F.J. Fonseca del Pozo’s research while affiliated with Distrito Sanitario Granada-Metropolitano and other places

La ventilación mecánica no invasiva (VMNI) es un instrumento terapéutico que puesto en manos del urgenciólogo como apoyo inicial al paciente con insuficiencia respiratoria aguda (IRA) puede marcar de forma definitiva la evolución de ese cuadro clínico. Múltiples ventajas que avalan la VMNI frente a las formas invasivas de ventilación: preserva mecanismos como la tos, permiten al paciente hablar o alimentarse, sin invadir la vía aérea y evita las complicaciones que ello comporta. En los últimos años han aparecido multitud de estudios que apoyan su aplicación precoz en pacientes adecuadamente seleccionados. Tras los documentos de consenso de 2001 de la American Thoracic Society, y en 2002 de la British Thoracic Society en que consideraban la VMNI como un elemento más en el manejo inicial de la IRA, tanto hipoxémica como hipercápnica, en sus diferentes modos ventilatorios, cada vez se encuentra más extendido su uso en los servicios de urgencias hospitalarios, en los equipos de emergencias, así como su aplicación domiciliaria en pacientes crónicos. En un futuro inmediato el reto es la formación de los profesionales que integran los equipos asistenciales de urgencias y emergencias, adiestrándolos en manejo de la IRA y sus bases fisiopatológicas, sin dejar a un lado el desarrollo y consolidación de la cadena asistencial en ventilación no invasiva, mediante el establecimiento de documentos de consenso interservicios.

Optimum management of the airway and ventilation in critical patients continues to be a basic cornerstone in survival, evolution and prognosis. orotracheal intubation (OTI) is the “gold standard”in these situations. Knowing the position, maneuvers and material that “facilitate”the OTI and how to perform previous adequate oxygen-ventilation and sedoanalgesia will significantly increase the possibilities of success. There are times when, although being orthodox in the technique performance, we do not achieve the desired purpose (no intubation, no ventilation), defining such a situation as difficult airway (DAW). Primary Health Care physicians and nurses should be prepared for this and have the necessary material and training to face this critical moment in the management of severe patients. Taking the clinical guidelines of the principal scientific societies into account in the management of the airway (Spanish Group for the Management of the Airway [GEMVA], American Society of Anesthesiology [ASA], and the American College of Surgeons), we present a review of the alternatives recommended, focusing on a brief description of the material and a more extensive presentation of the technique.

The routine use of non-invasive ventilation (NIV) should begin as soon as possible in the hospital or prehospital Urgency and Emergency setting, both by emergency teams or in primary health care emergency sites. After a suitable selection of the patient, the best form should be applied for the disease in case, either continuous positive airway pressure (CPAP) or BiPAP model (two levels of pressure). The most practical and easy method to be used in primary health care emergency service is CPAP, through which we try to improve the situation of respiratory failure (basically in acute lung edema) without invading the airway. If we apply CPAP in the prehospital setting, we gain time as we use it in the first level of care, as early as possible, and this is beneficial to the patient.

The little governmental support provided for the training of health care professionals working at Urgency and Emergency Services has decided us to write this article, in which we make an historical review, we attempt to identify the problem and we try to find a solution. Improvement of the quality of human resources involves helping people to be aware of their need for continuous improvement and here is where new habits must be acquired through knowledge, capabilities and skills. Self-education and self-demand among Urgency and Emergency professionals have been a constant over the past decade and currently we can say that the quality of health care provided by these professionals is excellent. However, we must not forget that training in the skills that are needed to take care of Urgencies and Emergencies must be continuous and that the ultimate responsibility devolves on the managers of the relevant company or the high officials of the relevant administration, these being also responsible for the qualification of the professionals that initiate their training in Urgencies and for the harmonization of the content of such training until the creation of the awaited Specialty of Urgency and Emergency Medicine.

The objective of this article is to serve as a guide for the professionals of the sanitary transport. We expose all the signs that the Technical in Sanitary Emergencies (TES) or the Auxiliary of Sanitary Transport (AUTS) must know. They must also be able to search those situations in which the application of oxygen therapy is necessary and to identify the patients that are going to be benefited with it. The most frequent situations in which is recommendable to use oxygen therapy are indicated in the article. In the same way, there are indicated the most frequent situations in which the oxygen therapy must be applied as first therapy in patients.

We present the case of a 70-year-old patient with histories of arterial hypertension (HTN), electrocardiographic left ventricular hypertrophy (LVH), trigeminal neuralgia, and with controlled blood pressure. In the last year, she has undergone several changes in her hypertensive treatment in response to gradual BP elevations. She attends the consult for reasons of physical weakness, stress intolerance, malaise, paresthesias and muscular cramps of several months evolution which had been becoming worse. After a detailed study, it becomes evident that we are dealing with beta-blocker side effects, together with a secondary hyponatremia resulting from the use of diuretics and carbamazepine. We also note that the assumption of “good blood pressure control” was incorrect. A simple home self-measurement with a validated automatic device revealed continued morning rises in BP. After appropriate treatment modifications and a later follow-up, symptoms are observed to disappear and ionic alterations are normalized.