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1.
Prehosp Disaster Med ; 36(5): 547-552, 2021 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-34254579

RESUMO

INTRODUCTION: Prehospital pediatric tracheal intubation (TI) is a possible life-saving intervention that requires adequate experience to mitigate associated complications. The pediatric airway and respiratory physiology present challenges in addition to a relatively rare incidence of prehospital pediatric TI. STUDY OBJECTIVE: The aim of this study was to describe characteristics and outcomes of prehospital TI in pediatric patients treated by critical care teams. METHODS: This is a sub-group analysis of all pediatric (<16 years old) patients from a prospective, observational, multi-center study on prehospital advanced airway management in the Nordic countries from May 2015 through November 2016. The TIs were performed by anesthesiologists and nurse anesthetists staffing six helicopter and six Rapid Response Car (RRC) prehospital critical care teams. RESULTS: In the study, 74 children were tracheal intubated, which corresponds to 3.7% (74/2,027) of the total number of patients. The pediatric patients were intubated by very experienced providers, of which 80% had performed ≥2,500 TIs. The overall TI success rate, first pass success rate, and airway complication rate were in all children (<16 years) 98%, 82%, and 12%. The corresponding rates among infants (<2 years) were 94%, 67%, and 11%. The median time on scene was 30 minutes. CONCLUSION: This study observed a high overall prehospital TI success rate in children with relatively few associated complications and short time on scene, despite the challenges presented by the pediatric prehospital TI.


Assuntos
Serviços Médicos de Emergência , Enfermeiros Anestesistas , Adolescente , Manuseio das Vias Aéreas , Anestesiologistas , Criança , Cuidados Críticos , Humanos , Lactente , Intubação Intratraqueal , Estudos Prospectivos , Estudos Retrospectivos
2.
Acta Anaesthesiol Scand ; 65(9): 1329-1336, 2021 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-34152597

RESUMO

BACKGROUND: Pre-hospital tracheal intubation in trauma patients has recently been questioned. However, not only the trauma and patient characteristics but also airway provider competence differ between systems making simplified statements difficult. METHOD: The study is a subgroup analysis of trauma patients included in the PHAST study. PHAST was a prospective, observational, multicentre study on pre-hospital advanced airway management by anaesthesiologist and nurse anaesthetist manned pre-hospital critical care teams in the Nordic countries May 2015-November 2016. Endpoints include intubation success rate, complication rate (airway-related complication according to Utstein Airway Template by Sollid et al), scene time (time from arrival of the critical care team to departure of the patient) and pre-hospital mortality. RESULT: The critical care teams intubated 385 trauma patients, of which 65 were in shock (SBP <90 mm Hg), during the study. Of the trauma patients, 93% suffered from blunt trauma, the mean GCS was 6 and 75% were intubated by an experienced provider who had performed >2500 tracheal intubations. The pre-hospital tracheal intubation overall success rate was 98.6% and the complication rate was 13.6%, with no difference between patients with or without shock. The mean scene time was significantly shorter in trauma patients with shock (21.4 min) compared to without shock (21.4 vs 25.1 min). Following pre-hospital tracheal intubation, 97% of trauma patients without shock and 91% of the patients in shock with measurable blood pressure were alive upon arrival to the ED. CONCLUSION: Pre-hospital tracheal intubation success and complication rates in trauma patients were comparable with in-hospital rates in a system with very experienced airway providers. Whether the short scene times contributed to a low pre-hospital mortality needs further investigation in future studies.


Assuntos
Anestesia , Serviços Médicos de Emergência , Cuidados Críticos , Hospitais , Humanos , Intubação Intratraqueal , Enfermeiros Anestesistas , Estudos Prospectivos
3.
Acta Anaesthesiol Scand ; 64(1): 124-130, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31436306

RESUMO

BACKGROUND: In pre-hospital care, pre-intubation checklists (PICL) are widely implemented as a safety measure and guidelines support their use. However, the true value of PICL among experienced airway providers is unknown. This study aims to explore possible benefits and disadvantages of PICL in the pre-hospital setting. METHODS: We performed a subgroup analysis of a prospective, observational, multicentre study on pre-hospital advanced airway management in the Nordic countries between May 2015 and November 2016. The original trial was designed to investigate the success rates of pre-hospital tracheal intubations and the incidence of complications. Our study limited inclusion to drug assisted intubations performed by anaesthesiologists. Intubation success rates and complication rates were plotted against checklist use. RESULTS: We analyzed 588 pre-hospital intubations for medical and traumatic emergencies. Overall, checklists were used in 60.5% of instances. Applying checklists was associated with increased success at first and second intubation attempts. There was no significant difference in the overall success rates (99.4% and 99.1%). Oesophageal misplacement was more common in the No-PICL group (2.2% vs 0.3%) but otherwise the incidence of airway related complications did not differ between the groups. Scene time was significantly shorter in the No-PICL group (23.6 vs 27.5 minutes). CONCLUSION: In this retrospective study, checklist use correlated with fewer attempts at intubation when securing the airway. Despite this, we found no association between checklist use and the overall TI success rate or the incidence of serious adverse events. Scene times were shorter without PICL.


