regions is essential to facilitate the concept of 'horizontal' resuscitation. The current positioning of trauma patient, with arms adducted, restricts this approach. Instead, the therapeutic cruciform positioning, with arms abducted at 90°, allows planning and performing of multiple life-saving interventions simultaneously. This positioning also provides a practical surgical field with improved sterility and procedural access.
Bathory, I; Frascarolo, P; Kern, C; Schoettker, P
Application of cervical collars may reduce cervical spine movements but render tracheal intubation with a standard laryngoscope difficult if not impossible. We hypothesised that despite the presence of a Philadelphia Patriot cervical collar and with the patient's head taped to the trolley, tracheal intubation would be possible in 50 adult patients using the GlideScope and its dedicated stylet. Laryngoscopy was attempted using a Macintosh laryngoscope with a size 4 blade, and the modified Cormack-Lehane grade was scored. Subsequently, laryngoscopy with the GlideScope was graded and followed by tracheal intubation. All patients' tracheas were successfully intubated with the GlideScope. The median (IQR) intubation time was 50 s (43-61 s). The modified Cormack-Lehane grade was 3 or 4 at direct laryngoscopy. It was significantly reduced with the GlideScope (p < 0.0001), reaching grade 2a in most patients. Tracheal intubation in patients wearing a semi-rigid collar and having their head taped to the trolley is possible with the help of the GlideScope.
Bossers, Sebastiaan M.; Schwarte, Lothar A.; Loer, Stephan A.; Twisk, Jos W. R.; Boer, Christa; Schober, Patrick
Background Patients with severe traumatic brain injury (TBI) are at high risk for airway obstruction and hypoxia at the accident scene, and routine prehospital endotracheal intubation has been widely advocated. However, the effects on outcome are unclear. We therefore aim to determine effects of prehospital intubation on mortality and hypothesize that such effects may depend on the emergency medical service providers’ skill and experience in performing this intervention. Methods and Findings PubMed, Embase and Web of Science were searched without restrictions up to July 2015. Studies comparing effects of prehospital intubation versus non-invasive airway management on mortality in non-paediatric patients with severe TBI were selected for the systematic review. Results were pooled across a subset of studies that met predefined quality criteria. Random effects meta-analysis, stratified by experience, was used to obtain pooled estimates of the effect of prehospital intubation on mortality. Meta-regression was used to formally assess differences between experience groups. Mortality was the main outcome measure, and odds ratios refer to the odds of mortality in patients undergoing prehospital intubation versus odds of mortality in patients who are not intubated in the field. The study was registered at the International Prospective Register of Systematic Reviews (PROSPERO) with number CRD42014015506. The search provided 733 studies, of which 6 studies including data from 4772 patients met inclusion and quality criteria for the meta-analysis. Prehospital intubation by providers with limited experience was associated with an approximately twofold increase in the odds of mortality (OR 2.33, 95% CI 1.61 to 3.38, p<0.001). In contrast, there was no evidence for higher mortality in patients who were intubated by providers with extended level of training (OR 0.75, 95% CI 0.52 to 1.08, p = 0.126). Meta-regression confirmed that experience is a significant predictor of
Bossers, Sebastiaan M; Schwarte, Lothar A; Loer, Stephan A; Twisk, Jos W R; Boer, Christa; Schober, Patrick
Patients with severe traumatic brain injury (TBI) are at high risk for airway obstruction and hypoxia at the accident scene, and routine prehospital endotracheal intubation has been widely advocated. However, the effects on outcome are unclear. We therefore aim to determine effects of prehospital intubation on mortality and hypothesize that such effects may depend on the emergency medical service providers' skill and experience in performing this intervention. PubMed, Embase and Web of Science were searched without restrictions up to July 2015. Studies comparing effects of prehospital intubation versus non-invasive airway management on mortality in non-paediatric patients with severe TBI were selected for the systematic review. Results were pooled across a subset of studies that met predefined quality criteria. Random effects meta-analysis, stratified by experience, was used to obtain pooled estimates of the effect of prehospital intubation on mortality. Meta-regression was used to formally assess differences between experience groups. Mortality was the main outcome measure, and odds ratios refer to the odds of mortality in patients undergoing prehospital intubation versus odds of mortality in patients who are not intubated in the field. The study was registered at the International Prospective Register of Systematic Reviews (PROSPERO) with number CRD42014015506. The search provided 733 studies, of which 6 studies including data from 4772 patients met inclusion and quality criteria for the meta-analysis. Prehospital intubation by providers with limited experience was associated with an approximately twofold increase in the odds of mortality (OR 2.33, 95% CI 1.61 to 3.38, p<0.001). In contrast, there was no evidence for higher mortality in patients who were intubated by providers with extended level of training (OR 0.75, 95% CI 0.52 to 1.08, p = 0.126). Meta-regression confirmed that experience is a significant predictor of mortality (p = 0.009). Effects of
Chan, J K; Ng, I; Ang, J P; Koh, S M; Lee, K; Mezzavia, P; Morris, J; Loh, F; Segal, R
Fibreoptic intubation remains an essential skill for anaesthetists to master. In addition to the reusable fibrescope, an alternative disposable videoscope is available (aScope(™)2, Ambu®, Ballerup, Denmark). A total of 60 anaesthetised adult patients were randomised to either having orotracheal intubation using the aScope 2 or a Karl Storz fibrescope. Intubations were performed by experienced operators who were familiar with both devices. The primary outcome was the Global Rating Scale score. Secondary outcomes included intubation success, number of intubation attempts and intubation time. Other subjective outcomes including practicality, useability and image quality were also recorded. There was no significant difference in the Global Rating Scale score, intubation success orintubation time between the aScope 2 or Karl Storz fibrescope. Global Rating Scale scores were three and two in the aScope 2 and Karl Storz groups respectively (P=0.14). All of the other subjective outcomes were similar between the two groups, except that operators found it easier to use the aScope 2 compared to the fibrescope. There was no significant difference in clinical performance between the aScope 2 and the Karl Storz fibreoptic bronchoscope. The aScope's practicality, disposability and recently improved version (aScope(™)3) potentially make it an acceptable alternative to the reusable fibrescope.
Petty, John K
Although venous thromboembolism (VTE) occurs in less than 1% of hospitalized pediatric trauma patients, care providers must make decisions about VTE prophylaxis on a daily basis. The consequences of VTE are significant; the risks of developing VTE are variable; and the effectiveness of prophylaxis against VTE is not conclusive in children. While the value of VTE prophylaxis is well defined in adult trauma care, it is unclear how this translates to the care of injured children. This review evaluates the incidence and risks of VTE in pediatric trauma and assesses the merits of prophylaxis in children. Pharmacologic prophylaxis against VTE is a reasonable strategy in critically injured adolescent trauma patients. Further study is needed to establish the risks and benefits of VTE prophylaxis across the spectrum of injured children. Copyright © 2017 Elsevier Inc. All rights reserved.
Jennings, Fiona L; Mitchell, Marion
Trauma patient management is complex and challenging for nurses in the Intensive Care Unit. One strategy to promote quality and evidence based care may be through utilising specialty nursing experts both internal and external to the Intensive Care Unit in the form of a nursing round. Inter Specialty Trauma Nursing Rounds have the potential to improve patient care, collaboration and nurses' knowledge. The purpose of this quality improvement project was to improve trauma patient care and evaluate the nurses perception of improvement. The project included structured, weekly rounds that were conducted at the bedside. Nursing experts and others collaborated to assess and make changes to trauma patients' care. The rounds were evaluated to assess the nurse's perception of improvement. There were 132 trauma patients assessed. A total of 452 changes to patient care occurred. On average, three changes per patient resulted. Changes included nursing management, medical management and wound care. Nursing staff reported an overall improvement of trauma patient care, trauma knowledge, and collaboration with colleagues. Inter Specialty Trauma Nursing Rounds utilizes expert nursing knowledge. They are suggested as an innovative way to address the clinical challenges of caring for trauma patients and are perceived to enhance patient care and nursing knowledge. Copyright © 2017 Elsevier Ltd. All rights reserved.
Mashio, H; Kojima, T; Goda, Y; Kawahigashi, H; Ito, Y; Kato, M
A 71-year-old male patient with rheumatoid arthritis was scheduled for posterior fusion of the cervical spine. He showed limited cervical movement and atrophic mandible. Tracheal intubation was difficult in his last anesthetic management for the same surgery. This time, we planned a special procedure for predicted difficult tracheal intubation. After induction of general anesthesia, a size-4 laryngeal mask airway was inserted. Next, a flexible fiberscope sheathed with a 6.0-mm-ID cuffed endotracheal tube was inserted through a laryngeal mask airway into the trachea, and the fiberscope was withdrawn. Then, an endotracheal tube changer was inserted through the endotracheal tube. The laryngeal mask airway and the endotracheal tube were withdrawn simultaneously leaving the tube changer. Finally, a 7.5-mm-ID armored endotracheal tube was inserted through the tube changer. The procedure applied in this case is a safe and reliable intubating method in patients with difficult tracheal intubation.
... RF, McGill JW, Clinton JE. Tracheal intubation. In: Roberts JR, ed. Roberts and Hedges' Clinical Procedures in Emergency Medicine . 6th ... commercial use must be authorized in writing by ADAM Health Solutions. About MedlinePlus Site Map FAQs Customer ...
Häggman-Henrikson, B; Rezvani, M; List, T
The purpose of this systematic review was to describe the prevalence of whiplash trauma in patients with temporomandibular disorders (TMDs) and to describe clinical signs and symptoms in comorbid TMD/whiplash compared with TMD localised to the facial region. A systematic literature search of the PubMed, Cochrane Library and Bandolier databases was carried out for articles published from 1 January 1966 to 31 December 2012. The systematic search identified 129 articles. After the initial screening of abstracts, 32 articles were reviewed in full text applying inclusion and exclusion criteria. Six studies on the prevalence of neck trauma in patients with TMD met the inclusion criteria and were included in the review. Two of the authors evaluated the methodological quality of the included studies. The reported prevalence of whiplash trauma ranged from 8·4% to 70% (median 35%) in TMD populations, compared with 1·7-13% in the non-TMD control groups. Compared with patients with TMD localised to the facial region, TMD patients with a history of whiplash trauma reported more TMD symptoms, such as limited jaw opening and more TMD pain, and also more headaches and stress symptoms. In conclusion, the prevalence of whiplash trauma is higher in patients with TMD compared with non-TMD controls. Furthermore, patients with comorbid TMD/whiplash present with more jaw pain and more severe jaw dysfunction compared with TMD patients without a history of head-neck trauma. These results suggest that whiplash trauma might be an initiating and/or aggravating factor as well as a comorbid condition for TMD.
Lapinsky, Stephen E
Endotracheal intubation in the ICU is a high-risk procedure, resulting in significant morbidity and mortality. Up to 40% of cases are associated with marked hypoxemia or hypotension. The ICU patient is physiologically very different from the usual patient who undergoes intubation in the operating room, and different intubation techniques should be considered. The common operating room practice of sedation and neuromuscular blockade to facilitate intubation may carry significant risk in the ICU patient with a marked oxygenation abnormality, particularly when performed by the non-expert. Preoxygenation is largely ineffective in these patients and oxygen desaturation occurs rapidly on induction of anesthesia, limiting the time available to secure the airway. The ICU environment is less favorable for complex airway management than the operating room, given the frequent lack of availability of additional equipment or additional expert staff. ICU intubations are frequently carried out by trainees, with a lesser degree of airway experience. Even in the presence of a non-concerning airway assessment, these patients are optimally managed as a difficult airway, utilizing an awake approach. Endotracheal intubation may be achieved by awake direct laryngoscopy in the sick ICU patient whose level of consciousness may be reduced by sepsis, hypercapnia or hypoxemia. As the patient's spontaneous respiratory efforts are not depressed by the administration of drugs, additional time is available to obtain equipment and expertise in the event of failure to secure the airway. ICU intubation complications should be tracked as part of the ICU quality improvement process.
Ciesla, David J; Pracht, Etienne E; Cha, John Y; Langland-Orban, Barbara
Despite decades of trauma system development, many severely injured patients fail to reach a trauma center for definitive care. The purpose of this study was to define the regions served by Florida's designated trauma centers and define the geographic distribution of severely injured patients who do not access the state's trauma system. Severely injured patients discharged from Florida hospitals were identified using the 2009 Florida Agency for Health Care Administration database. The home zip codes of patients discharged from trauma and nontrauma center hospitals were used as a surrogate for injury location and plotted on a map. A radial distance containing 75% of trauma center discharges defined trauma center catchment area. Only 52% of severely injured patients were discharged from trauma centers. The catchment areas varied from 204 square miles to 12,682 square miles and together encompassed 92% state's area. Although 93% of patients lived within a trauma center catchment area, the proportion treated at a trauma center in each catchment area varied from 13% to 58%. Mapping of patient residences identified regions of limited access to the trauma system despite proximity to trauma centers. The distribution of severely injured patients who do not reach trauma centers presents an opportunity for trauma system improvement. Those in proximity to trauma centers may benefit from improved and secondary triage guidelines and interfacility transfer agreements, whereas those distant from trauma centers may suggest a need for additional trauma system resources. Epidemiologic study, level III.
Powell, Eleanor; Alkhouri, Hatem; McCarthy, Sally; Mackenzie, John; Fogg, Toby; Vassiliadis, John; Cresswell, Chris
To describe the practice and procedure of emergency intubation in Whanganui Emergency Department, New Zealand and determine whether intubation can be carried out effectively in the rural setting. A prospective observational study using the Australia and New Zealand Airway Registry proforma to collect data on the indication, lead intubator, first-pass success rate and peri-procedural complications. Data were also collected on whether a formal airway assessment was carried out and whether a checklist was used. Twenty-three patients were intubated in the emergency department over a 12-month period. Sixty-two percent (14/23 cases) were medical encounters and the remaining 38% of indications due to a trauma. Head injury was the most common indication (23%). Ninety-two percent of primary intubators were emergency department-based Fellowship of the Australasian College for Emergency Medicine or resident medical officers, while anaesthetic-trained operators accounted for just 8%. Our first-pass intubation success rate was 87% and 16% of cases had procedural complications. Sixty-five percent (15/23) carried out a formal airway assessment and a checklist was only used in 23% of cases. This sequential case series is the first study looking at airway management in rural New Zealand emergency department airway practice. Overall intubation success rates were comparable to larger tertiary centres across Australasia. We have demonstrated that with adequate resources and adherence to interventions, a rural emergency department can provide effective airway management. © 2017 National Rural Health Alliance Inc.
Kaewlai, Rathachai; de Moya, Marc A; Santos, Antonio; Asrani, Ashwin V; Avery, Laura L; Novelline, Robert A
Trauma patients with thoracic aortic injury (TAI) suffer blunt cardiac injury (BCI) at variable frequencies. This investigation aimed to determine the frequency of BCI in trauma patients with TAI and compare with those without TAI. All trauma patients with TAI who had admission electrocardiography (ECG) and serum creatine kinase-MB (CK-MB) from January 1999 to May 2009 were included as a study group at a level I trauma center. BCI was diagnosed if there was a positive ECG with either an elevated CK-MB or abnormal echocardiography. There were 26 patients (19 men, mean age 45.1 years, mean ISS 34.4) in the study group; 20 had evidence of BCI. Of 52 patients in the control group (38 men, mean age 46.9 years, mean ISS 38.7), eighteen had evidence of BCI. There was a significantly higher rate of BCI in trauma patients with TAI versus those without TAI (77% versus 35%, P < 0.001).
Kaewlai, Rathachai; de Moya, Marc A.; Santos, Antonio; Asrani, Ashwin V.; Avery, Laura L.; Novelline, Robert A.
