Cricoid Pressure During Intubation of Trauma Patients: Helpful or Harmful?
Release of cricoid pressure improved the laryngoscopic view in 11 of 22 patients.
The purported value of cricoid pressure during intubation is to protect the pulmonary tree from aspiration of vomitus. However, recent evidence suggests that cricoid pressure impairs laryngoscopic view, reduces bag-valve-mask ventilation efficiency, and does not prevent aspiration (Ann Emerg Med 2007; 50:653). In a prospective observational study, researchers compared the effect on laryngoscopic view of three laryngeal maneuvers (release of cricoid pressure, BURP [backwards, upwards, rightward pressure], and laryngeal manipulation under direct vision) in 400 adult trauma patients who were intubated with cricoid pressure in a London air–ground emergency medical services system during a 16-month period. Airways were managed by attending or senior residents in emergency medicine, critical care, or anesthesia. Removal of the laryngoscope, additional preoxygenation, and repeat laryngoscopy was defined as an additional attempt.
Overall, 87.5% of patients were intubated on the first attempt, and 98.8% were intubated within two attempts. Four patients required three attempts, and one patient required rescue cricothyroidotomy. The laryngoscopic view was improved by at least one Cormack-Lehane grade with release of cricoid pressure in 11 of 22 patients (50%), with laryngeal manipulation in 15 of 25 patients (60%), and with the BURP maneuver in 9 of 14 patients (64%). No maneuver made the view worse. Release of cricoid pressure was followed by vomiting in two patients (9%), both of whom had prolonged bag-valve-mask ventilation; neither patient developed aspiration pneumonia.
Comment:
Cricoid pressure during intubation is considered necessary by many emergency medicine societies. These findings place this recommendation under scrutiny, just as the widely promulgated need for in-line cervical stabilization has recently been challenged (JW Emerg Med Aug 14 2009). Until a randomized, prospective trial demonstrates benefit from cricoid pressure, practitioners performing emergency trauma (and nontrauma) intubations should consider cricoid pressure an optional maneuver and be aware that it might lower the chance for successful intubation.
—
John A. Marx, MD, FAAEM
Published in Journal Watch Emergency Medicine July 23, 2010
CITATION(S): Harris T et al. Cricoid pressure and laryngeal manipulation in 402 pre-hospital emergency anaesthetics: Essential safety measure or a hindrance to rapid safe intubation? Resuscitation 2010 Jul; 81:810.
2010年7月23日 星期五
2010年7月20日 星期二
收縮壓維持在130左右最好
Blood Pressure Control in Patients with Diabetes and Coronary Artery Disease
No benefit for lowering BP to below 130/80 mm Hg
Several organizations recommend a blood pressure (BP) goal of below 130/80 mm Hg for patients with diabetes. To determine whether this goal is appropriate for patients with diabetes and known coronary artery disease (CAD), researchers conducted a secondary analysis of data from the INVEST study, a randomized trial in which hypertensive patients with CAD received β-blocker–based or calcium-channel blocker–based regimens (JW Gen Med Dec 23 2003). Researchers reported previously that overly aggressive BP lowering in these patients was associated with excess risk for adverse cardiovascular events (JW Gen Med Aug 10 2006); now, they focus on subset of 6400 INVEST patients with diabetes.
Patients were divided into three groups according to their average systolic BP during the trial: tight control (below 130 mm Hg), usual control (130–139 mm Hg), or uncontrolled (above 139 mm Hg). During median follow-up of 3 years, the primary outcome (all-cause mortality or nonfatal myocardial infarction or stroke) occurred in 12.7% of the tight-control group, in 12.6% of the usual-control group, and in 19.8% of the uncontrolled group. In adjusted analyses that included secondary outcomes, researchers found no difference between tight and usual control. After an additional 5-year follow-up, all-cause mortality was higher in the tight-control group than in the usual-control group (22.8% vs. 21.8%; P=0.04).
Comment: Because this was a post hoc analysis of observational data from patients who weren't randomized to different BP targets, confounding factors could have influenced the findings. However, in the recently published ACCORD BP trial, high-risk patients with diabetes were randomized to one of two systolic BP targets (120 mm Hg or 140 mm Hg), and researchers found no difference in adverse cardiovascular events between the groups (JW Cardiol Mar 14 2010). Taken together, INVEST and ACCORD suggest that a systolic BP goal in the 130s is reasonable for hypertensive diabetic patients with CAD or multiple cardiovascular risk factors.
