Emergency Treatment - Science topic

Treatment and management of cholera are best accomplished by the administration of copious amounts of intravenous or oral fluids to replace fluids lost from the severe diarrhea. The administration of antimicrobial agent can be shorten the duration of diarrhea and thereby reduce fluid losses. However, resistance to tetracycline and doxycycline has been reported. Therefore administration of additional antimicrobials such as azithromycin and ciprofloxacin may be necessary.

SOURCE: Mahon book

As all of you can see, we've wasted 6 years by our inaction. It's too late now to prepare for COVID-19, but when this is over, if history repeats it's self, there will be a big push to "fight the last war" like we did after 9/11 with lots of money to prevent the next pandemic. This will provide an opportunity to expand the "emergency scope of practice" for dentists. As I'm in the twilight of my career, it is up to the next generation to fight the good fight.

Positivity (positive attitude) leads to the hope of improving the disease and in my opinion it really accelerate the speed of recovery from a disease.

For curing cancer pranayam (breathing practices) and meditation are really beneficial.

A good clinical study to explore, possibly by comparing pre and post implementation data, but also keeping in mind some other factors that may impact the outcome.

Very recently in Resuscitation: http://www.sciencedirect.com/science/article/pii/S030095721730254X

Hi to all,

As i experience it here ( Wallonia, Belgium ;) ).

We only give or receive feedback when it's really bad.

Otherwise we do not really exchange.  

Dear Natalia,

I asked for in-hospital cardiac arrests data to major Hub Hospitals in Lombardy. I hope to tell You something as soon as possible!

Greetings G.F. Villa

in Kayseri, Turkey

I thank you for your input into my query. Our research project will be starting this spring, so hope to have solid evidence on film wrap's efficacy.

Regarding the elderly patients there are some kind of problems in my opinion:

Among European nation there are some different ethical problem regarding end-of-life decision, religious and economic issue. Therefore there is an organizational problem, it is different when patient is admitted to ICU in an University Hospital or in a Community one. Then there are clinical issues elderly patients admitted to ICU after elective surgery have a better early and long term outcome than elderly admitted for unplanned surgery or medical problems. So, maybe, would be necessary a sort of score which can help physicians to chose for admitting elderly patients in ICU.

Dear Aya,

Please see the followings:

1-Health Aff (Millwood). 2006 Mar-Apr;25(2):501-9.

Paramedic intubation errors: isolated events or symptoms of larger problems?

Wang HE1, Lave JR, Sirio CA, Yealy DM.

Author information

 

Abstract

Paramedics provide life-saving emergency medical care to patients in the out-of-hospital setting, but only selected emergency interventions have proved to be safe or effective. Endotracheal intubation (the insertion of an emergency breathing tube into the trachea) is an important and high-profile procedure performed by paramedics. In our study population, we found that errors occurred in 22 percent of intubation attempts, with a frequency of up to 40 percent in selected ambulance systems. These findings indicate frequent errors associated with this life-saving technique. These events might be emblematic of larger issues in the structure and delivery of out-of-hospital emergency care.

2- Resuscitation. 2009 Jan;80(1):50-5. doi: 10.1016/j.resuscitation.2008.08.016. Epub 2008 Oct 25.

Outcomes after out-of-hospital endotracheal intubation errors.

Wang HE1, Cook LJ, Chang CC, Yealy DM, Lave JR.

Author information

 

Abstract

INTRODUCTION:

We sought to evaluate the association between three key out-of-hospital endotracheal intubation (ETI) errors and patient outcomes.

METHODS:

We prospectively collected multicenter data on out-of-hospital ETI attempted by Emergency Medical Service (EMS) rescuers. We probabilistically linked these data to statewide EMS, death and hospital discharge data sets. The key ETI error events were (1) endotracheal tube misplacement or dislodgement, (2) multiple ETI attempts (> or =4 laryngoscopies) and (3) failed ETI. The primary outcomes were death (survival to hospital discharge) and secondary complications identified through ICD-9 discharge diagnoses. Using Cox regression with heavyside functions, we identified the associations between out-of-hospital ETI errors and early (in the field or emergency department) and later (on or after hospital admission) death. We censored non-linked cases, adjusted for important clinical covariates, and used a shared frailty regression model to account for clustering by EMS agency. We evaluated the associations between out-of-hospital ETI errors and secondary complications using univariable odds ratios with exact 95% confidence intervals.

