Asma aguda severa: su manejo en la emergencia y cuidado intensivo / Severe acute asthma: its management in Emergency visits and intensive care

Todos los pacientes asmáticos tienen riesgo de sufrir una crisis de asma aguda en el curso de su vida, que puede eventualmente llegar a ser fatal. Las hospitalizaciones y su atención a nivel de los servicios de emergencia/cuidado crítico constituyen un aspecto fundamental en la asistencia del asmático, donde se invierte un porcentaje muy importante de los aportes económicos que la sociedad hace en su conjunto, siendo por lo tanto de particular importancia establecer planes de prevención, educación y racionalización terapéutica a nivel de la asistencia primaria que estabilicen la enfermedad y disminuyan las agudizaciones. La severidad de las exacerbaciones puede variar entre una crisis leve hasta un asma potencialmente-fatal o fatal, estando la mortalidad fundamentalmente vinculada a una inadecuada valoración de la severidad del paciente, lo que trae como consecuencia un tratamiento inadecuado en la emergencia y un retraso en su ingreso hospitalario. En esta revisión exploraremos aspectos como la epidemiología, costes, fisiopatología, mortalidad y el manejo del paciente asmático adulto en la emergencia y en el cuidado intensivo, en particular lo relativo a la ventilación mecánica no invasiva y a las formas convencionales de la asistencia respiratoria mecánica, con las actuales modificaciones en su estrategia operativa

All patients with asthma are at risk of suffering an acute asthma attack over their lifetime, and these may finally be fatal. Hospitalizations and emergency department visits and intensive care account for a large proportion of the health-care cost burden of asthma. Thus, it is especially important to establish plans for prevention, education and therapeutic rationalization of primary care that establishes the disease and decreases its worsening. The severity of the exacerbations may vary from a mild to life threatening. The mortality is basically linked to inadequate assessment of the patient's severity. This leads to inadequate treatment in the emergency and delay in the patient's hospitalization. This review describes the epidemiology, costs, pathophysiology, mortality and management of adult acute asthma patients in the emergency department and intensive care, especially that related to non-invasive mechanical ventilation and conventional forms of mechanical respiratory care, with the current changes in its operational strategy

Medida de la calidad asistencial que se ofrece a los pacientes con intoxicaciones agudas en el Servicio de Urgencias / Measurement of the quality of medical care of patients with acute poisoning in the Emergency Department

Objetivo: Medir la calidad asistencial ofrecida en el Servicio de Urgencias (SU) a los pacientes intoxicados, mediante un mapa de indicadores. Método: Se diseñan 25 indicadores de calidad (6 estructurales, 15 funcionales y 4 administrativos), definiendo unos estándares mínimos. Se evalúa la asistencia que reciben los intoxicados atendidos durante un mes, utilizando los mencionados indicadores, y analizando los informes asistenciales, médico y de enfermería, y los documentos administrativos del paciente. Resultados: Se han valorado 139 intoxicados. Se disponía del protocolo terapéutico, de los antídotos necesarios y de sondas gástricas adecuadas en el 100% de los casos. La analítica toxicológica cualitativa estaba disponible en el 89% y la cuantitativa en el 49%. El tiempo transcurrido entre la llegada al SU y la atención al paciente fue inferior a 15 min en el 78% de casos. El intervalo entre la llegada al SU y el inicio de la descontaminación digestiva fue inferior a 15 min en el 57% de casos. La aplicación adecuada de los diversos algoritmos de valoración clínica, diagnóstico y tratamiento osciló entre un 50 y un 95%. Los registros de presión arterial, frecuencia cardiaca, respiratoria y temperatura constaban entre un 35 y un 81% de los pacientes. El parte judicial se realizó en el 31% de los casos y la interconsulta con el psiquiatra en todos los intentos de suicidio. La mortalidad fue del 0%. Conclusiones: El SU ofrece a los intoxicados una calidad asistencial satisfactoria en aspectos estructurales (protocolos y técnicas analíticas), debe mejorarse a nivel funcional (aplicación de técnicas y tiempos de atención) y muestra deficiencias en los aspectos administrativos (AU)

