Oxygenation/ventilation of transported intubated adult patients: a national survey of organizational practices.

INTRODUCTION: Transporting intubated patients is common among ground and air crews, and providing adequate oxygenation/ventilation through transport ventilators (TV) or manual ventilation (MV) is clinically challenging. However, very little data chronicle service or practice patterns of oxygenation/ventilation within the industry. METHODS: During February 1998, a national sample of 250 air transport agencies was surveyed regarding activities and services surrounding this population of transported patients. One-hundred-ninety-three surveys (77%) were returned. RESULTS: Approximately 40% of responding agencies use rotor-wing transportation only. Various combinations of rotor-, fixed-wing, and critical care ground transport were reported among the sample. Crew configuration consisted primarily of RN/EMT-P (75%). For pre-hospital intubated patients, MV alone (37.3%), TV alone (10.9%), or a combination of MV and TV (43.5%) was used, depending on transport circumstances. Programs not involved in pre-hospital transports accounted for 8.3% of returned surveys. Interfacility transports used MV (6.8%), TV (39.4%), and a combination (53.4%). One respondent did not answer the question, accounting for 0.4% of the returned surveys. More than 75% of programs monitored oxygenation/ventilation during transport. Usually some combination of pulse oximetry and CO2 monitoring was used. More than half (59%) of reporting agencies transport more than 80 intubated adults each year. CONCLUSION: Considerable variation exists in practices involving the transport of intubated patients.

A quicker saphenous vein cutdown and a better way to teach it.

The saphenous vein cutdown has long been a mainstay for venous access in the trauma patient. During the past several years, however, its popularity and frequency of use have declined markedly. Percutaneous femoral catheterization using the Seldinger approach has essentially replaced the cutdown as the method of choice for gaining vascular access in most circumstances. There remains a group of critically ill patients, however, often without palpable femoral pulses, in whom percutaneous femoral lines are difficult if not impossible to place. The saphenous vein cutdown can be lifesaving in these patients, provided that physicians can preserve the skill to place the cutdowns efficiently. This will be even less likely in time because the new revision of the Advanced Trauma Life Support textbook will make the saphenous vein cutdown an "optional" skill to be taught at the discretion of the course director. Presented is a faster, more efficient saphenous vein cutdown procedure using a Seldinger wire-guided dilator. Also presented is an effective, inexpensive model for teaching this procedure and for skill preservation.

Massive pulmonary embolism.

An otherwise healthy 48-year-old woman presented in respiratory extremis from massive pulmonary embolism and promptly arrested. She underwent open-chest cardiopulmonary resuscitation followed by portable partial cardiopulmonary bypass and embolectomy but could not be resuscitated. Massive pulmonary embolism is frequently a desperate situation, but aggressive therapy with thrombolysis or embolectomy (in patients with contraindications to thrombolysis) may be lifesaving.