RESULTS:

Of 1954 out-of-hospital ETI, 444 (22.7%) patients experienced one or more ETI errors, including tube misplacement or dislodgement in 61 (3%), multiple ETI attempts in 62 (3%) and failed ETI in 359 (15%). Of the 1196 (61%) cases linked to outcomes, 872 (73%) died and 323 (27%) survived to hospital discharge. ETI errors were not associated with early death (tube misplacement or dislodgement: Hazard Ratio 0.98, 95% CI 0.65-1.47; multiple ETI attempts: 1.22, 0.80-1.85; failed ETI: 1.10, 0.88-1.39) or later death (tube misplacement or dislodgement: 0.40, 0.10-1.62; multiple ETI attempts: 1.77, 0.23-13.30; failed ETI: 0.76, 0.47-1.25). Pneumonitis was associated with failed ETI (n=20, 19%; univariable OR 2.54; 95% CI 1.24-5.25).

CONCLUSION:

Out-of-hospital ETI errors are not associated with mortality. Failed out-of-hospital ETI increases the odds of pneumonitis.

3- Avoiding Common Laryngoscopy Errors

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NO COMMENTSIntubation has unique educational challenges because of severe time restrictions and patient risk. Repetitive practice cannot be done on the same patient to separate and examine the components of the procedure in real time. As a result, most clinicians improve their skills slowly, through cumulated experience of trial and error. Intubation should involve a planned strategy to achieve first pass success, prevent hypoxemia and avoid aspiration. This article highlights two of the most common errors of direct laryngoscopy, and how to avoid them.

 Intubation has unique educational challenges because of severe time restrictions and patient risk. Repetitive practice cannot be done on the same patient to separate and examine the components of the procedure in real time. As a result, most clinicians improve their skills slowly, through cumulated experience of trial and error. Intubation should involve a planned strategy to achieve first pass success, prevent hypoxemia and avoid aspiration. This article highlights two of the most common errors of direct laryngoscopy, and how to avoid them.

4- Airway Management Errors & Intubation Negligence

Airway management is a crucial aspect of both emergent and non-emergent medical care and involves any strategy that is used to maintain a patient’s airway so that he or she has continued access to oxygen.

Advanced airway management techniques such as intubation and extubation should only be performed by highly trained professionals with readily available special equipment. Intubation is the insertion of a breathing tube into the throat, nasal cavities, or esophagus to ensure the passage of oxygen to a patient’s lungs. Extubation is simply the reverse process whereby the breathing tube is removed (either permanently because it is no longer needed or to be replaced with a new tube in the case of chronic needs for assistance breathing).

Once an airway is obstructed and oxygen becomes unavailable, time is of the essence. Permanent brain damage can occur within minutes of the time a patient is without oxygen. For this reason, medical professionals and anesthesiologists are specially trained on airway management procedures such as intubation, extubation, and in severe or chronic cases, surgical methods such asTracheostomy.

For infants, children, adolescents, or adults that need long-term or permanent airway management, a Tracheostomy is a common solution. Tracheostomy is a procedure whereby an opening is surgically created in a patient’s trachea/windpipe through the neck. This opening is called a stoma. A Tracheostomy tube is inserted. Tracheostomy tubes require special management so the patient can get enough oxygen.

Despite intensive training procedures in airway management, anesthesiologists, paramedics, physicians, and other medical staff can still make mistakes. Unfortunately, mistakes in advanced airway management techniques can be devastating, if not fatal, for a patient.

5- ntubation Complications

When Intubation Complications Contribute to Complications or DeathIn serious medical situations, patients require some type of ventilation procedure to survive or heal. Patients requiring assistance while breathing often need intubation performed by medical staff. Intubation involves inserting a long tube down the patient’s airway to connect it to a ventilator. However, the procedure is often extremely complex, which can lead to dangerous complications where even a slight mistake can cause severe, life-threatening long-term problems.