Objective: To measure the quality of medical care of patients with acute poisoning in the Emergency Department (ED) using a series of indicators. Method: 25 indicators of quality were designed (6 structural, 15 functional and 4 administrative) to define minimum standards. The care received by patients with poisonings was evaluated for one month using the study indicators and relevant hospital, medical and nursing and administrative records. Results: 139 patients were evaluated. A therapeutic protocol, the necessary antidotes and adequate gastric tubes were available in 100% of the cases. Qualitative toxicological tests were available in 89% of cases and quantitative tests in 49%. The time from arrival at the ED to the first medical care was less than 15 minutes in 78% of cases. The time from arrival at the ED to commencement of digestive decontamination was less than 15 minutes in 57% of cases. The adequate use of various algorithms for clinical assessment, diagnosis and treatment ranged between 50 and 95%. Records of blood pressure, cardiac and respiratory frequency and temperature were available in between 35 and 81% of patients. A legal report was made in 31% of cases and psychiatric services were consulted in all cases of attempted suicide. Mortality was 0%. Conclusions: Emergency departments offer satisfactory medical care to patients with acute poisoning with respect to structural aspects (protocols and analytical tests), although improvements could be made at the functional level (application of techniques and rapidity of medical care). Some defects were found in administrative aspects of the process (AU)

Freqüência de fraturas faciais em pacientes atendidos num serviço hospitalar / Frequency of facial fractures in patients seen at a hospital service

Foi realizado um estudo epidemiológico da freqüencia de fraturas faciais entre 296 pacientes atendidos no serviço de cirurgia e traumatologia buco-maxilo-facial do Hospital Municipal "Dr. Arthur R. de Saboya", ocorridas no período de um ano. Houve maior freqüencia para o sexo masculino (78,4 por cento) e para a faixa etária entre 21 e 30 anos (32,8 por cento). Foram detectadas 327 fraturas, totalizando uma média de 1,1 fraturas por paciente. A principal causa foi a queda (33,8 por cento), seguida de agressäo (26,0 por cento). Os diagnósticos foram: ossos próprios do nariz, 35,8 por cento; complexo zigomático, 22,3 por cento, mandíbula, 21,9 por cento; dento-alveolar, 12,2 por cento; Le Fort, 2,0 por cento; fraturas associadas, 5,8 por cento. As localizaçöes mais freqüentes por tipo de fratura foram: mandíbula - regiäo de corpo (35,2 por cento); complexo zigomático - malar (60,0 por cento); Le Fort - tipo II (50,0 por cento)

Advances in pediatric emergency department procedures.

Pediatric procedures in the Emergency Department typically involve techniques for stabilization, evaluation, and treatment of the child. This article considers indications and techniques for vascular access, lumbar puncture, arterial lines, pulse oximetry, and urine collection. Multiple routes of medication administration and pain management modalities also are reviewed.

Clinical utility of a saliva alcohol dipstick estimate of serum ethanol concentrations in the emergency department.

Rapid determination of serum ethanol concentrations can be a useful adjunct in evaluating patients with decreased levels of consciousness. Previous reports suggest that saliva ethanol concentrations measured by a colorimetric saliva dipstick assay correlate well with serum ethanol concentrations and could be useful in the emergency department. We compared saliva dipstick assay results with concurrent serum ethanol measurements in 67 emergency department patients with altered mental status. Color changes of the stick are calibrated to reflect serum ethanol concentrations of negative (no color change), 4.3 mmol/L, 10.8 mmol/L, 21.7 mmol/L, and greater than or equal to 65.1 mmol/L. Emergency department staff were instructed to conduct the measurement according to the manufacturer's directions and round up equivocal results to the next highest concentration. Serum ethanol concentrations (mean +/- SD) grouped by dipstick results were: negative, 5.2 +/- 13.1 mmol/L; 4.3 mmol/L, 29.1 +/- 18.0 mmol/L; 10.8 mmol/L, 46.6 +/- 27.6 mmol/L; 21.7 mmol/L, 47.0 +/- 18.5 mmol/L; and 65.1 mmol/L, 62.4 +/- 24.2 mmol/L. There were 12 false-negative and 2 false-positive results. Correlation between dipstick results and serum ethanol concentrations was rho = 0.611 (p less than 0.0005). The lack of accuracy of the saliva dipstick measurements and the high number of false-negative results make it a poor choice for determining alcohol use in the emergency department patient.

Transport of critically ill adults.

Interhospital transport can be hazardous because of rapid changes in a patient's physiologic status and the use of monitoring systems. A retrospective study evaluated the first 204 critically ill adult patients transported from community hospitals to Stanford Medical Center by a special transport team. To relate the risk of transport to severity of illness, a retrospective scoring system was devised. Sixty-one percent (n = 125) of the patients were at high risk for transport. The patients were stabilized at the referring hospital, and invasive monitoring was used as mandated by the patient's condition. The average transport distance was 133 km, and the average duration of transport was 4.38 h. One hundred and five patients (51.5%) were transported by air, and the remaining patients were transported by surface ambulance. All patients survived the transport, and 71.6% were eventually discharged from the hospital. Hospital mortality correlated with the risk-scoring system (p less than .01) and increased five-fold as severity of illness increased. This study demonstrates that, with appropriate hemodynamic stabilization and monitoring, severely ill patients can be transported safely.