Assuntos
Manuseio das Vias Aéreas/métodos , Lista de Checagem/métodos , Serviços Médicos de Emergência , Humanos , Estudos Prospectivos , Estudos Retrospectivos , Países Escandinavos e Nórdicos
4.
Air Med J ; 37(5): 306-311, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-30322633

RESUMO

OBJECTIVE: The gold standard for prehospital intubation is to avoid intubating in confined spaces. For our helicopter service, this is not always realistic. Operating in a rural region with a subarctic, cold climate, our crews are frequently forced to intubate inside ambulances or in our helicopter. This article describes a protocol for in-cabin intubation and compares it with standard open space conditions. METHODS: Fourteen prehospital physicians were randomized to solve a simplified clinical scenario during which they were to intubate a mannequin either inside the helicopter, in accordance with our in-cabin protocol, or outside on an ambulance stretcher. Participants scored intubating conditions using a visual analog scale (VAS) and the Cormack-Lehane classification. The number of intubation attempts was recorded. Three timing end points were also measured. RESULTS: All intubations were successful on the first attempt. All participants reported an optimal glottic view of Cormack-Lehane 1 in both scenario conditions. Participants perceived in-cabin intubation to be less difficult than intubating outdoors. (VAS 1 vs. VAS 2, P = .02). We found no difference in the duration of intubation. Scene time was 53.5 seconds (P = .04) shorter in the in-cabin group. In-cabin intubation delayed the establishment of a secure airway by 63 seconds (P = .01). CONCLUSION: Our study suggests that protocolized in-cabin intubation can be performed in a timely manner under conditions that are equal to or better than when intubating outside on a stretcher with 360-degree patient access. Although delaying the establishment of a secure airway, in-cabin intubation may reduce scene times.


Assuntos
Resgate Aéreo , Intubação Intratraqueal/métodos , Competência Clínica , Protocolos Clínicos , Estudos Cross-Over , Humanos , Intubação Intratraqueal/normas , Manequins , Pessoa de Meia-Idade , Estudos Prospectivos
5.
BMC Emerg Med ; 18(1): 28, 2018 08 29.
Artigo em Inglês | MEDLINE | ID: mdl-30157756

RESUMO

BACKGROUND: Physician-staffed helicopter emergency services (HEMS) can provide benefit through the delivery of specialist competence and equipment to the prehospital scene and through expedient transport of critically ill patients to specialist care. This paper describes the integration of such a system in a rural Swedish county. METHODS: This is a retrospective database study recording the outcomes of every emergency call centre dispatch request as well as the clinical and operational data from all completed missions during this service's first year in operation. RESULTS: During the study period, HEMS completed 478 missions out of which 405 (84,7%) were primary missions to prehospital settings and 73 (15,3%) were inter-hospital critical care transfers. A majority (55,3%) of primary missions occurred in the regions furthest from our hospitals, in municipalities housing only 15,6% of the county's population. The NACA (IQR) score on primary and secondary missions was 4 (2) and 5 (1), respectively. CONCLUSIONS: This study describes the successful integration of a physician-based air ambulance service in a Scandinavian rural region. Municipalities distant from our hospitals benefitted as they now have access to early specialist intervention and expedient transport to critical hospital care. Our hospitals and most populated areas benefitted from HEMS secondary mission capability as they gained a dedicated ICU transport service that could provide specialist intensive care during rapid inter-hospital transfer.


Assuntos
Resgate Aéreo/estatística & dados numéricos , Anestesiologistas/estatística & dados numéricos , Cuidados Críticos/organização & administração , Transferência de Pacientes/estatística & dados numéricos , Humanos , Estudos Retrospectivos , População Rural , Estações do Ano , Suécia , Fatores de Tempo , Tempo (Meteorologia)
6.
Scand J Trauma Resusc Emerg Med ; 25(1): 2, 2017 Jan 05.
Artigo em Inglês | MEDLINE | ID: mdl-28057029

RESUMO

The traditional prehospital management of trauma victims with potential spinal injury has become increasingly questioned as authors and clinicians have raised concerns about over-triage and harm. In order to address these concerns, the Norwegian National Competence Service for Traumatology commissioned a faculty to provide a national guideline for pre-hospital spinal stabilisation. This work is based on a systematic review of available literature and a standardised consensus process. The faculty recommends a selective approach to spinal stabilisation as well as the implementation of triaging tools based on clinical findings. A strategy of minimal handling should be observed.