Trauma patients with thoracic aortic injury (TAI) suffer blunt cardiac injury (BCI) at variable frequencies. This investigation aimed to determine the frequency of BCI in trauma patients with TAI and compare with those without TAI. All trauma patients with TAI who had admission electrocardiography (ECG) and serum creatine kinase-MB (CK-MB) from January 1999 to May 2009 were included as a study group at a level I trauma center. BCI was diagnosed if there was a positive ECG with either an elevated CK-MB or abnormal echocardiography. There were 26 patients (19 men, mean age 45.1 years, mean ISS 34.4) in the study group; 20 had evidence of BCI. Of 52 patients in the control group (38 men, mean age 46.9 years, mean ISS 38.7), eighteen had evidence of BCI. There was a significantly higher rate of BCI in trauma patients with TAI versus those without TAI (77% versus 35%, P < 0.001). PMID:22046549
Ptak, Thomas; Sheridan, Robert L; Rhea, James T; Gervasini, Alice A; Yun, Jong H; Curran, Marjorie A; Borszuk, Pierre; Petrovick, Laurie; Novelline, Robert A
Previous studies evaluating quantitative cerebral white matter diffusion anisotropy indexes have shown alteration in patients after trauma. To date, no clinically applicable scale exists by which to gauge and test the relevance of these findings. We propose the cerebral fractional anisotropy score in trauma (C-FAST) as an index of white matter injury, and we correlate C-FAST with several predictor and outcome variables. Fifteen patients were randomly selected from the trauma surgery service. Thirty control patients were randomly selected from the emergency department. All patients were subjected to MRI evaluation, including a diffusion-weighted sequence. Data extracted from the record of each subject included Glasgow Coma Scale, revised trauma score, Abbreviated Injury Scale, initial head CT results, patient disposition, length of hospital stay, and length of stay in intensive care unit. Region of interest measurements were made in fractional anisotropy maps in each of 12 white matter regions. Univariate statistics and a two-tailed t test were performed on the raw fractional anisotropy data. Data were then dichotomized using thresholds from univariate statistics. A C-FAST score was devised from the dichotomized data. Logistic regression analyses were performed among the C-FAST, outcome, and predictor data. Good correlation was noted between the C-FAST and death, hospital stay greater than 10 days, and intensive care unit stay greater than 5 days. Correlation with discharge to rehabilitation facility was good when adjusted for age and sex. Glasgow Coma Scale, revised trauma score, and Abbreviated Injury Scale show good correlation as predictors of a critical C-FAST. The C-FAST is a promising index derived from MRI diffusion fractional anisotropy measurements that shows successful correlation with outcome and predictor variables. A larger investigation is needed to verify the validity and stability of the correlations.
Nakhjavan-Shahraki, Babak; Yousefifard, Mahmoud; Hajighanbari, Mohammad Javad; Karimi, Parviz; Baikpour, Masoud; Mirzay Razaz, Jalaledin; Yaseri, Mehdi; Shahsavari, Kavous; Mahdizadeh, Fatemeh; Hosseini, Mostafa
Introduction: Awareness about the outcome of trauma patients in the emergency department (ED) has become a topic of interest. Accordingly, the present study aimed to compare the rapid trauma score (RTS) and worthing physiological scoring system (WPSS) in predicting in-hospital mortality and poor outcome of trauma patients. Methods: In this comparative study trauma patients brought to five EDs in different cities of Iran during the year 2016 were included. After data collection, discriminatory power and calibration of the models were assessed and compared using STATA 11. Results: 2148 patients with the mean age of 39.50±17.27 years were included (75.56% males). The AUC of RTS and WPSS models for prediction of mortality were 0.86 (95% CI: 0.82-0.90) and 0.91 (95% CI: 0.87-0.94), respectively (p=0.006). RTS had a sensitivity of 71.54 (95% CI: 62.59-79.13) and a specificity of 97.38 (95% CI: 96.56-98.01) in prediction of mortality. These measures for the WPSS were 87.80 (95% CI: 80.38-92.78) and 83.45 (95% CI: 81.75-85.04), respectively. The AUC of RTS and WPSS in predicting poor outcome were 0.81 (95% CI: 0.77-0.85) and 0.89 (95% CI: 0.85-0.92), respectively (p<0.0001). Conclusion: The findings showed a higher prognostic value for the WPSS model in predicting mortality and severe disabilities in trauma patients compared to the RTS model. Both models had good overall performance in prediction of mortality and poor outcome. PMID:28286838
Donaubauer, B; Fakler, J; Gries, A; Kaisers, U X; Josten, C; Bernhard, M
The recommendations still have to be implemented 3 years after publication of the S3 guidelines on the treatment of patients with severe and multiple injuries. This article reiterates some of the essential core statements of the S3 guidelines and also gives an overview of new scientific studies. In a selective literature search new studies on airway management, traumatic cardiac arrest, shock classification, coagulation therapy, whole-body computed tomography, air rescue and trauma centers were identified and are discussed in the light of the S3 guideline recommendations. The recommendations on airway management are up to date; however, recommendations on difficult airway evaluation tools, e.g. the LEMON law, should be included. The first pass success (i.e. intubation success at the first attempt) must be considered as a quality marker in the future. Video laryngoscopy is identified as a leading airway procedure in order to reach this aim. Recently estimated learning curves for endotracheal intubation and supraglottic airway devices should be implemented in qualification statements. Life-saving emergency interventions have to be performed in the prehospital setting as they do not prolong the complete treatment period for severely injured patients up to discharge from the resuscitation room. The outcome of patients suffering from traumatic cardiac arrest is better than expected. Recently developed algorithms for trauma patients have to be implemented. The prehospital trauma life support (PHTLS) and advanced trauma life support (ATLS) shock classification does not reflect the clinical reality; therefore, lactate, lactate clearance and base deficit should be used for evaluating the shock state in the resuscitation room. Concerning coagulation therapy, tranexamic acid is easy to administer, safe and effective as an antifibrinolytic therapy and should not be restricted to the most severely injured patients. Numerous studies have shown the positive effect of whole
Uleberg, Oddvar; Vinjevoll, Ole-Petter; Kristiansen, Thomas; Klepstad, Pål
Approximately 10% of the Norwegian population is injured every year, with injuries ranging from minor injuries treated by general practitioners to major and complex injuries requiring specialist in-hospital care. There is a lack of knowledge concerning the caseload of potentially severely injured patients in Norwegian hospitals. Aim of the study was to describe the current status of the Norwegian trauma system by identifying the number and the distribution of contributing hospitals and the caseload of potentially severely injured trauma patients within these hospitals. A cross-sectional survey with a structured questionnaire was sent in the summer of 2012 to all Norwegian hospitals that receive trauma patients. These were defined by number of trauma team activations in the included hospitals. A literature review was performed to assess over time the development of hospitals receiving trauma patients. Forty-one hospitals responded and were included in the study. In 2011, four trauma centres and 37 acute care hospitals received a total of 6,570 trauma patients. Trauma centres received 2,175 (33%) patients and other hospitals received 4,395 (67%) patients. There were significant regional differences between health care regions in the distribution of trauma patients between trauma centres and acute care hospitals. More than half (52.5%) of the hospitals received fewer than 100 patients annually. The national rate of hospital admission via trauma teams was 13 per 10,000 inhabitants. There was a 37% (from 65 to 41) reduction in the number of hospitals receiving trauma patients between 1988 and 2011. In 2011, hospital acute trauma care in Norway was delivered by four trauma centres and 37 acute care hospitals. Many hospitals still receive a small number of potentially severely injured patients and only a few hospitals have an electronic trauma registry. Future development of the Norwegian trauma system needs to address the challenge posed by a scattered population and
Band, Roger A; Salhi, Rama A; Holena, Daniel N; Powell, Elizabeth; Branas, Charles C; Carr, Brendan G
Two decades ago, Philadelphia began allowing police transport of patients with penetrating trauma. We conduct a large, multiyear, citywide analysis of this policy. We examine the association between mode of out-of-hospital transport (police department versus emergency medical services [EMS]) and mortality among patients with penetrating trauma in Philadelphia. This is a retrospective cohort study of trauma registry data. Patients who sustained any proximal penetrating trauma and presented to any Level I or II trauma center in Philadelphia between January 1, 2003, and December 31, 2007, were included. Analyses were conducted with logistic regression models and were adjusted for injury severity with the Trauma and Injury Severity Score and for case mix with a modified Charlson index. Four thousand one hundred twenty-two subjects were identified. Overall mortality was 27.4%. In unadjusted analyses, patients transported by police were more likely to die than patients transported by ambulance (29.8% versus 26.5%; OR 1.18; 95% confidence interval [CI] 1.00 to 1.39). In adjusted models, no significant difference was observed in overall mortality between the police department and EMS groups (odds ratio [OR] 0.78; 95% CI 0.61 to 1.01). In subgroup analysis, patients with severe injury (Injury Severity Score >15) (OR 0.73; 95% CI 0.59 to 0.90), patients with gunshot wounds (OR 0.70; 95% CI 0.53 to 0.94), and patients with stab wounds (OR 0.19; 95% CI 0.08 to 0.45) were more likely to survive if transported by police. We found no significant overall difference in adjusted mortality between patients transported by the police department compared with EMS but found increased adjusted survival among 3 key subgroups of patients transported by police. This practice may augment traditional care. Copyright © 2014 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.
Engels, Paul T; Passos, Edward; Beckett, Andrew N; Doyle, Jeffrey D; Tien, Homer C
Exsanguinating haemorrhage is a leading cause of death in severely injured trauma patients. Management includes achieving haemostasis, replacing lost intravascular volume with fluids and blood, and treating coagulopathy. The provision of fluids and blood products is contingent on obtaining adequate vascular access to the patient's venous system. We sought to examine the nature and timing of achieving adequate intravenous (IV) access in trauma patients requiring uncrossmatched blood in the trauma bay. We performed a retrospective chart review of all patients admitted to our trauma centre from 2005 to 2009 who were transfused uncrossmatched blood in the trauma bay. We examined the impact of IV access on prehospital times and time to first PRBC transfusion. Of 208 study patients, 168 (81%) received prehospital IV access, and the on-scene time for these patients was 5 min longer (16.1 vs 11.4, p<0.01). Time to achieving adequate IV access in those without any prehospital IVs occurred on average 21 min (6.6-30.5) after arrival to the trauma bay. A central venous catheter was placed in 92 (44%) of patients. Time to first blood transfusion correlated most strongly with time to achieving central venous access (Pearson correlation coefficient 0.94, p<0.001) as opposed to time to achieving adequate peripheral IV access (Pearson correlation coefficient 0.19, p=0.12). We found that most bleeding patients received a prehospital IV; however, we also found that obtaining prehospital IVs was associated with longer EMS on-scene times and longer prehospital times. Interestingly, we found that obtaining a prehospital IV was not associated with more rapid initiation of blood product transfusion. Obtaining optimal IV access and subsequent blood transfusion in severely injured patients continues to present a challenge. Copyright © 2013 Elsevier Ltd. All rights reserved.
Wheeler, Krista K; Shi, Junxin; Xiang, Henry; Thakkar, Rajan K; Groner, Jonathan I
We sought to determine readmission rates and risk factors for acutely injured pediatric trauma patients. We produced 30-day unplanned readmission rates for pediatric trauma patients using the 2013 National Readmission Database (NRD). In US pediatric trauma patients, 1.7% had unplanned readmissions within 30days. The readmission rate for patients with index operating room procedures was no higher at 1.8%. Higher readmission rates were seen in patients with injury severity scores (ISS)=16-24 (3.4%) and ISS ≥25 (4.9%). Higher rates were also seen in patients with LOS beyond a week, severe abdominal and pelvic region injuries (3.0%), crushing (2.8%) and firearm injuries (4.5%), and in patients with fluid and electrolyte disorders (3.9%). The most common readmission principal diagnoses were injury, musculoskeletal/integumentary diagnoses and infection. Nearly 39% of readmitted patients required readmission operative procedures. Most common were operations on the musculoskeletal system (23.9% of all readmitted patients), the integumentary system (8.6%), the nervous system (6.6%), and digestive system (2.5%). Overall, the readmission rate for pediatric trauma patients was low. Measures of injury severity, specifically length of stay, were most useful in identifying those who would benefit from targeted care coordination resources. This is a Level III retrospective comparative study. Copyright © 2017 Elsevier Inc. All rights reserved.
Introduction Recent experimental data suggest that continuous external negative-pressure ventilation (CENPV) results in better oxygenation and less lung injury than continuous positive-pressure ventilation (CPPV). The effects of CENPV on patients with acute respiratory distress syndrome (ARDS) remain unknown. Methods We compared 2 h CENPV in a tankrespirator ("iron lung") with 2 h CPPV. The six intubated patients developed ARDS after pulmonary thrombectomy (n = 1), aspiration (n = 3), sepsis (n = 1) or both (n = 1). We used a tidal volume of 6 ml/kg predicted body weight and matched lung volumes at end expiration. Haemodynamics were assessed using the pulse contour cardiac output (PiCCO) system, and pressure measurements were referenced to atmospheric pressure. Results CENPV resulted in better oxygenation compared to CPPV (median ratio of arterial oxygen pressure to fraction of inspired oxygen of 345 mmHg (minimum-maximum 183 to 438 mmHg) vs 256 mmHg (minimum-maximum 123 to 419 mmHg) (P < 0.05). Tank pressures were -32.5 cmH2O (minimum-maximum -30 to -43) at end inspiration and -15 cmH2O (minimum-maximum -15 to -19 cmH2O) at end expiration. NO Inspiratory transpulmonary pressures decreased (P = 0.04) and airway pressures were considerably lower at inspiration (-1.5 cmH2O (minimum-maximum -3 to 0 cmH2O) vs 34.5 cmH2O (minimum-maximum 30 to 47 cmH2O), P = 0.03) and expiration (4.5 cmH2O (minimum-maximum 2 to 5) vs 16 cmH2O (minimum-maximum 16 to 23), P =0.03). During CENPV, intraabdominal pressures decreased from 20.5 mmHg (12 to 30 mmHg) to 1 mmHg (minimum-maximum -7 to 5 mmHg) (P = 0.03). Arterial pressures decreased by approximately 10 mmHg and central venous pressures by 18 mmHg. Intrathoracic blood volume indices and cardiac indices increased at the initiation of CENPV by 15% and 20% (P < 0.05), respectively. Heart rate and extravascular lung water indices remained unchanged. Conclusions CENPV with a tank respirator improved gas exchange in patients with ARDS at
Loh, Pui-San; Ng, Kevin Wei Shan
Airway management for patients with recent oral facial injuries is always a challenge for the anesthetist. We describe how the glidescope (GLS) and fiber-optic (FOB) can be effectively combined in three patients undergoing oral maxillofacial surgeries after sustaining multiple facial fractures from trauma to allow less traumatic intubation, an option to visualize on either monitor and faster intubating time (mean 1 min 14 s for our cases) compared to the use of either one alone. Although it allows for better visualization of the vocal cords, it requires 2 trained anaesthetists to perform and this would need to be considered when using this technique.
El-Gamasy, Mohamed Abd El-Aziz; Elezz, Ahmed Abd El Basset Abo; Basuni, Ahmed Sobhy Mohamed; Elrazek, Mohamed El Sayed Ali Abd
Trauma is a worldwide health problem and the major cause of death and disability, particularly affecting the young population. It is important to remember that pediatric trauma care has made a significant improvement in the outcomes of these injured children. This study aimed at evaluation of pediatric trauma BIG score in comparison with New Injury Severity Score (NISS) and Pediatric Trauma Score (PTS) in Tanta University Emergency Hospital. The study was conducted in Tanta University Emergency Hospital to all multiple trauma pediatric patients attended to the Emergency Department for 1 year. Pediatric trauma BIG score, PTS, and NISS scores were calculated and results compared to each other and to observed mortality. BIG score ≥12.7 has sensitivity 86.7% and specificity 71.4%, whereas PTS at value ≤3.5 has sensitivity 63.3% and specificity 68.6% and NISS at value ≥39.5 has sensitivity 53.3% and specificity 54.3%. There was a significant positive correlation between BIG score value and mortality rate. The pediatric BIG score is a reliable mortality-prediction score for children with traumatic injuries; it uses international normalization ratio (INR), Base Excess (BE), and Glasgow Coma Scale (GCS) values that can be measured within a few minutes of sampling, so it can be readily applied in the Pediatric Emergency Department, but it cannot be applied on patients with chronic diseases that affect INR, BE, or GCS.
Matzek, Brett A; Linklater, Derek R
Traumatic dislocation of the testicle is a rare injury that may result from blunt abdominopelvic trauma. The majority of cases reportedly occur in young adults secondary to severe scrotal trauma during high-speed motorcycle crashes. Our review of the available English medical literature revealed only one pediatric case. We present a case of pediatric testicular dislocation and torsion resulting from minor abdominopelvic trauma. The case report is followed by a brief review of the available literature. A 10-year-old boy presented to the Pediatric Emergency Department with abdominal pain. He had suffered a strike to the abdomen and groin during an attempt at flipping over a "monkey bar" at school. A tender mass was found in his right inguinal canal and the genital examination revealed an empty right hemiscrotum. Bedside ultrasonography was used to locate the testicle and it was noted by color-flow Doppler to lack demonstrable blood flow. The patient was taken emergently to the operating room, where he underwent orchiopexy and hernia repair after a viable testicle was found. He had a subsequently uneventful recovery. Although rare, testicular dislocation may be a serious result of abdominopelvic trauma. Emergency providers who care for trauma patients must include this condition in their differential diagnosis; to do otherwise risks a delay in diagnosis that may affect testicular viability. In this case, testicular dislocation may have resulted from the combination of trauma and a previously undiagnosed indirect inguinal hernia. Published by Elsevier Inc.