—
Thomas L. Schwenk, MD
Published in Journal Watch General Medicine July 20, 2010
Citation(s): Cooper-DeHoff RM et al. Tight blood pressure control and cardiovascular outcomes among hypertensive patients with diabetes and coronary artery disease. JAMA 2010 Jul 7; 304:61. (http://dx.doi.org/10.1001/jama.2010.884)
No benefit for lowering BP to below 130/80 mm Hg
Several organizations recommend a blood pressure (BP) goal of below 130/80 mm Hg for patients with diabetes. To determine whether this goal is appropriate for patients with diabetes and known coronary artery disease (CAD), researchers conducted a secondary analysis of data from the INVEST study, a randomized trial in which hypertensive patients with CAD received β-blocker–based or calcium-channel blocker–based regimens (JW Gen Med Dec 23 2003). Researchers reported previously that overly aggressive BP lowering in these patients was associated with excess risk for adverse cardiovascular events (JW Gen Med Aug 10 2006); now, they focus on subset of 6400 INVEST patients with diabetes.
Patients were divided into three groups according to their average systolic BP during the trial: tight control (below 130 mm Hg), usual control (130–139 mm Hg), or uncontrolled (above 139 mm Hg). During median follow-up of 3 years, the primary outcome (all-cause mortality or nonfatal myocardial infarction or stroke) occurred in 12.7% of the tight-control group, in 12.6% of the usual-control group, and in 19.8% of the uncontrolled group. In adjusted analyses that included secondary outcomes, researchers found no difference between tight and usual control. After an additional 5-year follow-up, all-cause mortality was higher in the tight-control group than in the usual-control group (22.8% vs. 21.8%; P=0.04).
Comment: Because this was a post hoc analysis of observational data from patients who weren't randomized to different BP targets, confounding factors could have influenced the findings. However, in the recently published ACCORD BP trial, high-risk patients with diabetes were randomized to one of two systolic BP targets (120 mm Hg or 140 mm Hg), and researchers found no difference in adverse cardiovascular events between the groups (JW Cardiol Mar 14 2010). Taken together, INVEST and ACCORD suggest that a systolic BP goal in the 130s is reasonable for hypertensive diabetic patients with CAD or multiple cardiovascular risk factors.
—
Thomas L. Schwenk, MD
Published in Journal Watch General Medicine July 20, 2010
Citation(s): Cooper-DeHoff RM et al. Tight blood pressure control and cardiovascular outcomes among hypertensive patients with diabetes and coronary artery disease. JAMA 2010 Jul 7; 304:61. (http://dx.doi.org/10.1001/jama.2010.884)
Pelvic packing for pelvic fractures
Direct retroperitoneal pelvic packing versus pelvic angiography: A comparison of two management protocols for haemodynamically unstable pelvic fractures.
OBJECTIVE: To evaluate the outcomes of haemodynamically unstable cases of pelvic ring injury treated with a protocol focused on either direct retroperitoneal pelvic packing or early pelvic angiography and embolisation.
METHODS: A retrospective review of a prospectively collected database in an academic level I trauma centre, treating matched haemodynamically unstable cases of pelvic fracture with either pelvic packing (PACK group, n=20) or early pelvic angiography (ANGIO group, n=20). Physiological markers of haemorrhage, time to intervention, transfusion requirements, complications and early mortality were recorded.
RESULTS: The PACK group underwent operative packing at a median of 45min from admission; the median time to angiography in the ANGIO group was 130min. The PACK group, but not the ANGIO group, demonstrated a significant decrease in blood transfusions over the next 24h post intervention. In the ANGIO group, ten people required embolisation and six died, two from acute haemorrhage; in the PACK group, three people required embolisation; four died, none due to uncontrolled haemorrhage.
CONCLUSIONS: Pelvic packing is as effective as pelvic angiography for stabilising haemodynamically unstable casualties with pelvic fractures, decreases need for pelvic embolisation and post-procedure blood transfusions, and may reduce early mortality due to exsanguination from pelvic haemorrhage.
OBJECTIVE: To evaluate the outcomes of haemodynamically unstable cases of pelvic ring injury treated with a protocol focused on either direct retroperitoneal pelvic packing or early pelvic angiography and embolisation.
METHODS: A retrospective review of a prospectively collected database in an academic level I trauma centre, treating matched haemodynamically unstable cases of pelvic fracture with either pelvic packing (PACK group, n=20) or early pelvic angiography (ANGIO group, n=20). Physiological markers of haemorrhage, time to intervention, transfusion requirements, complications and early mortality were recorded.