Assuntos
Serviços Médicos de Emergência/normas , Imobilização/normas , Guias de Prática Clínica como Assunto , Traumatismos da Coluna Vertebral/terapia , Triagem/normas , Consenso , Humanos , Noruega
7.
Wilderness Environ Med ; 27(2): 321-5, 2016 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-27140319

RESUMO

OBJECTIVE: The immediate medical management of buried avalanche victims will to some extent be dictated by the victim's body positioning in the snow. Medical personnel are trained to assess and manage victims in a supine body position. Furthermore, avalanche first responders are trained to handle extricated avalanche victims carefully out of concerns for causing hemodynamic instability or for aggravating spinal injury. Thus, locating and extricating avalanche victims in positions other than supine has the potential to complicate immediate medical management. To our knowledge, the current medical literature does not detail the body positioning of buried victims. METHODS: In order to ascertain the most common body positioning of buried avalanche victims we reviewed the avalanche incident database of the Colorado Avalanche Information Center (CAIC). This comprehensive database strives to track over 160 fields of information for each avalanche victim, including the body and head positioning of buried victims. RESULTS: Head positioning was recorded for 159 buried victims. We found that 65% of buried avalanche victims were found with their heads in a downhill position, 23% with their heads uphill and 11% with their heads in the same level as the rest of their bodies. Body positioning was recorded in 253 victims. 45% of victims were found lying prone, 24% supine, 16% were sitting or standing and 15% were found lying on their sides. We identified 135 victims where both head and body position was registered. 40% of victims were found prone with their heads in a downhill position CONCLUSIONS: The majority of victims will be extricated with their heads in a downhill position. Moreover, almost half of victims will be found prone. We believe this will have significant impact on the immediate medical management. We believe current training in avalanche medical rescue should emphasize managing victims in non-supine positions. Finally, our findings may represent another benefit of modern extrication techniques.


Assuntos
Avalanche , Posicionamento do Paciente , Trabalho de Resgate , Acidentes , Avalanche/estatística & dados numéricos , Colorado , Bases de Dados Factuais , Humanos , Esqui
8.
J R Army Med Corps ; 162(6): 406-412, 2016 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-26092971

RESUMO

Avalanche accidents are frequently lethal events with an overall mortality of 23%. Mortality increases dramatically to 50% in instances of complete burial. With modern day dense networks of ambulance services and rescue helicopters, health workers often become involved during the early stages of avalanche rescue. Historically, some of the most devastating avalanche accidents have involved military personnel. Armed forces are frequently deployed to mountain regions in order to train for mountain warfare or as part of ongoing conflicts. Furthermore, military units are frequently called to assist civilian organised rescue in avalanche rescue operations. It is therefore important that clinicians associated with units operating in mountain regions have an understanding of, the medical management of avalanche victims, and of the preceding rescue phase. The ensuing review of the available literature aims to describe the pathophysiology particular to avalanche victims and to outline a structured approach to the search, rescue and prehospital medical management.


Assuntos
Asfixia/terapia , Avalanche , Parada Cardíaca/terapia , Hipotermia/terapia , Hipóxia/terapia , Militares , Trabalho de Resgate , Cuidados de Suporte Avançado de Vida no Trauma , Aeronaves , Reanimação Cardiopulmonar , Desastres , Serviços Médicos de Emergência , Humanos , Reaquecimento , Triagem , Ferimentos e Lesões
9.
World J Emerg Surg ; 9(1): 54, 2014.
Artigo em Inglês | MEDLINE | ID: mdl-25352911

RESUMO

Since the popularisation of closed chest cardiac compressions in the 1960s, open chest compressions in non-traumatic cardiac arrest have become a largely forgotten art. Today, open chest compressions are only rarely performed outside operating theatres. Early defibrillation and high quality closed chest compressions is the dominating gold standard for the layman on the street as well as for the resuscitation specialist. In this paper we argue that the concept of open chest direct cardiac compressions in non-traumatic cardiac arrest should be revisited and that it might be due for a revival. Numerous studies demonstrate how open chest cardiac compressions are superior to closed chest compressions in regards to physiological parameters and outcomes. Thus, by incorporating resuscitative thoracotomies and open chest compressions in our algorithms for non-traumatic cardiac arrest we may improve outcomes.

10.
Case Rep Crit Care ; 2014: 916360, 2014.
Artigo em Inglês | MEDLINE | ID: mdl-25114807

RESUMO

Introduction. It is important to know which clinical situations prevent ketamine from working. Case Report. We present the case of the psychiatric inpatient who was admitted to our emergency department after ingesting a toxic dose of lamotrigine, unknown at that time. On admission, she was clearly in distress, displaying extreme agitation and violent ataxic movements. We opted to achieve sedation using intravenous ketamine boluses. Unexpectedly, after being injected with a total of 250 mg ketamine, our patient displayed no signs of dissociative anaesthesia. Discussion. There was no apparent reason for why ketamine failed, but an interaction between lamotrigine and ketamine was suspected. A literature search was performed. Very few articles describe interactions between lamotrigine and ketamine. Experimental studies, however, demonstrate how lamotrigine attenuates the neuropsychiatric effects of ketamine. Ketamine is classically described as an NMDA antagonist. Ketamine's dissociative effects, however, are thought to be mediated by increased glutamate release via a pathway not dependent on NMDA receptors. Lamotrigine, on the other hand, is known to reduce cortical glutamate release. Conclusion. Lamotrigine reduces the glutamate release needed to mediate ketamine's dissociative anaesthesia. This is important knowledge for anaesthesiologists in the emergency room where ketamine is often administered to unstable patients.

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