El-Gamasy, Mohamed Abd El-Aziz; Elezz, Ahmed Abd El Basset Abo; Basuni, Ahmed Sobhy Mohamed; Elrazek, Mohamed El Sayed Ali Abd
Background: Trauma is a worldwide health problem and the major cause of death and disability, particularly affecting the young population. It is important to remember that pediatric trauma care has made a significant improvement in the outcomes of these injured children. Aim of the Work: This study aimed at evaluation of pediatric trauma BIG score in comparison with New Injury Severity Score (NISS) and Pediatric Trauma Score (PTS) in Tanta University Emergency Hospital. Materials and Methods: The study was conducted in Tanta University Emergency Hospital to all multiple trauma pediatric patients attended to the Emergency Department for 1 year. Pediatric trauma BIG score, PTS, and NISS scores were calculated and results compared to each other and to observed mortality. Results: BIG score ≥12.7 has sensitivity 86.7% and specificity 71.4%, whereas PTS at value ≤3.5 has sensitivity 63.3% and specificity 68.6% and NISS at value ≥39.5 has sensitivity 53.3% and specificity 54.3%. There was a significant positive correlation between BIG score value and mortality rate. Conclusion: The pediatric BIG score is a reliable mortality-prediction score for children with traumatic injuries; it uses international normalization ratio (INR), Base Excess (BE), and Glasgow Coma Scale (GCS) values that can be measured within a few minutes of sampling, so it can be readily applied in the Pediatric Emergency Department, but it cannot be applied on patients with chronic diseases that affect INR, BE, or GCS. PMID:27994378
Koch, S M; Mehlhorn, U; Baggstrom, E; Donovan, D; Allen, S J
This study was undertaken to determine the role of calcium-regulatory hormones (calcitonin [CT], parathyroid hormone [PTH], and vitamin D analogs) during the first 48 hours after acute trauma. Eleven acutely traumatized patients admitted to the shock-trauma intensive care unit (STICU) in a tertiary care teaching hospital were enrolled. Eleven same-day elective surgery patients served as the control group. Levels of ionized calcium (Ca2+), total calcium, magnesium, phosphate, CT, PTH, vitamin D analogs, electrolyte supplementation, and renal electrolyte loss were recorded during the first 48 hours after admission to the STICU. Control-group measurements consisted of Ca2+ and CT. At admission, 91% of the patients had ionized hypocalcemia (1.04 +/- 0.10 mmol/L). Ca2+ levels increased significantly over time (1.13 +/- 0.08 at 24 hours; 1.16 +/- 0.07 at 48 hours) but remained below the control-group value (1.28 +/- 0.05; P < .05) despite supplementation. Ninety-one percent of the patients had increased CT values at admission, 91% at 24 hours, and 78% at 48 hours. Median CT values in the trauma patients were higher throughout the study than in the control group (P < .05). Urinary calcium loss in the trauma patients was within the normal range. PTH and vitamin D analog values were within the normal range throughout the study. Multiple regression analysis did not show any significant correlation between electrolytes and hormone or protein concentrations. Acute trauma patients have ionized hypocalcemia associated with inappropriate urinary calcium loss, increased CT levels, and normal PTH and vitamin D analog values. We believe the degree of calciuria we observed was inappropriate in the context of ionized hypocalcemia. The cause of these increased CT levels is unclear. Our results suggest that Ca(2+)-regulatory mechanisms may be disrupted in the acute trauma patient.
Janus, Todd J; Vaughan-Sarrazin, Mary S; Baker, Larry J; Smith, Hayden L
The purpose of this article was to determine assessable risk levels for pneumonia in trauma patients with pulmonary contusion. A retrospective review and analysis of national trauma data of patients with pulmonary contusion were identified to develop a risk assessment model. Trauma data for 2007 were used to determine risk factors for subsequent complication of pneumonia in pulmonary contusion patients. Available patient comorbidities were considered in model development. Next, 2008 data were used to test and finalize model. Pneumonia risk was categorized into 3 ordinal levels, based on equal-sized proportions of pulmonary contusion patients. Significant risk factors for pneumonia included age, gender, pulse rate, systolic blood pressure, obesity, Glasgow Coma Scale motor score, and ventilation on admission. The final risk adjustment model had good fit and discrimination. Study analyses used more than 40 000 trauma patient data to devise assessable risk levels for pneumonia in pulmonary contusion diagnosed patients. Study data can assist in direction of care and triaging of urgent care patients at risk of pneumonia, possibly leading to mitigation and prevention of pneumonia in at risk patients. Further review of study outcomes should occur to fully understand applicability and usefulness in urgent settings.
Wafaisade, Arasch; Lefering, Rolf; Maegele, Marc; Lendemans, Sven; Flohé, Sascha; Hussmann, Björn; Defosse, Jerome M; Probst, Christian; Paffrath, Thomas; Bouillon, Bertil
Recent findings have emphasized the need for early and aggressive coagulation support in bleeding trauma patients. This study aimed to examine whether blood component transfusion and hemostatic drug administration during acute trauma care have changed in daily practice during the recent years. The multicenter trauma registry of the German Society for Trauma was retrospectively analyzed for primarily admitted patients older than 16 years with an Injury Severity Score ≥ 16 who had received at least five red blood cell (RBC) units between emergency room arrival and intensive care unit admission. Administration of fresh frozen plasma and platelet units has been documented since 2002, and use of hemostatic drugs since 2005. From 2002 until 2009 (n = 2,813), the fresh frozen plasma:RBC ratio increased from 0.65 to 0.75 (p = 0.02) and the platelet:RBC ratio from 0.04 to 0.09 (p < 0.0001). A constant increase was also observed regarding the overall use of hemostatic drugs (n = 1,811; 2005-2009) as these were administered to 43.4% of the patients in 2005 and to 60.7% in 2009 (p < 0.0001). Especially, the administration of fibrinogen concentrate (2005: 17.0%, 2009: 45.6%; p < 0.0001) and recombinant factor VIIa (2005: 1.9%, 2009: 6.3%; p = 0.04) showed a marked increase. However, mortality rates remained unchanged during the 8-year study period. The therapy of bleeding trauma patients has changed in Germany during the recent years toward more aggressive coagulation support. This development continues although grades of evidence are still low regarding most of the changes reported in our study. Randomized controlled trials are needed with respect to blood component therapy using predefined ratios and to the administration of hemostatic drugs commonly used for the severely injured.
Yeh, Lijen; Chen, Hung-Shu; Tan, Ping-Heng; Liu, Ping-Hsin; Hsieh, Shao-Wei; Hung, Kuo-Chuan
Airway management in patients with giant neck masses is usually a challenge to anesthesiologists. A giant neck mass could compress the airway and thus impede endotracheal intubation. We encountered a situation where the giant neck masses of a patient pushed the epiglottis posteriorly toward the posterior pharyngeal wall and compressed the laryngeal aperture narrowing after anesthetic induction, causing direct laryngoscopic intubation and sequential fiber-optic intubation failed. The neck masses twisted the aryepiglottic fold tortuously and clogged the laryngeal aperture tightly, making a flexible fiber-optic bronchoscope unable to pass through the laryngeal aperture. Later, we utilized a McCoy laryngoscope alternately to lift the compressed larynx up and away from the posterior pharyngeal wall, creating a passage and completing endotracheal intubation successfully with the aid of a gum elastic bougie. Our case suggested that the tilting tip blade of the McCoy laryngoscope could lever the tongue base up against the tumor mass compression to improve laryngeal views and facilitate endotracheal intubation when a difficult fiber-optic intubation was encountered on a compressed laryngeal aperture.
Ball, Chad G.; Dente, Christopher J.; Kirkpatrick, Andrew W.; Shah, Amit D.; Rajani, Ravi R.; Wyrzykowski, Amy D.; Vercruysse, Gary A.; Rozycki, Grace S.; Nicholas, Jeffrey M.; Salomone, Jeffrey P.; Feliciano, David V.
Background Supine anteroposterior (AP) chest radiography is an insensitive test for detecting posttraumatic pneumothoraces (PTXs). Computed tomography (CT) often identifies occult pneumothoraces (OPTXs) not diagnosed by chest radiography. All previous literature describes the epidemiology of OPTX in patients with blunt polytrauma. Our goal was to identify the frequency of OPTXs in patients with penetrating trauma. Methods All patients with penetrating trauma admitted over a 10-year period to Grady Memorial Hospital with a PTX were identified. We reviewed patients’ thoracoabdominal CT scans and corresponding chest radiographs. Results Records for 1121 (20%) patients with a PTX (penetrating mechanism) were audited; CT imaging was available for 146 (13%) patients. Of these, 127 (87%) had undergone upright chest radiography. The remainder (19 patients) had a supine AP chest radiograph. Fifteen (79%) of the PTXs detected on supine AP chest radiographs were occult. Only 10 (8%) were occult when an upright chest radiograph was used (p < 0.001). Posttraumatic PTXs were occult on chest radiographs in 17% (25/146) of patients. Fourteen (56%) patients with OPTXs underwent tube thoracostomy, compared with 95% (115/121) of patients with overt PTXs (p < 0.001). Conclusion Up to 17% of all PTXs in patients injured by penetrating mechanisms will be missed by standard trauma chest radiographs. This increases to nearly 80% with supine AP chest radiographs. Upright chest radiography detects 92% of all PTXs and is available to most patients without spinal trauma. The frequency of tube thoracostomy use in patients with overt PTXs is significantly higher than for OPTXs in blunt and penetrating trauma. PMID:20646399
19a. NAME OF RESPONSIBLE PERSON a. REPORT unclassified b. ABSTRACT unclassified c . THIS PAGE unclassified Standard Form 298 (Rev. 8-98...Algorithm for Patients with Blunt Abdominal Trauma RTO-MP-HFM-109 P6 - 7 Table 1: Patients undergoing laparotomy U S US results C T CT result...11] Henneman PL, Marx JA, Moore EE. 1990. Diagnostic
Sofocleous, Constantinos T. Hinrichs, Clay R.; Hubbi, Basil; Doddakashi, Satish; Bahramipour, Philip; Schubert, Johanna
Purpose. The purpose of the study was to evaluate the angiographic findings and results of embolotherapy in the management of lumbar artery trauma. Methods. All patients with lumbar artery injury who underwent angiography and percutaneous embolization in a state trauma center within a 10-year period were retrospectively reviewed. Radiological information and procedural reports were reviewed to assess immediate angiographic findings and embolization results. Long-term clinical outcome was obtained by communication with the trauma physicians as well as with chart review. Results. In a 10-year period, 255 trauma patients underwent abdominal aortography. Eleven of these patients (three women and eight men) suffered a lumbar artery injury. Angiography demonstrated active extravasation (in nine) and/or pseudoaneurysm (in four). Successful selective embolization of abnormal vessel(s) was performed in all patients. Coils were used in six patients, particles in one and gelfoam in five patients. Complications included one retroperitoneal abscess, which was treated successfully. One patient returned for embolization of an adjacent lumbar artery due to late pseudoaneurysm formation. Conclusions. In hemodynamically stable patients, selective embolization is a safe and effective method for immediate control of active extravasation, as well as to prevent future hemorrhage from an injured lumbar artery.
Chadwick, Jessica R
One of the leading causes of mortality in the intensive care unit is Acute Respiratory Distress Syndrome (ARDS). Acute Respiratory Distress Syndrome can occur as a result from multiorgan dysfunction syndrome and sepsis. In the trauma population, ARDS accounts for an increase in mortality as well as morbidity and disability. Nurses have an essential role in the care of the trauma patients with ARDS or acute lung injury patients. Respiratory treatments such as airway pressure release ventilation and chest physiotherapy are utilized often for ARDS treatment. A lesser used therapy, intermittent prone positioning has also been found to be effective in increasing the pulmonary gas exchange in trauma patients. This article will explain the nursing roles and responsibilities in the initiation, continuation, and cessation of intermittent prone positioning.
Prunet, Bertrand; Lacroix, Guillaume; Asencio, Yves; Cathelinaud, Olivier; Avaro, Jean-Philippe; Goutorbe, Philippe
Background Tracheal rupture is a rare but life-threatening complication that most commonly occurrs after blunt trauma to the chest, but which may also complicate tracheal intubation. We report a case of post-intubation tracheal rupture after cataract surgery under general anesthesia treated conservatively. Case presentation Four hours after extubation, a 67 year-old woman developed subcutaneous emphysema of the facial, bilateral laterocervical and upper anterior chest. Tracheobronchial fiberendoscopy showed a posterior tracheal transmural rupture 4 cm long located 2.5 cm above the carina that opened in inspiration. The location of the lesion and features of the patient favoured conservative treatment with antibiotic cover. The patient made a full and uncomplicated recovery and was discharged fourteen days after the original injury. Conclusion Two therapeutic strategies are currently employed for post-intubation tracheal rupture: a non-surgical strategy for small injuries and a surgical strategy for larger injuries. This case report presented the non-surgical therapeutic strategy of a large tracheal injury. PMID:18945364
Dacombe, Peter Jonathan; Amirfeyz, Rouin; Davis, Tim
Background: Patient-reported outcome measures (PROMs) are important tools for assessing outcomes following injuries to the hand and wrist. Many commonly used PROMs have no evidence of reliability, validity, and responsiveness in a hand and wrist trauma population. This systematic review examines the PROMs used in the assessment of hand and wrist trauma patients, and the evidence for reliability, validity, and responsiveness of each measure in this population. Methods: A systematic review of Pubmed, Medline, and CINAHL searching for randomized controlled trials of patients with traumatic injuries to the hand and wrist was carried out to identify the PROMs. For each identified PROM, evidence of reliability, validity, and responsiveness was identified using a further systematic review of the Pubmed, Medline, CINAHL, and reverse citation trail audit procedure. Results: The PROM used most often was the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire; the Patient-Rated Wrist Evaluation (PRWE), Gartland and Werley score, Michigan Hand Outcomes score, Mayo Wrist Score, and Short Form 36 were also commonly used. Only the DASH and PRWE have evidence of reliability, validity, and responsiveness in patients with traumatic injuries to the hand and wrist; other measures either have incomplete evidence or evidence gathered in a nontraumatic population. Conclusions: The DASH and PRWE both have evidence of reliability, validity, and responsiveness in a hand and wrist trauma population. Other PROMs used to assess hand and wrist trauma patients do not. This should be considered when selecting a PROM for patients with traumatic hand and wrist pathology. PMID:27418884
Iirola, Timo T; Laaksonen, Mikko I; Vahlberg, Tero J; Pälve, Heikki K
The aim of the study was to assess the immediate and long-term effect of a helicopter emergency physician giving advanced life support on-scene compared with conventional load and go principle in urban and rural settings in treating blunt trauma patients. In a retrospective study, 81 blunt trauma patients treated prehospitally by a physician-staffed helicopter emergency medical service were compared with 77 patients treated before the era of the helicopter emergency medical service. The data were collected in the prehospital and hospital files and a questionnaire was sent to the survivors 3 years after the trauma. The physicians treated the patients more aggressively (gave drugs, intubated and cannulated) and had the patients transported directly to a university hospital. The given treatment did not delay arrival at the hospital. No statistically significant difference was found, but a trend (P = 0.065) to lower survival in the helicopter emergency medical service group. Almost half of the deaths in the helicopter emergency medical service group and none in the control group, however, occurred in the emergency department. No difference was found 3 years later between the groups in the health-related quality of life or decrease in the income owing to the accident. The physicians treated the patients more aggressively, but it did not delay the arrival at the hospital. A beneficial effect of this aggressive treatment or direct transport to a university hospital could not be seen in the immediate physiological parameters or later health-related quality of life. The physician-staffed helicopter emergency medical service was not beneficial to blunt trauma patients in this setting.
