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8 results

  • 18 - Acute Decompensated Heart Failure

  • from Section 4 - Cardiovascular Emergencies
  • Edited by Kaushal Shah, Weill Cornell Medical Center, New York, Jarone Lee, Massachusetts General Hospital, Boston
  • Edited in association with Clark G. Owyang, Weill Cornell Medical Center, New York, Benjamin Christian Renne, Massachusetts General Hospital, Boston
  • Book:
    Practical Emergency Resuscitation and Critical Care
    Published online:
    02 November 2023
    Print publication:
    23 November 2023, pp 159-168

  • Summary

    • Heart failure (HF) is a clinical syndrome marked by elevated filling pressures to maintain acceptable cardiac output. Current guidelines use left ventricular ejection fraction (LVEF) to distinguish between reduced (HFrEF; LVEF < 40%), preserved (HFpEF; LVEF > 50%) and midrange ejection fractions (HFmrEF; LVEF between 40–49%).

    • Beta blockers, angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor neprilysin inhibitors (ARNI), sodium-glucose transporter-2 (SGLT2) inhibitors and cardiac resynchronization therapy, among other therapies, improve outcomes in HFrEF. HFpEF management focuses on comorbidity management with recent data showing benefit from SGLT-2 inhibitor, empagliflozin.

  • Chapter 13 - Artificial Ventilation

  • Edited by Daniel Rodger, Kevin Henshaw, Paul Rawling, Scott Miller
  • Book:
    Fundamentals of Operating Department Practice
    Published online:
    18 August 2022
    Print publication:
    08 September 2022, pp 134-142

  • Summary

    This chapter provides an overview of artificial ventilation, an intervention that has developed from a basic resuscitation technique to highly sophisticated intensive care ventilators used today. Artificial ventilation is provided to unconscious patients, whether unconsciousness was caused by a medical problem (e.g., head injury) or by anaesthesia. Ventilation is usually provided through an endotracheal tube, via a breathing system which is attached to a ventilator. A heat and moisture exchange filter is used to warm and humidify the gases that reach the patient. The healthcare professional caring for the patient will adjust various parameters to ensure the ventilation strategy is appropriate for each patient and their specific needs. Positive-pressure ventilation is used to push gases into the airways of the patient and allow gas exchange to occur. Ventilators may have several different modes for delivering breaths to patients but usually are based around limiting tidal volume or peak inspiratory pressure. Artificial ventilation can affect many different physiological systems particularly the heart and blood vessels, the brain, and the kidneys.

  • On-Scene Rescue Breathing Resulting in Gastric Perforation and Massive Pneumoperitoneum

  • Mike Butterfield, Tamas Peredy
  • Journal:
    Prehospital and Disaster Medicine / Volume 32 / Issue 6 / December 2017
    Published online by Cambridge University Press:
    03 July 2017, pp. 682-683
    Print publication:
    December 2017

  • Rescue breathing performed too vigorously or by untrained individuals may cause gastric distension and perforation. A 26-year-old woman is presented who developed acute abdominal pain and distension after receiving rescue breathing following a heroin overdose. Massive pneumoperitoneum was seen on chest x-ray, and on subsequent laparotomy, a 4cm laceration was found in the lesser curvature of the stomach. Review of the literature suggests that the lesser curvature is particularly susceptible to perforation following over-distension. Emergency personnel should be aware of this rare, but serious, complication. Expansion of community and first responder naloxone use in the proper clinical setting may further diminish utilization of rescue breathing.

    ButterfieldM, PeredyT. On-Scene Rescue Breathing Resulting in Gastric Perforation and Massive Pneumoperitoneum. Prehosp Disaster Med. 2017;32(6):682–683.

  • Chest compressions do not disrupt the seal created by the laryngeal mask airway during positive pressure ventilation: a preliminary porcine study

  • Jestin N. Carlson, Brian P. Suffoletto, David D. Salcido, Eric S. Logue, James J. Menegazzi
  • Journal:
    Canadian Journal of Emergency Medicine / Volume 16 / Issue 5 / September 2014
    Published online by Cambridge University Press:
    04 March 2015, pp. 378-382
    Print publication:
    September 2014
    • Article
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  • Objective:

    Pulmonary aspiration of gastric contents occurs 20 to 30% of the time during cardiopulmonary resuscitation (CPR) of cardiac arrest due to loss of protective airway reflexes, pressure changes generated during CPR, and positive pressure ventilation (PPV). Although the American Heart Association has recommended the laryngeal mask airway (LMA) as an acceptable alternative airway for use by emergency medical service personnel, concerns over the capacity of the device to protect from pulmonary aspiration remain.We sought to determine the occurrence of aspiration after LMA placement, CPR, and PPV.

    Methods:

    We inserted a size 4 LMA, modified so that a vacuum catheter could be advanced past the LMA diaphragm, into the hypopharynx of 16 consecutive postexperimental mixed-breed domestic swine. Fifteen millilitres of heparinized blood was instilled into the oropharynx. Chest compressions were performed for 60 seconds with asynchronous ventilation via a mechanical ventilator. We then suctioned through the LMA for 1 minute. The catheter was removed and inspected for signs of blood. The LMA cuff was deflated, removed, and inspected for signs of blood.

    Results:

    None of 16 animals (95% CI 0-17%) had a positive test for the presence of blood in both the vacuum catheter and the intima of the LMA diaphragm.

    Conclusions:

    In this swine model of regurgitation after LMA placement, there were no cases with evidence of blood beyond the seal created by the LMA cuff. Future studies are needed to determine the frequency of pulmonary aspiration after LMA placement during CPR and PPV in the clinical setting.