Injury to the patient’s airway can easily occur during many intubation procedures where the nasotracheal or endotracheal breathing tube causes injury when placed in position or removed. Despite precise intubation guidelines, effective protocols, years of training, and the frequency of performing the procedure by the anesthesiologist, catastrophic complications still happen resulting in serious injuries or death.

6- Outcomes after out-of-hospital endotracheal intubation errors☆☆☆

Henry E. Wang

,Lawrence J. Cook

,Chung-Chou H. Chang

,Donald M. Yealy

,Judith R. Lave

 

DOI: http://dx.doi.org/10.1016/j.resuscitation.2008.08.016

  

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Abstract

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Summary

Introduction

We sought to evaluate the association between three key out-of-hospital endotracheal intubation (ETI) errors and patient outcomes.

Methods

We prospectively collected multicenter data on out-of-hospital ETI attempted by Emergency Medical Service (EMS) rescuers. We probabilistically linked these data to statewide EMS, death and hospital discharge data sets. The key ETI error events were (1) endotracheal tube misplacement or dislodgement, (2) multiple ETI attempts (≥4 laryngoscopies) and (3) failed ETI. The primary outcomes were death (survival to hospital discharge) and secondary complications identified through ICD-9 discharge diagnoses. Using Cox regression with heavyside functions, we identified the associations between out-of-hospital ETI errors and early (in the field or emergency department) and later (on or after hospital admission) death. We censored non-linked cases, adjusted for important clinical covariates, and used a shared frailty regression model to account for clustering by EMS agency. We evaluated the associations between out-of-hospital ETI errors and secondary complications using univariable odds ratios with exact 95% confidence intervals.

Results

Of 1954 out-of-hospital ETI, 444 (22.7%) patients experienced one or more ETI errors, including tube misplacement or dislodgement in 61 (3%), multiple ETI attempts in 62 (3%) and failed ETI in 359 (15%). Of the 1196 (61%) cases linked to outcomes, 872 (73%) died and 323 (27%) survived to hospital discharge. ETI errors were not associated with early death (tube misplacement or dislodgement: Hazard Ratio 0.98, 95% CI 0.65–1.47; multiple ETI attempts: 1.22, 0.80–1.85; failed ETI: 1.10, 0.88–1.39) or later death (tube misplacement or dislodgement: 0.40, 0.10–1.62; multiple ETI attempts: 1.77, 0.23–13.30; failed ETI: 0.76, 0.47–1.25). Pneumonitis was associated with failed ETI (n = 20, 19%; univariable OR 2.54; 95% CI 1.24–5.25).

Conclusion

Out-of-hospital ETI errors are not associated with mortality. Failed out-of-hospital ETI increases the odds of pneumonitis.

7- Out-of-hospital endotracheal intubation errors are not linked to deaths, but failed attempts may boost pneumonitis risk

Research Activities, September 2009

To resuscitate out-of-hospital patients, paramedics often perform endotracheal intubation (ETI), insertion of a breathing tube into the windpipe. However, a new study found that they make three key errors when treating one-fifth of patients. The errors included tube misplacement or dislodgement, multiple ETI attempts, or failed ETI (patient arrives at the emergency department without the tube in place). Patients don't generally die due to these errors; however, they are more likely to develop pneumonitis (lung inflammation), according to the study. If untreated, pneumonitis can lead to lung scarring and permanent difficulty breathing.

A team led by Henry E. Wang, M.D., M.P.H., of the University of Pittsburgh, examined the link between these three ETI errors and patient outcomes based on multicenter data on out-of-hospital ETI attempted by emergency medical service (EMS) rescuers from 40 advanced life support EMS Pennsylvania agencies. They linked these data to statewide EMS, death, and hospital discharge data to examine the impact of ETI errors on death and outcomes ranging from esophageal perforation or injury to pneumonia and death.