MacLennan, Paul A.; Backstrom, Ian; Creek, Aaron; Sawyer, Jeffrey
Objective To determine whether there are differences in fracture patterns and femur fracture treatment choices in obese vs. non-obese pediatric trauma patients. Design Prognostic study, retrospective chart review. Setting Two level I pediatric trauma centers. Patients The trauma registries of two pediatric hospitals were queried for patients with lower extremity long bone fractures resulting from blunt trauma. 2858 alerts were examined and 397 patients had lower extremity fractures. 331 patients with a total of 394 femur or tibia fractures met inclusion criteria, and 70 patients (21%) were obese. Main Outcome Measurements Weight for age >95th percentile was defined as obese. Radiographs were reviewed and fractures were classified according the OTA/AO pediatric fracture classification system. Fracture patterns (OTA subsegment), severity, and choice of intervention for femur fractures were primary outcomes. Results Overall, obese patients were twice as likely (RR=2.20, 95% CI 1.25–3.89) to have fractures involving the physis. Physeal fracture risk was greater for femur fractures (RR=3.25, 95% CI 1.35–7.78) than tibia fractures (RR=1.58, 95% CI 0.76–3.26). Severity did not differ between groups. Obese patients with femur fractures were more likely to be treated with locked nails. Conclusion Obese pediatric trauma patients are more likely to sustain fractures involving the physis than non-obese patients. This could be related to intrinsic changes to the physis related to obesity, or altered biomechanical forces. This is consistent with the observed relationships between obesity and other conditions affecting the physis including Blount’s and slipped capital femoral epiphysis. PMID:24740109
Zamboni, Caio; Yonamine, Alexandre Maris; Faria, Carlos Eduardo Nunes; Filho, Marco Antonio Machado; Christian, Ralph Walter; Mercadante, Marcelo Tomanik
Medical personnel in trauma centres in several countries have realised that undiagnosed injuries are common and are now focussing their attention on reducing the incidence of these injuries. Tertiary survey is a simple and easy approach to address the issue of undiagnosed injuries in trauma patients. Tertiary survey consists of reevaluating patients 24 hours after admission by means of an anamnesis protocol, physical examination, review of complementary tests and request for new tests when necessary. To show the importance of tertiary survey in trauma patients for diagnosing injuries undetected at the time of initial survey. A standardised protocol was used to perform a prospective observational study with patients admitted through the emergency department, Department of Orthopaedics and Trauma, Santa Casa de São Paulo. The patients were reevaluated 24 hours after admission or after recovering consciousness. New physical examinations were performed, tests performed on admission were reassessed and new tests were requested, when necessary. Between February 2012 and February 2013, 526 patients were evaluated, 81 (15.4%) were polytraumatised, and 445 (84.6%) had low-energy trauma. A total of 57 new injuries were diagnosed in 40 patients, 61.4% of which affected the lower limb. Diagnosis of 11 new injuries (19.3%) resulted in changes in procedure. The application of the protocol for tertiary survey proved to be easy, inexpensive and beneficial to patients (particularly polytraumatised patients) because it enabled identification of important injuries that were not detected on admission in a large group of patients. Copyright © 2014 Elsevier Ltd. All rights reserved.
Ahmed, Omar Z; Burd, Randall S
The management of critically ill pediatric patients with trauma poses many challenges because of the infrequency and diversity of severe injuries and a paucity of high-level evidence to guide care for these uncommon events. This article discusses recent recommendations for early resuscitation and blood component therapy for hypovolemic pediatric patients with trauma. It also highlights the specific types of injuries that lead to severe injury in children and presents challenges related to their management. Copyright © 2017 Elsevier Inc. All rights reserved.
Alekseev, V S; Ivanov, V A; Alekseev, S V; Vaniukov, V P
The work presents an analysis of condition severity of 139 casualties with isolated and combined spleen injuries on admission to a surgical hospital. The assessment of condition severity was made using the traditional gradation and score scale VPH-SP. The degree of the severity of combined trauma of the spleen was determined by the scales ISS. The investigation showed that the scale ISS and VPH-SP allowed objective measurement of the condition severity of patients with spleen trauma. The score assessment facilitated early detection of the severe category of the patients, determined the diagnostic algorithm and the well-timed medical aid.
Gilbert, Shawn R; MacLennan, Paul A; Backstrom, Ian; Creek, Aaron; Sawyer, Jeffrey
To determine whether there are differences in fracture patterns and femur fracture treatment choices in obese versus nonobese pediatric trauma patients. Prognostic study, retrospective chart review. Two level I pediatric trauma centers. The trauma registries of 2 pediatric hospitals were queried for patients with lower extremity long-bone fractures resulting from blunt trauma. 2858 alerts were examined, and 397 patients had lower extremity fractures. Three hundred thirty-one patients with a total of 394 femur or tibia fractures met the inclusion criteria, and 70 patients (21%) were obese. Weight for age >95th percentile was defined as obese. Radiographs were reviewed, and fractures were classified according the OTA/AO pediatric fracture classification system. Fracture patterns (OTA subsegment), severity, and choice of intervention for femur fractures were the primary outcomes. Overall, obese patients were twice as likely [risk ratio (RR), 2.20; 95% confidence interval (CI), 1.25-3.89] to have fractures involving the physis. Physeal fracture risk was greater for femur fractures (RR, 3.25; 95% CI, 1.35-7.78) than tibia fractures (RR, 1.58; 95% CI, 0.76-3.26). Severity did not differ between groups. Obese patients with femur fractures were more likely to be treated with locked nails. Obese pediatric trauma patients are more likely to sustain fractures involving the physis than nonobese patients. This could be related to intrinsic changes to the physis related to obesity or altered biomechanical forces. This is consistent with the observed relationships between obesity and other conditions affecting the physis including Blount disease and slipped capital femoral epiphysis. Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
van Zanten, Arthur RH; Dixon, J Mark; Nipshagen, Martine D; de Bree, Remco; Girbes, Armand RJ; Polderman, Kees H
Introduction Sinusitis is a well recognised but insufficiently understood complication of critical illness. It has been linked to nasotracheal intubation, but its occurrence after orotracheal intubation is less clear. We studied the incidence of sinusitis in patients with fever of unknown origin (FUO) in our intensive care unit with the aim of establishing a protocol that would be applicable in everyday clinical practice. Methods Sinus X-rays (SXRs) were performed in all patients with fever for which an initial screening (physical examination, microbiological cultures and chest X-ray) revealed no obvious cause. All patients were followed with a predefined protocol, including antral drainage in all patients with abnormal or equivocal results on their SXR. Results Initial screening revealed probable causes of fever in 153 of 351 patients (43.6%). SXRs were taken in the other 198 patients (56.4%); 129 had obvious or equivocal abnormalities. Sinus drainage revealed purulent material and positive cultures (predominantly Pseudomonas and Klebsiella species) in 84 patients. Final diagnosis for the cause of fever in all 351 patients based on X-ray results, microbiological cultures, and clinical response to sinus drainage indicated sinusitis as the sole cause of fever in 57 (16.2%) and as contributing factor in 48 (13.8%) patients with FUO. This will underestimate the actual incidence because SXR and drainage were not performed in all patients. Conclusion Physicians treating critically ill patients should be aware of the high risk of sinusitis and take appropriate preventive measures, including the removal of nasogastric tubes in patients requiring long-term mechanical ventilation. Routine investigation of FUO should include computed tomography scan, SXR or sinus ultrasonography, and drainage should be performed if any abnormalities are found. PMID:16277722
Sarkar, Bedabrata; Brunsvold, Melissa E; Cherry-Bukoweic, Jill R; Hemmila, Mark R; Park, Pauline K; Raghavendran, Krishnan; Wahl, Wendy L; Wang, Stewart C; Napolitano, Lena M
To examine the impact of an ongoing comprehensive performance improvement and patient safety (PIPS) program implemented in 2005 on mortality outcomes for trauma patients at an established American College of Surgeons (ACS)-verified Level I Trauma Center. The primary outcome measure was in-hospital mortality. Age, Injury Severity Score (ISS), and intensive care unit admissions were used as stratifying variables to examine outcomes over a 5-year period (2004-2008). Institution mortality rates were compared with the National Trauma Data Bank mortality rates stratified by ISS score. Enhancements to our comprehensive PIPS program included revision of trauma activation criteria, development of standardized protocols for initial resuscitation, massive transfusion, avoidance of over-resuscitation, tourniquet use, pelvic fracture management, emphasis on timely angiographic and surgical intervention, prompt spine clearance, reduction in time to computed tomography imaging, reduced dwell time in emergency department, evidence-based traumatic brain injury management, and multidisciplinary efforts to reduce healthcare-associated infections. In 2004 (baseline data), the in-hospital mortality rate for the most severely injured trauma patients (ISS >24) at our trauma center was 30%, consistent with the reported mortality rate from the National Trauma Data Bank for patients with this severity of injury. Over 5 years, our mortality rate decreased significantly for severely injured patients with an ISS >24, from 30.1% (2004) to 18.3% (2008), representing a 12% absolute reduction in mortality (p = 0.011). During the same 5-year time period, the proportion of elderly patients (age >65 years) cared for at our trauma center increased from 23.5% in 2004 to 30.6% in 2008 (p = 0.0002). Class I trauma activations increased significantly from 5.5% in 2004 to 15.5% in 2008 based on our reclassification. A greater percentage of patients were admitted to the intensive care unit (25.8% in 2004 to
Stubbs, James R; Zielinski, Martin D; Berns, Kathleen S; Badjie, Karafa S; Tauscher, Craig D; Hammel, Scott A; Zietlow, Scott P; Jenkins, Donald
Almost 50% of trauma-related fatalities within the first 24 hours of injury are related to hemorrhage. Improved survival in severely injured patients has been demonstrated when massive transfusion protocols are rapidly invoked as part of a therapeutic approach known as damage control resuscitation (DCR). DCR incorporates the early use of plasma to prevent or correct trauma-induced coagulopathy. DCR often requires the transfusion of plasma before determination of the recipient's ABO group. Historically, group AB plasma has been considered the "universal donor" plasma product. At our facility, the number of AB plasma products produced on an annual basis was found to be inadequate to support the trauma service's DCR program. A joint decision was made by the transfusion medicine and trauma services to provide group A thawed plasma (TP) for in-hospital and prehospital DCR protocols. A description of the implementation of group A TP into the DCR program is provided as well as outcome data pertaining to the use of TP in trauma patients.
Scarpazza, Paolo; Incorvaia, Cristoforo; Amboni, Paolo; di Franco, Giuseppe; Raschi, Stefania; Usai, Pierfranco; Bernareggi, Monica; Bonacina, Cristiano; Melacini, Chiara; Cattaneo, Roberta; Bencini, Serena; Pravettoni, Chiara; Riario-Sforza, Gian Galeazzo; Passalacqua, Gianni; Casali, Walter
Background: Noninvasive mechanical ventilation (NIMV) is an effective tool in treating patients with acute respiratory failure (ARF), since it reduces both the need for endotracheal intubation and the mortality in comparison with nonventilated patients. A particular issue is represented by the outcome of NIMV in patients referred to the emergency department for ARF and with a do-not-intubate (DNI) status because of advanced age or excessively critical conditions. This study evaluated long-term survival in a group of elderly patients with acute hypercapnic ARF who had a DNI order and who were successfully treated by NIMV. Methods: The population consisted of 54 patients with a favorable outcome after NIMV for ARF. They were followed up for 3 years by regular control visits, with at least one visit every 4 months, or as needed according to the patient’s condition. Of these, 31 continued NIMV at home and 23 were on long-term oxygen therapy (LTOT) alone. Results: A total of 16 of the 52 patients had not survived at the 1-year follow-up, and another eight patients died during the 3-year observation, with an overall mortality rate of 30.8% after 1 year and 46.2% after 3 years. Comparing patients who continued NIMV at home with those who were on LTOT alone, 9 of the 29 patients on home NIMV died (6 after 1 year and 3 after 3 years) and 15 of the 23 patients on LTOT alone died (10 after 1 year and 5 after 3 years). Conclusion: These results show that elderly patients with ARF successfully treated by NIMV following a DNI order have a satisfactory long-term survival. PMID:21814461
Gardner, Alison R; Diz, Debra I; Tooze, Janet A; Miller, Chadwick D; Petty, John
Hypotension after trauma is most commonly assumed to be hemorrhagic, or hypovolemic, in origin. However, hypotension may occur in pediatric patients with isolated head injury, challenging accepted tenets of trauma care. We sought to quantify the contribution of head injury to the development of hypotension after pediatric trauma. This is a retrospective cohort analysis using the National Trauma Data Bank registry 2009. Children aged 0 to 15 years were classified by injury pattern sustained during trauma using discharge diagnosis International Classification of Diseases, Ninth Revision, codes into isolated head, hemorrhagic, spinal cord, or other injury type. The primary outcome was hypotension for age at arrival to the emergency department. Risk of hypotension was estimated and compared by injury pattern using absolute and relative risks (RRs) stratified by age group (0-4 years, 5-11 years, 12-15 years). Rates of hypotension ranged from 1.8% to 2.3% by age, with the highest incidence in the 12- to 15-year group. The RR of hypotension from isolated head injury (RR, 2.5; 95% confidence interval, 2.0-3.2 vs. other) was not significantly different from the RR for hemorrhagic injury (RR, 2.7; 95% confidence interval, 2.1-3.5 vs. other) in the 0- to 4-year-old group. For the older age groups, the RR of hypotension from isolated head injury was significantly lower than from hemorrhagic injury. Hypotension occurs after isolated head injury in children, and the risk of hypotension is as great as hemorrhagic injuries in children aged 0 to 4 years. This finding should now lead us to confirm whether a cause-effect relationship exists and, if so, isolate the responsible mechanism. In turn, this could reveal an opportunity to tailor treatments to address the underlying mechanism for hypotension in these children. Prognostic and epidemiologic study, level III.
Klimo, Paul; Ware, Marcus L; Gupta, Nalin; Brockmeyer, Douglas
Injuries to the pediatric cervical spine occur infrequently. Numerous unique anatomic and biomechanical features of the pediatric spine render it much more flexible than the adult spine. These features give rise to significant differences in the presentation, diagnosis, treatment, and prognosis of pediatric cervical trauma compared with adults. Younger children more often suffer injury to the upper cervical spine with greater neurologic injury and fewer fractures. Once the child reaches the age of 10 years, he or she develops a more adult-type spine, and injuries are thus more similar to those seen in the adult population. The unique anatomic and biomechanical differences in the pediatric spine are discussed, along with the various common and unique injuries.
Serin, Gediz Murat; Derinsu, Ufuk; Sari, Murat; Gergin, Ozgül; Ciprut, Ayça; Akdaş, Ferda; Batman, Cağlar
Temporal bone fracture, which involves the otic capsule, can lead to complete loss of auditory and vestibular functions, whereas the patients without fractures may experience profound sensorineural hearing loss due to cochlear concussion. Cochlear implant is indicated in profound sensorineural hearing loss due to cochlear trauma but who still have an intact auditory nerve. This is a retrospective review study. We report 5 cases of postlingually deafened patients caused by cochlear trauma, who underwent cochlear implantation. Preoperative and postoperative hearing performance will be presented. These patients are cochlear implanted after the cochlear trauma in our department between 2001 and 2006. All patients performed very well with their implants, obtained open-set speech understanding. They all became good telephone users after implantation. Their performance in speech understanding was comparable to standard postlingual adult patients implanted. Cochlear implantation is an effective aural rehabilitation in profound sensorineural hearing loss caused by temporal bone trauma. Preoperative temporal bone computed tomography, magnetic resonance imaging, and promontorium stimulation testing are necessary to make decision for the surgery and to determine the side to be implanted. Surgery could be challenging and complicated because of anatomical irregularity. Moreover, fibrosis and partial or total ossification within the cochlea must be expected. Copyright 2010. Published by Elsevier Inc.