RESULTS: The PACK group underwent operative packing at a median of 45min from admission; the median time to angiography in the ANGIO group was 130min. The PACK group, but not the ANGIO group, demonstrated a significant decrease in blood transfusions over the next 24h post intervention. In the ANGIO group, ten people required embolisation and six died, two from acute haemorrhage; in the PACK group, three people required embolisation; four died, none due to uncontrolled haemorrhage.
CONCLUSIONS: Pelvic packing is as effective as pelvic angiography for stabilising haemodynamically unstable casualties with pelvic fractures, decreases need for pelvic embolisation and post-procedure blood transfusions, and may reduce early mortality due to exsanguination from pelvic haemorrhage.
---
Injury. 2009 Jan;40(1):54-60. Epub 2008 Nov 30.
2010年7月16日 星期五
單次掉血壓也可能是嚴重創傷的指標之一
Beware of Even a Single Hypotensive Blood Pressure Measurement in Trauma Patients
A single systolic BP reading less than 105 mm Hg in the emergency department portends serious injury and the potential need for immediate surgical or endovascular intervention.
Hypotension in trauma patients typically occurs after loss of 30% of total blood and, if persistent, can lead to end-organ injury resulting from hypoperfusion and uncompensated shock. In a prospective observational study at a single level I trauma center, researchers determined the systolic blood pressure (SBP) cutpoint value that best predicts the need for therapeutic surgical or endovascular procedures; 145 adult patients (77% men; 54% with blunt mechanism of injury) who had at least one SBP measurement below 110 mm Hg during initial trauma care were enrolled during a 6-month period. Exclusion criteria were transfer from another hospital, injury more than 2 hours before emergency department (ED) arrival, and isolated prehospital hypotension (below 90 mm Hg) or more than two SBP readings below 90 mm Hg in the ED.
SBP was measured manually within 10 minutes of ED arrival and then automatically at least every 5 minutes for the first 15 minutes, followed by every 15 minutes for the first hour, and then hourly thereafter. Cutpoint analysis showed that a single SBP measurement below 105 mm Hg best predicted need for immediate intervention. Patients with a single SBP measurement below 105 mm Hg, compared to those with no measurement below 105 mm Hg, were significantly more likely to undergo therapeutic intervention (38% vs. 10%), to be admitted to a surgical intensive care unit (54% vs. 25%), and to have a prolonged hospital stay (mean, 8.3 vs. 4.2 days). Other independent predictors of need for therapeutic intervention were gunshot wound mechanism of injury, higher injury severity score, and longer duration of initial resuscitation.
Comment:
A single systolic BP reading less than 105 mm Hg in the emergency department portends serious injury and the potential need for immediate surgical or endovascular intervention.
Hypotension in trauma patients typically occurs after loss of 30% of total blood and, if persistent, can lead to end-organ injury resulting from hypoperfusion and uncompensated shock. In a prospective observational study at a single level I trauma center, researchers determined the systolic blood pressure (SBP) cutpoint value that best predicts the need for therapeutic surgical or endovascular procedures; 145 adult patients (77% men; 54% with blunt mechanism of injury) who had at least one SBP measurement below 110 mm Hg during initial trauma care were enrolled during a 6-month period. Exclusion criteria were transfer from another hospital, injury more than 2 hours before emergency department (ED) arrival, and isolated prehospital hypotension (below 90 mm Hg) or more than two SBP readings below 90 mm Hg in the ED.
SBP was measured manually within 10 minutes of ED arrival and then automatically at least every 5 minutes for the first 15 minutes, followed by every 15 minutes for the first hour, and then hourly thereafter. Cutpoint analysis showed that a single SBP measurement below 105 mm Hg best predicted need for immediate intervention. Patients with a single SBP measurement below 105 mm Hg, compared to those with no measurement below 105 mm Hg, were significantly more likely to undergo therapeutic intervention (38% vs. 10%), to be admitted to a surgical intensive care unit (54% vs. 25%), and to have a prolonged hospital stay (mean, 8.3 vs. 4.2 days). Other independent predictors of need for therapeutic intervention were gunshot wound mechanism of injury, higher injury severity score, and longer duration of initial resuscitation.
Comment:
This small study suggests that even a single SBP measurement below 105 mm Hg in patients with trauma should not be dismissed as erroneous. A single low reading could reflect impending shock and indicate need for aggressive management as well as therapeutic surgical or endovascular procedures.