EMS technicians made one or more errors while resuscitating one-fifth (22.7 percent) of patients during 1,954 out-of-hospital ETIs. Mistakes included tube misplacement or dislodgement in 3 percent of patients treated, multiple ETI attempts in 3 percent, and failed ETI in 15 percent. Of the 1,196 cases linked to patient outcomes, 73 percent died and 27 percent survived to hospital discharge. ETI errors were not associated with early or later death. Cardiac arrest was linked to early death and clinical instability upon hospital admission was associated with later death. However, failed ETI was associated with more than twice the likelihood of the patient developing pneumonitis, after adjustment for other patient clinical factors and intubation methods.

The link between failed ETI and pneumonitis may be due to aspiration of particles into the lung that occurs prior to or independent of the ETI effort, note the researchers. Their study was supported in part by the Agency for Healthcare Research and Quality (HS13628).

See "Outcomes after out-of-hospital endotracheal intubation errors," by Dr. Wang, Lawrence J. Cook, Ph.D., Chung-Chou H. Chang, Ph.D., and others, in Resuscitation 80, pp. 50-55, 2009.

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Page last reviewed September 2009

Internet Citation: Out-of-hospital endotracheal intubation errors are not linked to deaths, but failed attempts may boost pneumonitis risk: Research Activities, September 2009. September 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://archive.ahrq.gov/news/newsletters/research-activities/sep09/0909RA29.html

Hoping this will be helpful,

Rafik

If you are happy to focus down to earthquake then look at the work of Thomas Kuhn and his colleagues at Johns Hopkins Bloomberg School of Population Health - they have done a meta analysis on this question..

Cait is correct in regards to the military and a good example is TRiM that was started by the Royal Marines. Royal Navy Handbook link attached.  Not aware of any First Responder organisation that has gone into it in this detail and as a member of the Victim Recovery and Identification Team in the late 80's I certainly didn't get any training.

Dear Naveen,

Those files are not very long but quite thin and pointy and being made of metal are radiopaque, right? I would follow the very good published guidance by the American Society for Gastrointestinal Endoscopy (ASGE) on sharp pointed objects:

Establish first that the instrument is not lodged in the oesophagus and that it has not passed beyond the stomach by radiological evaluation. If it is lodged in the oesophagus, its removal is an absolute emergency. If it has not passed beyond proximal duodenum remove endoscopically, as there is still a 35 % chance of complications by letting a small sharp object pass via its natural way. Otherwise careful observation with serial xrays and consider surgical intervention if the object has failed to be passed within three days. Warn patient/carer/family to immediately report abdominal pain, fever, vomiting, haematemesis melaena or pr bleeding.

Best wishes,

Immo

Dear Hilary,

Are you familiar with the Danish record label Quiet Please, which has been developing optimal relaxing music with doctors? This music has been used widely e.g. in ambulances. The record is “15 Minutes of Peace”, and it can be found on Spotify. There is some information about this project on the internet, but I am not sure if there is any in English.

Best regards

Anne

I think the key issue here is that we are talking really about two different patient populations. The accidentally hypothermic patient during or after surgery would likely have greater metabolic demands with the increased stress from inadvertent hypothermia and the consequent increased metabolic activity that is generated in order to combat it (particularly with shivering). On the other hand, post cardiac arrest, when there is purposeful induction of reduced temperature (whether you choose 36°C or 33°C, or somewhere in between, based on the current equipoise that exists around goal temperature), with proper sedation and monitoring, oxygen consumption and general metabolic activity decreases.

Hi Laura, sounds like a sensible approach.  I work in a combined adult/pead ED and we operate a 'blue card' system to fast track certain paed pts through to CAA (Childrens Assessment Unit).  These are typically for children with chronic conditions, and the card itself has relatively little info on it - it is essentially just the condition and it acts as a 'pass' to gain access.  The card is shown to the triage nurse who can then send the child directly to CAA without needing paperwork etc completed.  The ideal is that the parents have rung CAA to identify the issue, they then ring ED to give us a heads up that the child is coming, and on arrival direct transfer and all assessment and clerking in is carried out in CAA.  The only risk is that parents may at times assume the card will ensure faster access and or treatment in ED for any condition - not necessarily linked to the concern for which the card is issued.  All pt details / care plan etc is housed electronically and these children are usually well known to the paeds staff. Good luck with establishing the process.