Szewczyk, Tomasz; Gaszynska, Ewelina
Introduction. The use of videolaryngoscopes is recommended for morbidly obese patients. The aim of the study was to evaluate the Levitan FPS optical stylet (Levitan) vs Lafy-Flex videolaryngoscope (Lary-Flex) in a group of MO patients. Methods. Seventy-nine MO (BMI > 40 kg m−2) patients scheduled for bariatric surgery were included in the study and randomly allocated to the Levitan FPS or Lary-Flex group. The primary endpoint was time to intubation and evaluation laryngoscopic of glottic view. Anesthesiologists were asked to evaluate the glottic view first under direct laryngoscopy using the videolaryngoscope as a standard laryngoscope (monitor display was excluded from use) and then using devices. The secondary endpoint was the cardiovascular response to intubation and the participant's evaluation of such devices. Results. The time to intubation was 8.572.66 sec. versus 5.790.2 sec. for Levitan and Lary-Flex, respectively (P < 0.05). In all cases of CL grade >1 under direct laryngoscopy, the study devices improved CL grade to 1. The Levitan FPS produced a greater cardiovascular response than the Lary-Flex videolaryngoscope. Conclusion. The Lary-Flex videolaryngoscope and the Levitan FPS optical stylet improve the laryngeal visualization in morbidly obese patients, allowing for fast endotracheal intubation, but Lary-Flex produces less cardiovascular response to intubation attempt. PMID:24967423
Komatsu, Ryu; Nagata, Osamu; Sessler, Daniel I.; Ozaki, Makoto
Although the difficulty of tracheal intubation in the lateral position has not been systematically evaluated, airway loss during surgery in a laterally positioned patient may have hazardous consequences. We explored whether the intubating laryngeal mask airway (ILMA) facilitates tracheal intubation in patients with normal airway anatomy, i.e., Mallampati grade ≤ 3 and thyromental distance ≥ 5 cm, positioned in the lateral position. And we evaluated whether this technique can be used as a rescue when the airway is lost mid-case in laterally positioned patients with respect to success rate and intubation time. Anesthesia was induced with propofol, fentanyl, and vecuronium in 50 patients undergoing spine surgery for lumbar disk herniation (Lateral) and 50 undergoing other surgical procedures (Supine). Patients having disk surgery (Lateral) were positioned on their right or left sides before induction of general anesthesia, and intubation was performed in that position. Patients in control group (Supine) were anesthetized in supine position, and intubation was performed in that position. Intubation was performed blindly via an ILMA in both groups. The time required for intubation and number and types of adjusting maneuvers employed were recorded. Data were compared by Mann-Whitney U, Fisher’s exact, chi-square, or unpaired t-tests, as appropriate. Data presented as mean (SD). Demographic and airway measures were similar in the two groups, except for mouth opening which was slightly wider in patients in the lateral position: 5.1 (0.9) vs. 4.6 (0.7) cm. The time required for intubation was similar in each group (≈25 s), as was intubation success (96%). We conclude that blind intubation via an ILMA offers a frequent success rate and a clinically acceptable intubation time (< one min) even in the lateral position. Summary Blind intubation via the intubating laryngeal mask airway (ILMA) offers a high success rate and a clinically acceptable intubation time even in
Malcharek, Michael J; Rockmann, Kai; Zumpe, Ralph; Sorge, Oliver; Winter, Viktor; Sablotzki, Armin; Schneider, Gerhard
We compared two methods of asleep fibreoptic intubation in patients at risk of secondary cervical injury: the Aintree Intubation Catheter via a classic laryngeal mask airway (cLMA) versus the Fastrach technique via the intubating laryngeal mask airway (iLMA). To test which system has the highest rate of successful intubations in the clinical setting. A randomised controlled study. Single-centre, between 2007 and 2010. We randomly allocated 80 patients (30 women and 50 men) who underwent elective neurosurgery of the cervical spine to either group, placed in a neutral position and wearing a soft cervical collar. Entry criteria were ASA status 1 to 3, age 18 to 80 years and written informed consent. Exclusion criteria were patients with cervical instability, known or predicted difficult airway, BMI greater than 40 kg m⁻² and symptomatic gastro-oesophageal reflux. Two anaesthetists who were experienced in both techniques performed all anaesthesia procedures within the study. There was a maximum of three attempts for performing each technique. The primary outcome was the rate of successful fibreoptic intubation in a neutral position. We also investigated the timing sequence for both techniques, the Brimacombe and Berry Bronchoscopy Score, and differences in technical aspects. All 40 patients in the Aintree group but only 31 patients in the Fastrach group were intubated successfully. Thus, fibreoptic intubation failed significantly less using the Aintree technique (P = 0.002). For secondary outcomes, the cLMA was faster (260 versus 289 s, P = 0.039) and easier (P = 0.036) to insert than the iLMA. The fibreoptic view of the glottis according to the Brimacombe and Berry Bronchoscopy Score was better (P = 0.016) and the tracheal tube was easier to insert (P = 0.010) in the Aintree group. Fibreoptic intubation using the Aintree system was more successful than the Fastrach technique in our population of patients in a neutral position wearing a
total lymphocyte count , d) creatinine height index, and e) urine urea nitrogen (Anderson, 1987; Blazey et al., 1986; Curtas, Chapman, & Meguid, 1989...and burn patients as being at high-risk for hospital-induced malnutrition . The trauma patient has been demonstrated to experience a period of...Nutritional supplements were studied by Peterson et al. (1988) indicating a 32% septic complication rate for patients receiving total parenteral
Fernández-Mondéjar, Enrique; Vilar-López, Raquel; Navas, Juan F.; Portillo-Santamaría, Mónica; Rico-Martín, Sergio; Lardelli-Claret, Pablo
Objective Estimate the effectiveness of brief interventions in reducing trauma recidivism in hospitalized trauma patients who screened positive for alcohol and/or illicit drug use. Methods Dynamic cohort study based on registry data from 1818 patients included in a screening and brief intervention program for alcohol and illicit drug use for hospitalized trauma patients. Three subcohorts emerged from the data analysis: patients who screened negative, those who screened positive and were offered brief intervention, and those who screened positive and were not offered brief intervention. Follow-up lasted from 10 to 52 months. Trauma-free survival, adjusted hazard rate ratios (aHRR) and adjusted incidence rate ratios (aIRR) were calculated, and complier average causal effect (CACE) analysis was used. Results We found a higher cumulative risk of trauma recidivism in the subcohort who screened positive. In this subcohort, an aHRR of 0.63 (95% CI: 0.41–0.95) was obtained for the group offered brief intervention compared to the group not offered intervention. CACE analysis yielded an estimated 52% reduction in trauma recidivism associated with the brief intervention. Conclusion The brief intervention offered during hospitalization in trauma patients positive for alcohol and/or illicit drug use can halve the incidence of trauma recidivism. PMID:28813444
Cordovilla-Guardia, Sergio; Fernández-Mondéjar, Enrique; Vilar-López, Raquel; Navas, Juan F; Portillo-Santamaría, Mónica; Rico-Martín, Sergio; Lardelli-Claret, Pablo
Estimate the effectiveness of brief interventions in reducing trauma recidivism in hospitalized trauma patients who screened positive for alcohol and/or illicit drug use. Dynamic cohort study based on registry data from 1818 patients included in a screening and brief intervention program for alcohol and illicit drug use for hospitalized trauma patients. Three subcohorts emerged from the data analysis: patients who screened negative, those who screened positive and were offered brief intervention, and those who screened positive and were not offered brief intervention. Follow-up lasted from 10 to 52 months. Trauma-free survival, adjusted hazard rate ratios (aHRR) and adjusted incidence rate ratios (aIRR) were calculated, and complier average causal effect (CACE) analysis was used. We found a higher cumulative risk of trauma recidivism in the subcohort who screened positive. In this subcohort, an aHRR of 0.63 (95% CI: 0.41-0.95) was obtained for the group offered brief intervention compared to the group not offered intervention. CACE analysis yielded an estimated 52% reduction in trauma recidivism associated with the brief intervention. The brief intervention offered during hospitalization in trauma patients positive for alcohol and/or illicit drug use can halve the incidence of trauma recidivism.
Rashmi, H D; Komala, H K
The procedures in anesthesia such as laryngoscopy and endotracheal intubation are the most important skills to be mastered by an anesthesiologist. However, they produce marked cardiovascular responses such as hypertension and tachycardia. Various drugs have been used to suppress this response. One of those is a novel centrally acting α2 agonist - dexmedetomidine. It has numerous uses in anesthesia as it is having sedative, analgesic, hypnotic, and opioid sparing effects. It is also known to suppress the hemodynamic response to laryngoscopy and intubation. This study is aimed to know the effect of intravenous dexmedetomidine 0.6 μg/kg body weight on hemodynamic response to laryngoscopy and endotracheal intubation in patients undergoing thyroid surgeries. Sixty patients of American Society of Anaesthesiologist health status class I and II scheduled for thyroid surgery under general anesthesia were considered in this prospective randomized controlled double-blind study. The study population was randomly divided into two groups with 30 patients in each group using sealed envelopes containing the name of the group and patient is asked to pick up the envelope. Sixty euthyroid patients, scheduled for thyroid surgeries was randomly divided into two groups with 30 patients in each group. Group A (n = 30) received injection dexmedetomidine 0.6 μg/kg body weight and Group B (n = 30) received 10 ml of normal saline. Heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean arterial pressure (MAP) were recorded at regular intervals after intubation. Statistically significant decrease in HR, SBP, DBP, and MAP were observed in Group A after intubation when compared to Group B. We conclude that dexmedetomidine 0.6 μg/kg body weight obtunds the hemodynamic responses to laryngoscopy and tracheal intubation in patients undergoing thyroid surgeries.
Lee, Chan Woo; Kim, Miwoon
Dexmedetomidine is an alpha-2 adrenergic agonist with sedative, anxiolytic, and analgesic properties. This study was designed to evaluate the inhibitory effects of preoperative administration of 0.5 µg/kg dexmedetomidine on hemodynamic responses caused by endotracheal intubation in elderly patients undergoing treatment for hypertension. Forty elderly (≥ 65 years old) patients who had been receiving hypertension treatment, had American Society of Anesthesiologists physical status II, and were scheduled to undergo elective noncardiac surgery were randomly selected and assigned to 2 groups. Group C received normal saline and group D received 0.5 µg/kg dexmedetomidine intravenously over 10 min just before endotracheal intubation. Systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), and heart rate (HR) were recorded preoperatively in the ward, immediately after study drug administration, and at 1, 3, and 5 min after endotracheal intubation. Compared to group C, group D showed significantly lower SBP and MAP at 1, 3, and 5 min as well as significantly lower DBP and HR at 3 and 5 min after endotracheal intubation. In elderly patients receiving hypertension treatment, a single preanesthetic dose of dexmedetomidine (0.5 µg/kg) effectively suppressed the hemodynamic responses to endotracheal intubation.
Background Dexmedetomidine is an alpha-2 adrenergic agonist with sedative, anxiolytic, and analgesic properties. This study was designed to evaluate the inhibitory effects of preoperative administration of 0.5 µg/kg dexmedetomidine on hemodynamic responses caused by endotracheal intubation in elderly patients undergoing treatment for hypertension. Methods Forty elderly (≥ 65 years old) patients who had been receiving hypertension treatment, had American Society of Anesthesiologists physical status II, and were scheduled to undergo elective noncardiac surgery were randomly selected and assigned to 2 groups. Group C received normal saline and group D received 0.5 µg/kg dexmedetomidine intravenously over 10 min just before endotracheal intubation. Systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), and heart rate (HR) were recorded preoperatively in the ward, immediately after study drug administration, and at 1, 3, and 5 min after endotracheal intubation. Results Compared to group C, group D showed significantly lower SBP and MAP at 1, 3, and 5 min as well as significantly lower DBP and HR at 3 and 5 min after endotracheal intubation. Conclusions In elderly patients receiving hypertension treatment, a single preanesthetic dose of dexmedetomidine (0.5 µg/kg) effectively suppressed the hemodynamic responses to endotracheal intubation. PMID:28184265
Felt, George T; Soolari, Ahmad
The current report reviews a case of mixed dental trauma consequent to a fall by an older patient. The patient’s teeth were forced out of alignment by the trauma and suffered pulpal necrosis. Treatment involved not only healing the acute injuries, but also attending to some subtle delayed problems that became apparent during treatment. Treatments involving endodontics, periodontics, orthodontics, and restorative dentistry were used to address all of the patient’s concerns. This insured that the traumatic occlusion was corrected, appropriate esthetics was restored and normal speech and function was regained. All signs of trauma were recognized, every treatment step was documented, and appropriate follow-up was provided throughout the recovery period. PMID:25419251
Loggers, S A I; Koedam, T W A; Giannakopoulos, G F; Vandewalle, E; Erwteman, M; Zuidema, W P
Trauma is a great contributor to mortality worldwide. One of the challenges in trauma care is early identification and management of bleeding. The circulatory status of blunt trauma patients in the emergency room is evaluated using hemodynamic (HD) parameters. However, there is no consensus on which parameters to use. In this study, we evaluate the used terms and definitions in the literature for HD stability and compare those to the opinion of Dutch trauma team members. A systematic review was performed to collect the definitions used for HD stability. Studies describing the assessment and/or treatment of blunt trauma patients in the emergency room were included. In addition, an online survey was conducted amongst Dutch trauma team members. Out of a total of 222, 67 articles were found to be eligible for inclusion. HD stability was defined in 70% of these articles. The most used parameters were systolic blood pressure and heart rate. Besides the variety of parameters, a broad range of corresponding cut-off points is noted. Despite some common ground, high inter- and intra-variability is seen for the physicians that are part of the Dutch trauma teams. All authors acknowledge HD stability as the most important factor in the assessment and management of blunt trauma patients. There is, however, no consensus in the literature as well as none-to-fair consensus amongst Dutch trauma team members in the definition of HD stability. A trauma team ready to co-operate with consensus-based opinions together with a valid scoring system is in our opinion the best method to assess and treat seriously injured trauma patients.
Chauhan, Varun; Acharya, Gaurav
Nasal intubation technique was first described in 1902 by Kuhn. The others pioneering the nasal intubation techniques were Macewen, Rosenberg, Meltzer and Auer, and Elsberg. It is the most common method used for giving anesthesia in oral surgeries as it provides a good field for surgeons to operate. The anatomy behind nasal intubation is necessary to know as it gives an idea about the pathway of the endotracheal tube and complications encountered during nasotracheal intubation. Various techniques can be used to intubate the patient by nasal route and all of them have their own associated complications which are discussed in this article. Various complications may arise while doing nasotracheal intubation but a thorough knowledge of the anatomy and physics behind the procedure can help reduce such complications and manage appropriately. It is important for an anesthesiologist to be well versed with the basics of nasotracheal intubation and advances in the techniques. A thorough knowledge of the anatomy and the advent of newer devices have abolished the negative effect of blindness of the procedure. PMID:27994382
Kriege, Marc; Alflen, Christian; Tzanova, Irene; Schmidtmann, Irene; Piepho, Tim; Noppens, Ruediger R
The direct laryngoscopy technique using a Macintosh blade is the first choice globally for most anaesthetists. In case of an unanticipated difficult airway, the complication rate increases with the number of intubation attempts. Recently, McGrath MAC (McGrath) video laryngoscopy has become a widely accepted method for securing an airway by tracheal intubation because it allows the visualisation of the glottis without a direct line of sight. Several studies and case reports have highlighted the benefit of the video laryngoscope in the visualisation of the glottis and found it to be superior in difficult intubation situations. The aim of this study was to compare the first-pass intubation success rate using the (McGrath) video laryngoscope compared with conventional direct laryngoscopy in surgical patients. The EMMA trial is a multicentre, open-label, patient-blinded, randomised controlled trial. Consecutive patients requiring tracheal intubation are randomly allocated to either the McGrath video laryngoscope or direct laryngoscopy using the Macintosh laryngoscope. The expected rate of successful first-pass intubation is 95% in the McGrath group and 90% in the Macintosh group. Each group must include a total of 1000 patients to achieve 96% power for detecting a difference at the 5% significance level. Successful intubation with the first attempt is the primary endpoint. The secondary endpoints are the time to intubation, attempts for successful intubation, the necessity of alternatives, visualisation of the glottis using the Cormack & Lehane score and percentage of glottic opening score and definite complications. The project was approved by the local ethics committee of the Medical Association of the Rhineland Palatine state and Westphalia-Lippe. The results of this study will be made available in the form of manuscripts for publication and presentations at national and international meetings. ClinicalTrials.gov NCT 02611986; pre-results. © Article author(s) (or
Vanzant, Erin L.; Ozrazgat-Baslanti, Tezcan; Liu, Huazhi; Malik, Seemab; Davis, Ruth; Lanz, Jennifer; Miggins, Makesha V.; Gentile, Lori F.; Cuenca, Angela; Cuenca, Alex G.; Lottenberg, Lawrence; Moore, Frederick A.; Ang, Darwin N.; Bihorac, Azra
Abstract Background: The epidemiology of Clostridium difficile-associated infection (CDI) has changed, and it is evident that susceptibility is related not only to exposures and bacterial potency, but host factors as well. Several small studies have suggested that CDI after trauma is associated with a different patient phenotype. The purpose of this study was to examine and describe the epidemiologic factors associated with C. difficile in blunt trauma patients without traumatic brain injury using the Trauma-Related Database as a part of the “Inflammation and Host Response to Injury” (Glue Grant) and the University of Florida Integrated Data Repository. Methods: Previously recorded baseline characteristics, clinical data, and outcomes were compared between groups (67 C. difficile and 384 uncomplicated, 813 intermediate, and 761 complicated non-C. difficile patients) as defined by the Glue Grant on admission and at days seven and 14. Results: The majority of CDI patients experienced complicated or intermediate clinical courses. The mean ages of all cohorts were less than 65 y and CDI patients were significantly older than uncomplicated patients without CDI. The CDI patients had increased days in the hospital and on the ventilator, as well as significantly higher new injury severity scores (NISS), and a greater percentage of patients with NISS >34 points compared with non-CDI patients. They also had greater Marshall and Denver multiple organ dysfunction scores than non-CDI uncomplicated patients, and greater creatinine, alkaline phosphatase, neutrophil count, lactic acid, and PiO2:FiO2 compared with all non-CDI cohorts on admission. In addition, the CDI patients had higher glucose concentrations and base deficit from uncomplicated patients and greater leukocytosis than complicated patients on admission. Several of these changes persisted to days seven and 14. Conclusion: Analysis of severe blunt trauma patients with C. difficile, as compared with non
Comparison of intubation success and glottic visualization using King Vision and C-MAC videolaryngoscopes in patients with cervical spine injuries with cervical immobilization: A randomized clinical trial.