—
—
John A. Marx, MD, FAAEM
Published in Journal Watch Emergency Medicine July 16, 2010
Citation(s): Seamon MJ et al. Just one drop: The significance of a single hypotensive blood pressure reading during trauma resuscitations. J Trauma 2010 Jun; 68:1289.
Published in Journal Watch Emergency Medicine July 16, 2010
Citation(s): Seamon MJ et al. Just one drop: The significance of a single hypotensive blood pressure reading during trauma resuscitations. J Trauma 2010 Jun; 68:1289.
2010年7月2日 星期五
Af or AF可在急診做cardioversion
Rapid Treatment and Discharge of Patients with Recent-Onset Atrial Fibrillation or Flutter
Rapid cardioversion and discharge home is safe for emergency department patients who present within 48 hours of onset of atrial fibrillation or flutter.
Researchers evaluated the efficacy and safety of a protocol for rapid emergency department (ED) cardioversion and discharge of patients with recent-onset (<48 hours) atrial fibrillation or atrial flutter in a retrospective observational study of 660 consecutive patients (95% with atrial fibrillation, 5% with atrial flutter) at a single ED in Canada from 2000 to 2005. The protocol involved ED pharmacologic cardioversion with intravenous (IV) procainamide (1 g during 60 minutes) and, if needed, electrical cardioversion, followed by discharge home within 1 hour after cardioversion.
Sixty percent of patients with atrial fibrillation and 28% of those with atrial flutter converted to sinus rhythm with IV procainamide. Electrical cardioversion (not attempted in 32 patients) was successful in 92% and 100% of the remaining 243 patients with fibrillation and 20 with flutter, respectively. Overall, 97% of patients were discharged home, and 93% of discharged patients were in sinus rhythm. Median ED stay was 4.9 hours. Adverse events (including transient hypotension and bradycardia) occurred in 7.6% of patients, and 8.6% of patients relapsed within 7 days; no cases of torsades de pointes or stroke were reported and no deaths occurred.
Comment:
Primary ED cardioversion (by IV or oral antidysrhythmic agent [JW Gen Med Jan 11 2005 ] or synchronized electrical cardioversion) is a reasonable option for patients with uncomplicated atrial fibrillation or atrial flutter.
—
Kristi L. Koenig, MD, FACEP
Published in Journal Watch Emergency Medicine July 2, 2010
Citation(s): Stiell IG et al. Association of the Ottawa Aggressive Protocol with rapid discharge of emergency department patients with recent-onset atrial fibrillation or flutter. CJEM 2010 May; 12:181.
Rapid cardioversion and discharge home is safe for emergency department patients who present within 48 hours of onset of atrial fibrillation or flutter.
Researchers evaluated the efficacy and safety of a protocol for rapid emergency department (ED) cardioversion and discharge of patients with recent-onset (<48 hours) atrial fibrillation or atrial flutter in a retrospective observational study of 660 consecutive patients (95% with atrial fibrillation, 5% with atrial flutter) at a single ED in Canada from 2000 to 2005. The protocol involved ED pharmacologic cardioversion with intravenous (IV) procainamide (1 g during 60 minutes) and, if needed, electrical cardioversion, followed by discharge home within 1 hour after cardioversion.
Sixty percent of patients with atrial fibrillation and 28% of those with atrial flutter converted to sinus rhythm with IV procainamide. Electrical cardioversion (not attempted in 32 patients) was successful in 92% and 100% of the remaining 243 patients with fibrillation and 20 with flutter, respectively. Overall, 97% of patients were discharged home, and 93% of discharged patients were in sinus rhythm. Median ED stay was 4.9 hours. Adverse events (including transient hypotension and bradycardia) occurred in 7.6% of patients, and 8.6% of patients relapsed within 7 days; no cases of torsades de pointes or stroke were reported and no deaths occurred.
Comment:
Primary ED cardioversion (by IV or oral antidysrhythmic agent [JW Gen Med Jan 11 2005 ] or synchronized electrical cardioversion) is a reasonable option for patients with uncomplicated atrial fibrillation or atrial flutter.
—
Kristi L. Koenig, MD, FACEP
Published in Journal Watch Emergency Medicine July 2, 2010
Citation(s): Stiell IG et al. Association of the Ottawa Aggressive Protocol with rapid discharge of emergency department patients with recent-onset atrial fibrillation or flutter. CJEM 2010 May; 12:181.
訂閱：
文章 (Atom)