  • Trends in use in a Canadian pediatric emergency department

  • Quynh Doan, Emerson D. Genuis, Alvis Yu
  • Journal:
    Canadian Journal of Emergency Medicine / Volume 16 / Issue 5 / September 2014
    Published online by Cambridge University Press:
    04 March 2015, pp. 405-410
    Print publication:
    September 2014
    • Article
      • You have access
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  • Introduction:

    Emergency department (ED) crowding is a significant problem in Canada and has been associated with decreased quality of care in general and pediatric emergency departments (PEDs). Although boarding of admitted patients in the ED is the main contributor to adult ED overcrowding, factors involved in PED crowding may be different. The objective of this study was to report the trend in PED services use and to document the degree of overcrowding experienced in a Canadian PED.

    Methods:

    A retrospective cohort study was conducted using administrative data from a tertiary care PED from 2002 to 2011. The primary outcome was PED use (total volume of visits and case severity per triage levels using the Canadian Triage and Acuity Scale [CTAS] score and admissions). Secondary outcomes included measures of PED overcrowding, such as rates of patients leaving without being seen (LWBS) and length of stay (LOS).

    Results:

    Total volumes increased by 30% over the 10-year study period, whereas hospitalizations remained stable at approximately 10%. Trends in CTAS levels did not indicate meaningful changes in the severity of cases treated at our PED. LWBS proportions among CTAS 3, CTAS 4, and CTAS 5 groups and LOS for all CTAS groups progressively and statistically increased from year to year.

    Conclusions:

    Over the course of the study period, there was a substantial increase in PED visits,which likely contributed to the worsening markers of PED flow outcomes. Further study into the effects of PED crowding on patient outcomes is warranted.

  • Chapter 17 - Anesthesia for pleural and chest wall surgery

  • from Section 2 - Anesthesia for operative procedures
  • Edited by Cait P. Searl, Sameena T. Ahmed
  • Book:
    Core Topics in Thoracic Anesthesia
    Published online:
    10 December 2009
    Print publication:
    02 April 2009, pp 114-117

  • Summary

    Rigid bronchoscopy (RB) was a necessary art of assessment of fitness for lung resection surgery and placing lung separator devices (LSD). For RB, general anesthesia is the norm. For short procedures a propofol and opioid supplemented induction is a usual regimen, followed by a short-acting non-depolarizing agent such as mivacurium. Manufacturers of positive pressure ventilation equipment pay little attention to the needs of patient ventilation during operation of their devices. Intrinsic and extrinsic lesions of the trachea can present as life-threatening emergencies. The erosion of a major vessel in the bronchial tree occasionally results in unstoppable hemoptysis. With much of the cardiac output coming up an RB, it is impossible to do anything to intervene. The advent of self-expanding devices has considerably eased the burden of sharing access to the airway with surgeons or physicians.

  • 19 - Long-term ventilatory support

  • Edited by Iain Mackenzie
  • Book:
    Core Topics in Mechanical Ventilation
    Published online:
    14 October 2009
    Print publication:
    30 October 2008, pp 372-387

  • Summary

    The polio outbreaks that affected the developed world in the early and mid-twentieth century are of particular historical importance. They acted as an impetus to the development of intensive care as a place where 'life support' could be provided while awaiting recovery from critical illness. Second, as survival in those who developed respiratory failure occurred, particularly following the introduction of positive pressure ventilation, significant numbers then required long-term respiratory support. The evidence for the effectiveness of non-invasive positive pressure ventilation (NIV) has been better investigated in the progressive neuromuscular (NM) diseases and in complicating chronic obstructive pulmonary disease (COPD). It was quickly appreciated that the home mechanical ventilation (HMV) patient using physical or negative pressure devices could benefit from the new technology. There are numerous advantages of NIV compared with invasive ventilation. The initial reason for introducing NIV is symptom control.

  • Age-related changes in the epiglottis causing failure of nasal continuous positive airway pressure therapy

  • Thomas Verse, Wolfgang Pirsig
  • Journal:
    The Journal of Laryngology & Otology / Volume 113 / Issue 11 / November 1999
    Published online by Cambridge University Press:
    29 June 2007, pp. 1022-1025
    Print publication:
    November 1999

  • At 65 years of age, a former coal miner, now 72-years-old, developed a progressive loss of concentration with daytime sleepiness and sleep disturbances. Work-up in pneumological and medical sleep centres resulted in diagnosis of chronic obstructive pulmonary disease (COPD), borderline obstructive sleep apnoea syndrome and, later, upper airway resistance syndrome. In addition, there was evidence of reduced efficiency of sleep. Neither the initial administration of theophylline nor the later use at night of hyperbaric respiration led to improvement in the patient's symptoms. Instead, the patient developed loud snoring, as well as the inability to sleep while in a lying position.

    At age 71 years, otorhinolaryngological examination resulted in findings of age-related changes in the epiglottis, that completely blocked the hypopharynx upon inspiration. Polysomnography, which was possible only in a half-seated position, revealed reduction in deep sleep, with a maximum oxygen saturation of 77 per cent at an apnoea-hypopnoea index (AHI) of 4.8.

    Partial resection of the epiglottis with laser surgery resulted in complete improvement of diurnal drowsiness and reduced stamina. Sleeping in a supine position again became possible. Polysomnography revealed normalization of sleep architecture, but unchanged, low efficiency of sleep.

    This case underscores the importance of an interdisciplinary approach to the treatment of sleep-related breathing disorders.