Shravanalakshmi, Dhanyasi; Bidkar, Prasanna U; Narmadalakshmi, K; Lata, Suman; Mishra, Sandeep K; Adinarayanan, S
Glottic visualization can be difficult with cervical immobilization in patients with cervical spine injury. Indirect laryngoscopes may provide better glottic visualization in these groups of patients. Hence, we compared King Vision videolaryngoscope, C-MAC videolaryngoscope for endotracheal intubation in patients with proven/suspected cervical spine injury. After standard induction of anesthesia, 135 patients were randomized into three groups: group C (conventional C-MAC videolaryngoscope), group K (King Vision videolaryngoscope), and group D (D blade C-MAC videolaryngoscope). Cervical immobilization was maintained with Manual in line stabilization with anterior part of cervical collar removed. First pass intubation success, time for intubation, and glottic visualization (Cormack - Lehane grade and percentage of glottic opening) were noted. Intubation difficulty score (IDS) was used for grading difficulty of intubation. Five-point Likert scale was used for ease of insertion of laryngoscope. First attempt success rate were 100% (45/45), 93.3% (42/45), and 95.6% (43/45) in patients using conventional C-MAC, King Vision, and D blade C-MAC videolaryngoscopes, respectively. Time for intubation in seconds was significantly faster with conventional C-MAC videolaryngoscope (23.3 ± 4.7) compared to D blade C-MAC videolaryngoscope (26.7 ± 7.1), whereas conventional C-MAC and King Vision were comparable (24.9 ± 7.2). Good grade glottic visualization was obtained with all the three videolaryngoscopes. All the videolaryngoscopes provided good glottic visualization and first attempt success rate. Conventional C-MAC insertion was significantly easier. We conclude that all the three videolaryngoscopes can be used effectively in patients with cervical spine injury.
Comparison of intubation success and glottic visualization using King Vision and C-MAC videolaryngoscopes in patients with cervical spine injuries with cervical immobilization: A randomized clinical trial
Shravanalakshmi, Dhanyasi; Bidkar, Prasanna U.; Narmadalakshmi, K.; Lata, Suman; Mishra, Sandeep K.; Adinarayanan, S.
Background: Glottic visualization can be difficult with cervical immobilization in patients with cervical spine injury. Indirect laryngoscopes may provide better glottic visualization in these groups of patients. Hence, we compared King Vision videolaryngoscope, C-MAC videolaryngoscope for endotracheal intubation in patients with proven/suspected cervical spine injury. Methods: After standard induction of anesthesia, 135 patients were randomized into three groups: group C (conventional C-MAC videolaryngoscope), group K (King Vision videolaryngoscope), and group D (D blade C-MAC videolaryngoscope). Cervical immobilization was maintained with Manual in line stabilization with anterior part of cervical collar removed. First pass intubation success, time for intubation, and glottic visualization (Cormack – Lehane grade and percentage of glottic opening) were noted. Intubation difficulty score (IDS) was used for grading difficulty of intubation. Five-point Likert scale was used for ease of insertion of laryngoscope. Results: First attempt success rate were 100% (45/45), 93.3% (42/45), and 95.6% (43/45) in patients using conventional C-MAC, King Vision, and D blade C-MAC videolaryngoscopes, respectively. Time for intubation in seconds was significantly faster with conventional C-MAC videolaryngoscope (23.3 ± 4.7) compared to D blade C-MAC videolaryngoscope (26.7 ± 7.1), whereas conventional C-MAC and King Vision were comparable (24.9 ± 7.2). Good grade glottic visualization was obtained with all the three videolaryngoscopes. Conclusion: All the videolaryngoscopes provided good glottic visualization and first attempt success rate. Conventional C-MAC insertion was significantly easier. We conclude that all the three videolaryngoscopes can be used effectively in patients with cervical spine injury. PMID:28217398
A Case Report: Establishing a Definitive Airway in a Trauma Patient With a King Laryngeal Tube In Situ in the Presence of a Closed Head Injury and Difficult Airway: "Between the Devil and the Deep Blue Sea".
Koumpan, Yuri; Murdoch, John; Beyea, Jason A; Kahn, Michael; Colbeck, Jaime
Airway management in trauma is a crucial skill, because patients are at risk of aspiration, hypoxia, and hypoventilation, all of which may be fatal in the setting of increased intracranial pressure. The King Laryngeal Tube reusable supraglottic airway (King Systems, Noblesville, IN) allows for temporary management of a difficult airway but poses a challenge when an attempt is made to exchange the device for an endotracheal tube, often managed by emergency tracheostomy. We describe a novel fiberoptic, video laryngoscope-assisted approach to intubation in a difficult trauma airway with an in situ King Laryngeal Tube.
Farooq, Anum; Yousaf, Aasma
To determine the relationship between childhood trauma (physical, sexual, emotional abuse and neglect) and alexithymia in patients with conversion disorder, and to identify it as a predictor of alexithymia in conversion disorder. An analytical study. Multiple public sector hospitals in Lahore, from September 2012 to July 2013. Eighty women with conversion disorder were recruited on the basis of DSM IV-TR diagnostic criteria checklist to screen conversion disorder. Childhood abuse interview to measure childhood trauma and Bermond Vorst Alexithymia Questionnaire, DSM-IV TR Dianostic Criteria Checklist, and Childhood Abuse Interview to assess alexithymia were used, respectively. The mean age of the sample was 18 ±2.2 years. Thirty-six cases had a history of childhood trauma, physical abuse was the most reported trauma (f = 19, 23.8%) in their childhood. Patients with conversion disorder has a significant association with alexithymia (p < 0.05). Multiple regression analysis showed that childhood sexual abuse could predict alexithymia (F= 7.05, p < 0.05). Among the alexithymia domain, childhood physical abuse significantly predicted the difficulty in verbalizing emotions among the abused patients (F= 6.40, p < 0.05). The study highlighted childhood abuse and emotional pent up as an etiological factor of conversion disorder. Strategies should be devised to reduce this disorder among women in Pakistani society.
Sugimoto, Kenzaburo; Satoh, Masaaki; Kai, Makiko; Sata, Naho; Takeuchi, Mamoru
A 33-year-old male, without significant medical history, underwent elective tympanoplasty. It was difficult to manage his airway because of overbites, small jaw, and short neck. After intubation, his left chest revealed obvious abnormality in sound and movement, and showed free air in the mediastinum on X ray. CT revealed extensive atelectasis. Although he is a current smoker, the length of preoperative smoking cessation necessary to decrease postoperative pulmonary complications is not clear. This case demonstrates the importance of preoperative preparation including education in smoking damage.
Pfeifer, R; Pape, H-C
Severe trauma is still one of the leading causes of death worldwide. The initial treatment and diagnostics are of immense importance in polytraumatized patients. The initial approach mainly focuses on the advanced trauma life support (ATLS) concept. This includes the identification of life-threatening conditions and application of life-saving interventions. Depending on the physiological condition of the patient, the surgical treatment strategies of early total care (ETC) or damage control orthopedics (DCO) can be chosen. Appropriate surgical management can reduce the incidence of associated delayed systemic complications. This review summarizes the most commonly used definitions of polytrauma (including the Berlin polytrauma definition) and classification systems of severely injured patients. Moreover, the recently introduced treatment strategy of the safe definitive surgery concept for severely injured patients is also discussed in this article.
Kim, Yongsuk; Kim, Jeong Eun; Jeong, Da Hye
Patients with Pierre Robin syndrome are characterized by micrognathia, retrognathia, glossoptosis, and respiratory obstruction and are prone to have a difficult-to-intubate airway. The McGrath® MAC video laryngoscope provides a better view of the glottis than a Macintosh laryngoscope, but it is not easy to insert an endotracheal tube through the vocal cords because a video laryngoscope has a much greater curvature than that of a conventional direct laryngoscope and an endotracheal tube has a different curvature. The Frova Intubating Introducer is used as a railroad for an endotracheal tube in cases of a difficult airway. We thought that a combination of these two devices would make it easy to insert an endotracheal tube through the vocal cords, as a McGrath® MAC video laryngoscope provides a better glottic view and the Frova Intubating Introducer is a useful device for placing an endotracheal tube through the glottis. We report a successful endotracheal intubation with use of the McGrath® MAC video laryngoscope and Frova Intubating Introducer in a patient with Pierre Robin syndrome. PMID:24851168
Frerk, C; Mitchell, V S; McNarry, A F; Mendonca, C; Bhagrath, R; Patel, A; O'Sullivan, E P; Woodall, N M; Ahmad, I
These guidelines provide a strategy to manage unanticipated difficulty with tracheal intubation. They are founded on published evidence. Where evidence is lacking, they have been directed by feedback from members of the Difficult Airway Society and based on expert opinion. These guidelines have been informed by advances in the understanding of crisis management; they emphasize the recognition and declaration of difficulty during airway management. A simplified, single algorithm now covers unanticipated difficulties in both routine intubation and rapid sequence induction. Planning for failed intubation should form part of the pre-induction briefing, particularly for urgent surgery. Emphasis is placed on assessment, preparation, positioning, preoxygenation, maintenance of oxygenation, and minimizing trauma from airway interventions. It is recommended that the number of airway interventions are limited, and blind techniques using a bougie or through supraglottic airway devices have been superseded by video- or fibre-optically guided intubation. If tracheal intubation fails, supraglottic airway devices are recommended to provide a route for oxygenation while reviewing how to proceed. Second-generation devices have advantages and are recommended. When both tracheal intubation and supraglottic airway device insertion have failed, waking the patient is the default option. If at this stage, face-mask oxygenation is impossible in the presence of muscle relaxation, cricothyroidotomy should follow immediately. Scalpel cricothyroidotomy is recommended as the preferred rescue technique and should be practised by all anaesthetists. The plans outlined are designed to be simple and easy to follow. They should be regularly rehearsed and made familiar to the whole theatre team.
Gupta, Nidhi; Rath, Girija Prasad; Prabhakar, Hemanshu
This study was carried out to evaluate the relative efficacy of the C-MAC videolaryngoscope as compared to the conventional Macintosh laryngoscope using both styletted and non-styletted endotracheal tube (ETT) in patients undergoing elective cervical spine surgery with head and neck stabilized by manual in-line stabilization. We randomized 120 consenting adults into four groups (30 each) to undergo tracheal intubation using either the Macintosh laryngoscope or C-MAC videolaryngoscope with styletted and non-styletted ETT. There was no significant difference between the C-MAC videolaryngoscope and Macintosh laryngoscope in Intubation Difficulty Scale (IDS) score using either styletted [median (IQR) 2 (1, 3) vs. 3 (2, 4); p = 0.58] or non-styletted ETT [median (IQR) 4 (2, 6) vs. 3 (2, 8); p = 1.00]. Similarly, when using a similar ETT-stylet assembly, the duration of successful intubation attempt, first attempt success rate, complications, use of airway optimization maneuvers, and adjuncts to facilitate intubation were comparable. The Cormack-Lehane view of the glottis was better with the C-MAC videolaryngoscope (p < 0.001). The use of stylet significantly reduced the IDS score [median (IQR) 2 (1, 3) vs. 4 (2, 6); p = 0.02], intubation time [median (IQR) 27 s (23, 31) vs. 52 s (28, 76); p < 0.001], and use of gum elastic bougie (3.3% vs. 43.3%, p < 0.001) with the C-MAC videolaryngoscope whereas no such effect was observed with the Macintosh laryngoscope. Use of the C-MAC videolaryngoscope and Macintosh laryngoscope resulted in similar levels of intubation difficulty during cervical immobilization when used with a similar ETT-stylet assembly. The inclusion of the stylet significantly reduced the intubation difficulty experienced with the C-MAC videolaryngoscope.
Brotfain, Evgeni; Klein, Yoram; Toledano, Ronen; Koyfman, Leonid; Frank, Dmitry; Shamir, Micha Y; Klein, Moti
The urine output is an important clinical parameter of renal function and blood volume status, especially in critically ill multiple trauma patients. In the present study, the minute-to-minute urine flow rate and its variability were analyzed in hypotensive multiple trauma patients during the first 6 h of their ICU (intensive care unit) stay. These parameters have not been previously reported. The study was retrospective and observational. Demographic and clinical data were extracted from the computerized Register Information Systems. A total of 59 patients were included in the study. The patients were divided into two study groups. Group 1 consisted of 29 multiple trauma patients whose systolic blood pressure was greater than 90 mmHg on admission to the ICU and who were consequently deemed to be hemodynamically compromised. Group 2 consisted of 30 patients whose systolic blood pressure was less than 90 mmHg on admission to the ICU and who were therefore regarded as hemodynamically uncompromised. The urine output and urine flow rate variability during the first 6 h of the patients' ICU stay was significantly lower in group 2 than in group 1 (p < 0.001 and 0.006 respectively). Statistical analysis by the Pearson method demonstrated a strong direct correlation between decreased urine flow rate variability and decreased urine output per hour (R = 0.17; P = 0.009), decreased mean arterial blood pressure (R = 0.24; p = 0.001), and increased heart rate (R = 0.205; p = 0.001). These findings suggest that minute-to-minute urine flow rate variability is a reliable incipient marker of hypovolemia and that it should therefore take its place among the parameters used to monitor the hemodynamic status of critically ill multiple trauma patients.
Weinberg, Jordan A; MacLennan, Paul A; Vandromme-Cusick, Marianne J; Angotti, Jonathan M; Magnotti, Louis J; Kerby, Jeffrey D; Rue, Loring W; Barnum, Scott R; Patel, Rakesh P
Trauma patients are often transfused allogeneic red blood cells (RBCs) in an effort to augment tissue oxygen delivery. However, the effect of RBC transfusion on microvascular perfusion in this patient population is not well understood. To this end, we investigated the effect of RBC transfusion on sublingual microvascular perfusion in trauma patients. Sublingual microcirculation was imaged at bedside with a sidestream dark-field illumination microscope before and after transfusion of one RBC unit in hemodynamically stable, anemic trauma patients. The perfused proportion of capillaries (PPC) before and after transfusion was determined, and the percent change in capillary perfusion following transfusion (ΔPPC) calculated. Sublingual microcirculation was observed in 30 patients. Mean age was 47 (SD, 21) years, mean Injury Severity Score was 29 (SD, 16), and mean pretransfusion hemoglobin was 7.5 (SD, 0.9) g/dL. No patients had a mean arterial pressure of less than 65 mmHg (mean, 89 [SD, 17] mmHg) or lactate of greater than 2.5 mmol/L (mean, 1.1 [SD, 0.3] mmol/L). Following transfusion, ΔPPC ranged from +68% to -36% and was found to inversely correlate significantly with pretransfusion PPC (Spearman r = -0.63, P = 0.0002). Pretransfusion PPC may be selectively deranged in otherwise stable trauma patients. Patients with relatively altered baseline PPC tend to demonstrate improvement in perfusion following transfusion, whereas those with relatively normal perfusion at baseline tend to demonstrate either no change or, in fact, a decline in PPC. Bedside sublingual imaging may have the potential to detect subtle perfusion defects and ultimately inform clinical decision making with respect to transfusion.
