Emergency percutaneous tracheostomy in a severely burned patient with upper airway obstruction and circulatory failure.

Airway inaccessibility is one of the most dreaded situations in emergency medicine. Surgical tracheostomy is not indicated in emergency situations because it takes a long time and can result in death if respiratory support cannot be provided during the procedure. Emergency percutaneous tracheostomy (PCT) was widely regarded as absolutely counterindicated. Recently, however, a number of studies have appeared on the safety and feasibility of PCT in situations regarded as presenting relative contraindications. We describe the life-saving action of Griggs' PCT in a patient with upper airway obstruction resulting from burns, smoke injuries, and unsuccessful tracheal intubation attempts. Emergency PCT using the Griggs technique was immediately performed without aseptic care, and a 9-mm internal diameter tracheostomy tube was successfully inserted in less than one minute. Griggs' PCT is a quick technique that secures an airway when tracheal intubation fails. The feasibility - in selected cases - of using an emergency Griggs' PCT, in experienced hands, rather than cricothyroidotomy or surgical tracheostomy, is recommended.

Therapeutic Intervention Scoring System-28 as a tool of post ICU outcome prognosis and prevention.

AIM: To examine the effects of severity upon discharge from Intensive Care Unit (ICU) status, as assessed by the Therapeutic Intervention Scoring System-28 (TISS-28) on subsequent post ICU outcome. METHODS: One-year retrospective observational study. Six bed general ICU in a general hospital with no High Dependency ICU unit (HDU) available. We used data from all patients admitted to the ICU. From all discharged patients, data on mean length of ICU stay, APACHE II upon admission and TISS-28 upon discharge were collected. RESULTS: Eighty-six patients, mean age 63.2, were discharged to hospital wards between January 1999 and December 1999. Age is a significant factor to contribute to outcome prediction, (p=0.0478). TISS-28 is statistically significant related to survival status. Thirteen patients that did not survive had higher TISS-28 values (p=0.0032). Length of ICU stay has a borderline association (p=0.063) with survival. CONCLUSION: Patients discharged from ICU have post ICU hospital length of stay and prognosis related to their age, time of hospitalization in ICU and their severity status upon discharge from the ICU. We believe that, based on the TISS-28 scoring system, high risk patients can be identified and either ideally transferred to a HDU or discharged from ICU when further improvement has been achieved. TIS-28 is a valuable tool in post ICU outcome prediction and subsequently, in hospital mortality reduction. At the same time, through TISS-28 use, each hospital can locally identify the quality of care provided outside the ICU, given the outcomes measured in groups of patients at various severity levels.

Nonlinear binding of sex steroids to albumin and sex hormone binding globulin.

We have studied the binding of sex steroids to albumin and sex hormone binding globulin (SHBG) using gel filtration chromatography for the separation of the bound from the free fraction of the steroid. It was found that estradiol binds to the globulin and albumin in a nonlinear manner: a lag period of binding was observed at low concentrations of the proteins, followed by an exponential increase of the bound hormone as the protein concentration increased. The same was observed with dihydrotestosterone (DHT) and albumin but not with globulin. In the presence of a constant concentration of albumin, the increase of SHBG concentrations resulted in a rapid transfer of estradiol from albumin to globulin while the transfer of DHT was moderate. When whole serum was used, the increase of its amount again resulted in the transfer of estradiol from albumin to globulin. Our study showed that a substantial increase of globulin-bound hormone can occur, following small variations of the protein. This offers obvious advantages to the organism, by saving energy, material and time and plays a basic role in estradiol transfer from albumin to the much more biologically active globulin.