Weinberg, Jordan A.; MacLennan, Paul A.; Vandromme–Cusick, Marianne J.; Angotti, Jonathan M.; Magnotti, Louis J.; Kerby, Jeffrey D.; Rue, Loring W.; Barnum, Scott R.; Patel, Rakesh P.
Background Trauma patients are often transfused allogeneic red blood cells (RBCs) in an effort to augment tissue oxygen delivery. However, the effect of RBC transfusion on microvascular perfusion in this patient population is not well understood. To this end, we investigated the effect of RBC transfusion on sublingual microvascular perfusion in trauma patients. Methods Sublingual microcirculation was imaged at bedside with a sidestream dark field illumination microscope before and after transfusion of one RBC unit in hemodynamically stable, anemic trauma patients. The proportion of perfused capillaries (PPC) pre- and post-transfusion was determined, and the percent change in capillary perfusion following transfusion (ΔPPC) calculated. Results Sublingual microcirculation was observed in 30 patients. Mean age was 47 (SD=21), mean ISS was 29 (SD=16), and mean pre-transfusion hemoglobin was 7.5 g/dL (SD=0.9). No patients had MAP < 65 mm Hg (mean 89 mm Hg, SD 17) or lactate > 2.5 mmol/L (mean 1.1 mmol/L, SD 0.3). Following transfusion, ΔPPC ranged from +68% to -36% and was found to inversely correlate significantly with pre-transfusion PPC (Spearman r= -0.63, p=0.0002). Conclusions Pre-transfusion PPC may be selectively deranged in otherwise stable trauma patients. Patients with relatively altered baseline PPC tend to demonstrate improvement in perfusion following transfusion, while those with relatively normal perfusion at baseline tend to demonstrate either no change or, in fact, a decline in PPC. Bedside sublingual imaging may have the potential to detect subtle perfusion defects and ultimately inform clinical decision making with respect to transfusion. PMID:22344313
Hemmerling, Thomas M; Wehbe, Mohamad; Zaouter, Cedrick; Taddei, Riccardo; Morse, Joshua
Our goal in this study was to develop a robotic intubation system and to conduct a feasibility pilot study on the use of a robotic intubation system for endotracheal intubations. The Kepler Intubation System was developed, consisting of a remote control center (joystick and intubation cockpit) linked to a standard videolaryngoscope via a robotic arm. Ninety intubations were performed by the Kepler Intubation System on an airway trainer mannequin by a single operator. The first group of 30 intubations was performed with the operator in direct view of the mannequin (direct view group). The second group of 30 intubations was performed with the operator unable to see the mannequin (indirect view group). Thirty semiautomated intubations were also performed during which the robotic system replayed a trace of a previously recorded intubation maneuver (semiautomated group). First-attempt success rates and intubation times for each trial were recorded. Trends were analyzed using linear regression. Data are presented as mean (SD). All intubations were successful at first attempt. The mean intubation times were 46 (18) seconds, 51 (19) seconds, and 41 (1) seconds for the direct view, indirect view, and semiautomated group, respectively. Both the direct and indirect view groups had a negative slope, denoting that each successive trial required less time. The semiautomated group had a slope of 0 and a low SD of 1 second, illustrating the high reproducibility of automated intubations. We concluded that a robotic intubation system has been developed that can allow remote intubations within 40 to 60 seconds.
Coyle, Margaret J; Tyrrell, Robert; Godden, Andrew; Hughes, Ceri W; Perkins, Charles; Thomas, Steve; Godden, Daryl
In maxillofacial head and neck oncology, tracheostomy is often used to secure the airway, but not without risk. This study compared the existing practice of two units: one where tracheostomy was routinely done with one where overnight intubation was used. From both units we retrospectively analysed 50 consecutive patients who had intraoral resection, neck dissection, and microvascular reconstruction for head and neck cancer. When compared with tracheostomy, overnight intubation resulted in a shorter mean stay in the intensive therapy unit (ITU) (1.4 compared with 3.7 days), a shorter overall hospital stay (12.9 compared with 18.0 days), less time to first oral intake (8.9 compared with 12.8 days), and a lower rate of lower respiratory tract infection (LRTI) (10% compared with 38%). This study supports the discontinuation of routine tracheostomy and the adoption of a more selective practice to improve recovery. Copyright © 2013 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Haffejee, A A; Angorn, I B
The nutritional status of 15 patients suffering from unresectable carcinoma of the midthoracic esophagus was evaluated before and after palliative pulsion intubation. All patients showed evidence of protein-calorie malnutrition, prior to intubation. Oral alimentation using a formulated hospital ward diet with an elemental dietary supplement reversed the nutritional deficit. A mean daily positive nitrogen balance of seven grams was achieved three weeks following intubation. No episode of tube blockage was observed and the elemental diet supplement was well tolerated. PMID:74985
Haffejee, A A; Angorn, I B
The nutritional status of 15 patients suffering from unresectable carcinoma of the midthoracic esophagus was evaluated before and after palliative pulsion intubation. All patients showed evidence of protein-calorie malnutrition, prior to intubation. Oral alimentation using a formulated hospital ward diet with an elemental dietary supplement reversed the nutritional deficit. A mean daily positive nitrogen balance of seven grams was achieved three weeks following intubation. No episode of tube blockage was observed and the elemental diet supplement was well tolerated.
Bruce, Steven E.; Weisberg, Risa B.; Dolan, Regina T.; Machan, Jason T.; Kessler, Ronald C.; Manchester, Gertrude; Culpepper, Larry; Keller, Martin B.
Background: This article examines the nature of psychological trauma and posttraumatic stress disorder (PTSD) in 504 patients recruited from primary care settings. Method: Patients were screened for anxiety in waiting rooms at 14 general medical settings, and those with a sufficient number and severity of anxiety symptoms were administered a standardized diagnostic clinical interview. Those who met DSM-IV criteria for an anxiety disorder and who were willing to participate were included in this study. Of the 504 patients, 185 met DSM-IV criteria for PTSD. Results: Results indicated that 418 (83%) of primary care patients in our sample reported at least 1 traumatic event in their lifetime. The most prevalent traumas experienced by the entire sample of participants were witnessing others being seriously injured or killed, serious accidents, and rape. Of those participants with PTSD, rape was the strongest predictor of a PTSD diagnosis. Analyses examining gender differences indicated that, for women, a history of other unwanted sexual contact or witnessing a sexual assault, being attacked with a weapon or with intent to kill, or witnessing someone being injured were found to be risk factors for a PTSD diagnosis. Examination of clinical characteristics indicated a high rate of comorbidity of psychiatric disorders among patients with PTSD, including high rates of alcohol/substance abuse, depression, and suicide attempts. Conclusion: These findings emphasize the continued need to assess patients presenting at general medical facilities about trauma history. PMID:15014575
Adelgais, Kathleen M; Browne, Lorin; Holsti, Maija; Metzger, Ryan R; Murphy, Shannon Cox; Dudley, Nanette
Guidelines for evaluating the cervical spine in pediatric trauma patients recommend cervical spine CT (CSCT) when plain radiographs suggest an injury. Our objective was to compare usage of CSCT between a pediatric trauma center (PTC) and referral general emergency departments (GEDs). Patient data from a pediatric trauma registry from 2002 to 2011 were analyzed. Rates of CSI and CSCT of patients presenting to the PTC and GED were compared. Factors associated with use of CSCT were assessed using multivariate logistic regression. 5148 patients were evaluated, 2142 (41.6%) at the PTC and 3006 (58.4%) at the GED. Groups were similar with regard to age, gender, GCS, and triage category. GED patients had a higher median ISS (14 vs. 9, p<0.05) and more frequent ICU admissions (44.3% vs. 26.1% p<0.05). CSI rate was 2.1% (107/5148) and remained stable. CSCT use increased from 3.5% to 16.1% over time at the PTC (mean 9.6% 95% CI=8.3, 10.9) and increased from 6.8% to 42.0% (mean 26.9%, CI=25.4, 28.4) at the GED. Initial care at a GED remained strongly associated with CSCT. Despite a stable rate of CSI, rate of CSCT increased significantly over time, especially among patients initially evaluated at a GED. © 2014 Elsevier Inc. All rights reserved.
Finset, A; Anke, A W; Hofft, E; Roaldsen, K S; Pillgram-Larsen, J; Stanghelle, J K
Patients with sequelae from multiple trauma commonly display cognitive disturbances, specifically in the areas of attention and memory. This study was designed to assess cognitive functioning 3 years after severe multiple trauma and to investigate how cognitive performance is related to head injury severity and psychological distress respectively. Sixty-eight multiple trauma patients were tested with a screening battery consisting of six neuropsychological tasks 3 years after injury. A measure of psychological distress (20-item General Health Questionnaire, or GHQ-20) was also administered. Patients who neither showed signs of reduced consciousness on admission to the hospital nor reported significant psychological distress at follow-up tended to have normal test performance. In five of the six tasks, cognitive impairment was related to the severity of the traumatic brain injury as measured by the Glasgow Coma Scale (GCS). In both attention span tasks, patients designated as cases by the GHQ had significantly lower scores than noncase patients. These bivariate relationships were upheld in multiple regression analyses, in which age, sex, and GCS and GHQ scores were entered as independent variables. When patients with severe head injuries were excluded from the analyses, GCS scores still contributed to the variance in tests of verbal attention span and delayed recall, but performance on attentional tasks was more strongly related to psychological distress than to GCS scores. Cognitive deficits in multiple trauma patients were related both to the severity of the traumatic brain injury and to the degree of psychological distress. The strength of the association between brain injury as indicated by GCS scores and cognitive performance differed between different tasks. Neuropsychological testing may assist in differentiating primary organic from secondary psychogenic impairments.
Croce, Martin A; Brasel, Karen J; Coimbra, Raul; Adams, Charles A; Miller, Preston R; Pasquale, Michael D; McDonald, Chanchai S; Vuthipadadon, Somchan; Fabian, Timothy C; Tolley, Elizabeth A
Since its introduction by the Institute for Healthcare Improvement, the ventilator bundle (VB) has been credited with a reduction in ventilator-associated pneumonia (VAP). The VB consists of stress ulcer prophylaxis, deep venous thrombosis prophylaxis, head-of-bed elevation, and daily sedation vacation with weaning assessment. While there is little compelling evidence that the VB is effective, it has been widely accepted. The Centers for Medical and Medicaid Services has suggested that VAP should be a "never event" and may reduce payment to providers. To provide evidence of its efficacy, the National Trauma Institute organized a prospective multi-institutional trial to evaluate the utility of the VB. This prospective observational multi-institutional study included six Level I trauma centers. Entry criteria required at least 2 days of mechanical ventilation of trauma patients in an intensive care unit (ICU). Patients were followed up daily in the ICU until the development of VAP, ICU discharge, or death. Compliance for each VB component was recorded daily, along with patient risk factors and injury specifics. Primary outcomes were VAP and death. VB compliance was analyzed as a time-dependent covariate using Cox regression as it relates to outcomes. A total 630 patients were enrolled; 72% were male, predominately with blunt injury; and mean age, Injury Severity Score (ISS), and 24-hour Glasgow Coma Scale (GCS) score were 47, 24, and 8.7, respectively. VAP occurred in 36%; mortality was 15%. Logistic regression identified male sex and pulmonary contusion as independent predictors of VAP and age, ISS, and 24-hour Acute Physiology and Chronic Health Evaluation as independent predictors of death. Cox regression analysis demonstrated that the VB, as a time-dependent covariate, was not associated with VAP prevention. In trauma patients, VAP is independently associated with male sex and chest injury severity and not the VB. While quality improvement activities should
Midwinter, Mark J.; Woolley, Tom
Developments in the resuscitation of the severely injured trauma patient in the last decade have been through the increased understanding of the early pathophysiological consequences of injury together with some observations and experiences of recent casualties of conflict. In particular, the recognition of early derangements of haemostasis with hypocoagulopathy being associated with increased mortality and morbidity and the prime importance of tissue hypoperfusion as a central driver to this process in this population of patients has led to new resuscitation strategies. These strategies have focused on haemostatic resuscitation and the development of the ideas of damage control resuscitation and damage control surgery continuum. This in turn has led to a requirement to be able to more closely monitor the physiological status, of major trauma patients, including their coagulation status, and react in an anticipatory fashion. PMID:21149355
Huisman, Thierry A G M; Poretti, Andrea
Traumatic brain and spine injury (TBI/TSI) is a leading cause of death and lifelong disability in children. The biomechanical properties of the child's brain, skull, and spine, the size of the child, the age-specific activity pattern, and variance in trauma mechanisms result in a wide range of age-specific traumas and patterns of brain and spine injuries. A detailed knowledge about the various types of primary and secondary pediatric head and spine injuries is essential to better identify and understand pediatric TBI/TSI, which enhances sensitivity and specificity of diagnosis, will guide therapy, and may give important information about the prognosis. The purposes of this chapter are to: (1) discuss the unique epidemiology, mechanisms, and characteristics of TBI/TSI in children; (2) review the anatomic and functional imaging techniques that can be used to study common and rare pediatric TBI/TSI and their complications; (3) comprehensively review frequent primary and secondary brain injuries; and (4) to give a short overview of two special types of pediatric TBI/TSI: birth-related and nonaccidental injuries.
Sefrioui, I; Amadini, R; Mauro, J; El Fallahi, A; Gabbrielli, M
Exceptional circumstances like major incidents or natural disasters may cause a huge number of victims that might not be immediately and simultaneously saved. In these cases it is important to define priorities avoiding to waste time and resources for not savable victims. Trauma and Injury Severity Score (TRISS) methodology is the well-known and standard system usually used by practitioners to predict the survival probability of trauma patients. However, practitioners have noted that the accuracy of TRISS predictions is unacceptable especially for severely injured patients. Thus, alternative methods should be proposed. In this work we evaluate different approaches for predicting whether a patient will survive or not according to simple and easily measurable observations. We conducted a rigorous, comparative study based on the most important prediction techniques using real clinical data of the US National Trauma Data Bank. Empirical results show that well-known Machine Learning classifiers can outperform the TRISS methodology. Based on our findings, we can say that the best approach we evaluated is Random Forest: it has the best accuracy, the best area under the curve, and k-statistic, as well as the second-best sensitivity and specificity. It has also a good calibration curve. Furthermore, its performance monotonically increases as the dataset size grows, meaning that it can be very effective to exploit incoming knowledge. Considering the whole dataset, it is always better than TRISS. Finally, we implemented a new tool to compute the survival of victims. This will help medical practitioners to obtain a better accuracy than the TRISS tools. Random Forests may be a good candidate solution for improving the predictions on survival upon the standard TRISS methodology.
Finigan, Ryan; Pham, Jacqueline; Mendoza, Rosemarie; Lekawa, Michael; Dolich, Matthew; Kong, Allen; Bernal, Nicole; Lush, Stephanie; Barrios, Cristobal
The objective of this study was to determine if elderly trauma patients are at risk for contrast-induced nephropathy (CIN). A retrospective study was conducted identifying 362 patients 65 years and older in our Level I trauma center who received computerized tomography (CT) scans with intravenous contrast. CIN was defined as a 25 per cent increase in serum creatinine levels or a 0.5 mg/dL increase above baseline after CT. History of diabetes mellitus, hospital length of stay, intensive care unit length of stay, Injury Severity Score (ISS), and age were recorded. Eighteen per cent (21 of 118) of the patients had a peak in creatinine, 12 per cent (14 of 118) peaked and returned to baseline, and 6 per cent (7 of 118) peaked and stayed high. Pre-CT elevated creatinine, diabetes mellitus, increased hospital length of stay, ISS, and age show little association to CIN. The data suggest that CIN in elderly trauma patients is rare, regardless of history of diabetes mellitus, age, creatinine, high ISS, or result in higher length of stay. Therefore, there is little justification for the delay in diagnosis to assess a patient's renal susceptibility.
Kirkilas, Mary; Notrica, David M; Langlais, Crystal S; Muenzer, Jared T; Zoldos, Jozef; Graziano, Kathleen
Vascular trauma in children, although rare, carries significant risk for repair. Here we report outcomes from a single trauma center for children with extremity vascular trauma, proximal to the digits. Retrospective chart review of patients less than age 18years with an acute, non-iatrogenic traumatic arterial vascular injury of the upper and/or lower extremity between January 2008 and December 2013. Abstracted patient demographics, injury characteristics, surgical management, and disposition were summarized and compared with nonparametric methods. 23 children comprised the study cohort: median age of 8years (IQR: 4.6-12), 61% (n=14) males, 100% survival. Penetrating injuries were the predominate mechanism (n=17, 74%). The median time to presentation was 154min (IQR: 65-330). Acute operations for revascularization included a primary repair (n=15, 65%) or reversed vein graft (n=7, 30%). Fasciotomies were done for 3 (13%) patients. Three amputations were done for failed revascularization. Upper extremity vascular injury (n=15, 65%) was more common. The rate of associated extremity fracture was similar between upper (21%) and lower (33%) extremities (p=0.643). Eight (35%) patients required additional surgery most commonly for debridement, washouts and dressing changes. Three patients' hospital stays were complicated by infection. Impaired function was the most common short- and long-term complication (60%, 75%). Pediatric vascular injuries are commonly associated with penetrating injuries and male gender and occurred more frequently in the upper extremities. Overall patency rates after repair were 87%. Fasciotomies were done in 13% of patients, and the overall surgical amputation rate was 13%. There was no mortality in this cohort; however, multiple operations are commonly required, including the return to OR for washouts, debridements and dressing changes. The most common short- and long-term complication was impaired function. Overall good results are achievable in
Inaba, Kenji; Lustenberger, Thomas; Rhee, Peter; Holcomb, John B; Blackbourne, Lorne H; Shulman, Ira; Nelson, Janice; Talving, Peep; Demetriades, Demetrios
The impact of platelet transfusion in trauma patients undergoing a massive transfusion (MT) was evaluated. The Institutional Trauma Registry and Blood Bank Database at a Level I trauma center was used to identify all patients requiring an MT (≥10 packed red blood cells [PRBC] within 24 hours of admission). Mortality was evaluated according to 4 apheresis platelet (aPLT):PRBC ratios: Low ratio (<1:18), medium ratio (≥1:18 and <1:12), high ratio (≥1:12 and <1:6), and highest ratio (≥1:6). Of 32,289 trauma patients, a total of 657 (2.0%) required an MT. At 24 hours, 171 patients (26.0%) received a low ratio, 77 (11.7%) a medium ratio, 249 (37.9%) a high ratio, and 160 (24.4%) the highest ratio of aPLT:PRBC. After correcting for differences between groups, the mortality at 24 hours increased in a stepwise fashion with decreasing aPLT:PRBC ratio. Using the highest ratio group as a reference, the adjusted relative risk of death was 1.67 (adjusted p = 0.054) for the high ratio group, 2.28 (adjusted p = 0.013) for the medium ratio group, and 5.51 (adjusted p < 0.001) for the low ratio group. A similar stepwise increase in mortality with decreasing platelet ratio was observed at 12 hours after admission and for overall survival to discharge. After stepwise logistic regression, a high aPLT:PRBC ratio (adjusted p < 0.001) was independently associated with improved survival at 24 hours. For injured patients requiring a massive transfusion, as the apheresis platelet-to-red cell ratio increased, a stepwise improvement in survival was seen. Prospective evaluation of the role of platelet transfusion in massively transfused patients is warranted. Copyright © 2010 American College of Surgeons. All rights reserved.
Lai, Wei-Hung; Wu, Shao-Chun; Rau, Cheng-Shyuan; Kuo, Pao-Jen; Hsu, Shiun-Yuan; Chen, Yi-Chun; Hsieh, Hsiao-Yun; Hsieh, Ching-Hua
Background: Hemorrhage is a leading cause of preventable trauma death. In this study, we used the reverse shock index (RSI), a ratio of systolic blood pressure (SBP) to heart rate (HR), to evaluate the hemodynamic stability of trauma patients. As an SBP lower than the HR (RSI < 1) may indicate hemodynamic instability, the objective of this study was to assess the associated complications in trauma patients with an RSI < 1 upon arrival at the emergency department (ED) (indicated as (A)RSI) and at the time of departure from the ED (indicated as (L)RSI) to the operative room or for admission. Methods: Data obtained from all 16,548 hospitalized patients recorded in the trauma registry system at a Level I trauma center between January 2009 and December 2013 were retrospectively reviewed. A total of 10,234 adult trauma patients aged ≥20 were enrolled and subsequently divided into four groups: Group I, (A)RSI ≥ 1 and (L)RSI ≥ 1 (n = 9827); Group II, (A)RSI ≥ 1 and (L)RSI < 1 (n = 76); Group III, (A)RSI < 1 and (L)RSI ≥ 1 (n = 251); and Group IV, (A)RSI < 1 and (L)RSI < 1 (n = 80). Pearson’s χ2 test, Fisher’s exact test, or independent Student’s t-test was conducted to compare trauma patients in Groups II, III, and IV with those in Group I. Results: Patients in Groups II, III, and IV had a higher injury severity score and underwent a higher number of procedures, including intubation, chest tube insertion, and blood transfusion, than Group I patients. Additionally, patients of these groups had increased hospital length of stay (16.3 days, 14.9 days, and 22.0 days, respectively), proportion of patients admitted to the intensive care unit (ICU) (48.7%, 43.0%, and 62.5%, respectively), and in-hospital mortality (19.7%, 7.6%, and 27.5%, respectively). Although the trauma patients who had a SBP < 90 mmHg either upon arrival at or departure from the ED also present a more severe injury and poor outcome, those patients who had a SBP ≥ 90 mmHg but an RSI < 1 had
Lai, Wei-Hung; Wu, Shao-Chun; Rau, Cheng-Shyuan; Kuo, Pao-Jen; Hsu, Shiun-Yuan; Chen, Yi-Chun; Hsieh, Hsiao-Yun; Hsieh, Ching-Hua
Hemorrhage is a leading cause of preventable trauma death. In this study, we used the reverse shock index (RSI), a ratio of systolic blood pressure (SBP) to heart rate (HR), to evaluate the hemodynamic stability of trauma patients. As an SBP lower than the HR (RSI < 1) may indicate hemodynamic instability, the objective of this study was to assess the associated complications in trauma patients with an RSI < 1 upon arrival at the emergency department (ED) (indicated as (A)RSI) and at the time of departure from the ED (indicated as (L)RSI) to the operative room or for admission. Data obtained from all 16,548 hospitalized patients recorded in the trauma registry system at a Level I trauma center between January 2009 and December 2013 were retrospectively reviewed. A total of 10,234 adult trauma patients aged ≥20 were enrolled and subsequently divided into four groups: Group I, (A)RSI ≥ 1 and (L)RSI ≥ 1 (n = 9827); Group II, (A)RSI ≥ 1 and (L)RSI < 1 (n = 76); Group III, (A)RSI < 1 and (L)RSI ≥ 1 (n = 251); and Group IV, (A)RSI < 1 and (L)RSI < 1 (n = 80). Pearson's χ² test, Fisher's exact test, or independent Student's t-test was conducted to compare trauma patients in Groups II, III, and IV with those in Group I. Patients in Groups II, III, and IV had a higher injury severity score and underwent a higher number of procedures, including intubation, chest tube insertion, and blood transfusion, than Group I patients. Additionally, patients of these groups had increased hospital length of stay (16.3 days, 14.9 days, and 22.0 days, respectively), proportion of patients admitted to the intensive care unit (ICU) (48.7%, 43.0%, and 62.5%, respectively), and in-hospital mortality (19.7%, 7.6%, and 27.5%, respectively). Although the trauma patients who had a SBP < 90 mmHg either upon arrival at or departure from the ED also present a more severe injury and poor outcome, those patients who had a SBP ≥ 90 mmHg but an RSI < 1 had a more severe injury and poor
Bahten, Luiz CV; Mauro, Fernando HO; Domingos, Maria F; Scheffer, Paula H; Pagnoncelli, Bruno H; Wille, Marco AR
Background The metabolic changes in trauma patients with shock contribute directly to the survival of the patient. To understand these changes better, we made a rigorous analysis of the variations in the main examinations requested for seriously polytraumatized patients. Methods Prospective analysis of patients with blunt or penetrating trauma with hypovolemic shock, with systolic arterial pressure (SAP) equal to or lower than 90 mmHg at any time during initial treatment in the emergency room and aged between 14 and 60 years old. The following exams were analyzed: sodium, potassium, blood test, glycemia and arterial gasometry. The tests were carried out at intervals: T0 (the first exam, collected on admission) and followed by T24 (24 hours after admission), T48 (48 hours after admission), T72 (72 hours after admission). Results The test evaluations showed that there was a tendency towards hyperglycemia, which was more evident upon admission to hospital. The sodium in all the patients was found to be normal upon admission, with a later decline. However, no patient had significant hyponatremia; there was no significant variation in the potassium variable; the gasometry, low pH, BE (base excess) and bicarbonate levels when the first sample was collected and increased later with PO2 and PCO2 showing only slight variations, which meant an acidotic state during the hemorrhagic shock followed by a response from the organism to reestablish the equilibrium, retaining bicarbonate. The red blood count, shown by the GB (globular volume) and HB (hemoglobin) was normal upon entry but later it dropped steadily until it fell below normal; the white blood count (leukocytes, neutrophils and band neutrophil) remained high from the first moment of evaluation. Conclusion In this study we demonstrated the main alterations that took place in patients with serious trauma, emphasizing that even commonly requested laboratory tests can help to estimate metabolic alterations. Suitable
Leung, Sharon Shui Yee; Parumasivam, Thaigarajan; Tang, Patricia; Chan, Hak-Kim
A fatal incident was reported when a mechanical ventilated patient received nebulization of a reconstituted Relenza(®) formulation. We propose a delivery system to introduce Relenza and other inhalation dry powders to intubated patients to avoid accidental fatalities in the future. This is a bench study demonstrating the feasibility of a delivery system to introduce dry powder of Relenza to intubated patients. A dry powder inhaler placed within a delivery chamber was actuated by compressing a ventilation bag to disperse powder into a tracheal tube. The performance of two inhalers, a Diskhaler(®) and an Osmohaler(™), were compared. The effects of the length and size of the tracheal tube on the powder output and sizing of emitted powder were investigated using the more efficient Osmohaler(™). The efficiency of Osmohaler in delivering Relenza to the distal end [delivered dose=30.2±0.2% and fine particle fraction (FPF)=14.5±1.7%] was significantly higher than the Diskhaler (delivered dose=18.1±4.7% and FPF=3.4±2.1%). While no differences in the delivered dose and FPF were observed between the tracheostomy and endotracheal tubes of the same internal diameter, a larger endotracheal tube (9.0 mm internal diameter) gave a 6% higher FPF compared with the smaller counterpart (7.0 mm internal diameter). The dry powder delivery system has been demonstrated to be capable of delivering Relenza formulation to the distal end of tracheal tubes with a reasonable delivered dose and FPF. It would be necessary for further investigation into incorporating the proposed powder delivery system within a mechanical ventilator, as well as animal and clinical studies to prove its applicability to deliver zanamivir dry powder to ventilated influenza patients in the intensive care setting.
[Prophylactic use of icatibant before tracheal intubation of a patient with hereditary angioedema type III. (A literature review of perioperative management of patients with hereditary angioedema type III)].
Iturri Clavero, F; González Uriarte, A; Tamayo Medel, G; Gamboa Setién, P M
Type III hereditary angioedema is a rare familial disorder that has recently been described as a separate condition. Triggers for episodes of angioedema include surgery, dental procedures, and tracheal intubation maneuvers. Since episodes affecting the upper airway are potentially life-threatening, prophylactic treatment is recommended in these situations. The use of icatibant (Firazyr(®)), for prevention of angioedema prior to tracheal intubation, is reported in a patient with type iii hereditary angioedema. A literature review on the anesthetic management of this condition was conducted. Copyright © 2013 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Published by Elsevier España. All rights reserved.
Haut, Elliott R; Kalish, Brian T; Cotton, Bryan A; Efron, David T; Haider, Adil H; Stevens, Kent A; Kieninger, Alicia N; Cornwell, Edward E; Chang, David C
Prehospital intravenous (IV) fluid administration is common in trauma patients, although little evidence supports this practice. We hypothesized that trauma patients who received prehospital IV fluids have higher mortality than trauma patients who did not receive IV fluids in the prehospital setting. We performed a retrospective cohort study of patients from the National Trauma Data Bank. Multiple logistic regression was used with mortality as the primary outcome measure. We compared patients with versus without prehospital IV fluid administration, using patient demographics, mechanism, physiologic and anatomic injury severity, and other prehospital procedures as covariates. Subset analysis was performed based on mechanism (blunt/penetrating), hypotension, immediate surgery, severe head injury, and injury severity score. A total of 776,734 patients were studied. Approximately half (49.3%) received prehospital IV. Overall mortality was 4.6%. Unadjusted mortality was significantly higher in patients receiving prehospital IV fluids (4.8% vs. 4.5%, P < 0.001). Multivariable analysis demonstrated that patients receiving IV fluids were significantly more likely to die (odds ratio [OR] 1.11, 95% confidence interval [CI] 1.05–1.17). The association was identified in nearly all subsets of trauma patients. It is especially marked in patients with penetrating mechanism (OR 1.25, 95% CI 1.08–1.45), hypotension (OR 1.44, 95% CI1.29–1.59), severe head injury (OR 1.34, 95% CI 1.17–1.54), and patients undergoing immediate surgery (OR 1.35, 95% CI 1.22–1.50). The harm associated with prehospital IV fluid administration is significant for victims of trauma. The routine use of prehospital IV fluid administration for all trauma patients should be discouraged.
Vinayagam, S; Dhanger, S; Tilak, P; Gnanasekar, R
Parapharyngeal tumors are rare head and neck tumors which can present as an intraoral mass and can pose great challenge to anesthesiologists. The primary concern is the difficult airway due to gross anatomical distortion of the upper airway. Securing the airway in an awake state should be the primary goal of anesthesiologists to avoid catastrophic complications. Herewith, we report the successful use of C-MAC(®) video laryngoscope with the acute-angle D-BLADE™ in combination with Frova introducer for awake intubation in a patient with parapharyngeal mass after multiple attempts of failed fiber-optic intubation.
Vinayagam, S; Dhanger, S; Tilak, P; Gnanasekar, R
Parapharyngeal tumors are rare head and neck tumors which can present as an intraoral mass and can pose great challenge to anesthesiologists. The primary concern is the difficult airway due to gross anatomical distortion of the upper airway. Securing the airway in an awake state should be the primary goal of anesthesiologists to avoid catastrophic complications. Herewith, we report the successful use of C-MAC® video laryngoscope with the acute-angle D-BLADE™ in combination with Frova introducer for awake intubation in a patient with parapharyngeal mass after multiple attempts of failed fiber-optic intubation. PMID:27833500
Rösch, M; Klose, T; Leidl, R; Gebhard, F; Kinzl, L; Ebinger, T
Current clinical management after multiple trauma is expensive. The aim of the present study was to quantify the actual costs of inpatient treatment after multiple trauma in a German university hospital, to compare the actual costs with the reimbursement rates, and to identify important determinants of costs. Routine documentation of hospital costs at a patient level was not available. Therefore a method for calculating the costs of resource utilization during clinical treatment of patients was developed. The concept was based on financial and utilization data provided by the hospital administration and patient-specific data. The average costs per case in the study group (mean ISS = 37) were 73.613 DM, maximal costs were up to 292.490 DM. The most costly components were intensive care, accounting for 60%, followed by procedures in the operating room (24%). A comparison with the reimbursement rates resulted in an average loss of 23.211 DM per case. Factors significantly associated with the costs of acute care hospitalization were outcome, injury severity, pattern of injury, blood volume replacement, length of mechanical ventilation, and number of operations. Whereas patient age, CNS state, mechanism of injury, pre-hospital care, and time between accident and hospital admission revealed no effect. Given the current reimbursement rates, multiple trauma care clearly belongs to those categories of care which have to be subsidized within the hospital. Any challenge to the optimal level of care resulting from this should be avoided.
Kreipke, D L; Gillespie, K R; McCarthy, M C; Mail, J T; Lappas, J C; Broadie, T A
Common emergency room practice mandates cervical spine (C-spine) films in all trauma patients with potential injuries. With the increasing costs of medical care, such liberal criteria may not be justified. This 1-year prospective study of 860 patients who presented to a Level I Trauma Center was undertaken to determine the signs and symptoms that woul