Thank you everybody! Very helpful indeed. 

Have you researched political sites,CIHAHL,Medline, PubMed and other sites.

Dear Anne-Marie -

I just ran a quick search in Google Scholar and pulled these citations.  I didn't read them - so you'll need to evaluate the articles to see if they fit your needs.

Hope this helps.

      Melissa Barthold

___________________________________________

Try these articles: 

Falloon, G. (2010). Using avatars and virtual environments in learning: What do they have to offer?. British Journal of Educational Technology, 41(1), 108-122.

Wallace, P., & Maryott, J. (2009). The impact of avatar self-representation on collaboration in virtual worlds. Innovate: Journal of Online Education, 5(5), n5.

Janet Ward, (2010) "The avatar lecturer: learning and teaching in Second Life", Marketing Intelligence & Planning, Vol. 28 Iss: 7, pp.862 - 881

Peterson, M. (2005). Learning interaction in an avatar-based virtual environment: a preliminary study. PacCALL Journal, 1(1), 29-40.

Sheth, R. (2003). Avatar technology: giving a face to the e-learning interface. The eLearning Developers’ Journal, 1-10.

Yee, N., Bailenson, J. N., Urbanek, M., Chang, F., & Merget, D. (2007). The unbearable likeness of being digital: The persistence of nonverbal social norms in online virtual environments. CyberPsychology & Behavior, 10(1), 115-121.

Fedeli, L. (2009). Avatar-assisted learning: Second Life and the new challenges of online tutoring. In Workshop on Virtual Worlds for Academic, Organizational, and Life-Long Learning (ViWo 2009 Workshop), Aachen, Germany.

Warburton, S. (2009). Second Life in higher education: Assessing the potential for and the barriers to deploying virtual worlds in learning and teaching. British Journal of Educational Technology, 40(3), 414-426.

Basori, A. H., Tenriawaru, A., & Mansur, A. B. (2011). Intelligent avatar on E-learning using facial expression and haptic. TELKOMNIKA Indonesian Journal of Electrical Engineering, 9(1), 115-124.

Jones, S. L. (2009). Avatar-based learning in Second Life. China-USA Business Review, 8(10), 58-64.

Peterson, M. (2006). Learner interaction management in an avatar and chat-based virtual world. Computer Assisted Language Learning, 19(1), 79-103.

There is a big difference clinically between tension pneumothorax in spontaneous breathing patients and those on a ventilator - the latter usually developing much more rapidly. Once " tension"  has developed, however, they are the same and usually easy to diagnose clinically. A chest X-ray is of course desirable, but by definition a tension pneumothorax is an emergency and definitive action precludes prior investigation.

Peter

If they need analgesia, they don't need CPR; if they need CPR, they don't need analgesia.

Dear Manoj, you are right but we have seen fairly large number of chest tubes in dangerous locations viz. paracardiac.

What should we do to decrease this occurrence

Mr. Power,

I wish I could tell you the exact percentage insulin dependent diabetics experiencing rebound hypoglycemia after treatment; however, anecdotally, I would estimate <5%. The steps put in place to minimize the changes of reoccurrence are that the patients are required to have a BG of >100 Mg/Dl, eat a meal, and have a competent adult with them. You can find a copy of the State Protocol here: http://www.ncems.org/pdf2012/T3DiabeticAdultFinal2012.pdf

Here is a study out of Canada discussing the complications of refusal after IV D-50 administration, they found no significant difference between patients who were transport and patients who refused transport. http://onlinelibrary.wiley.com/store/10.1197/aemj.9.8.855/asset/aemj.9.8.855.pdf;jsessionid=3290E7B78F809B68D0FD44A51AA1776C.f01t01?v=1&t=hulbi3a4&s=29d4567338ab162c3a9e18030255263997120fb4

I hope this helps with your research!

Dear Dr Borodach..

Thank you for bringing attention to this guideline document. While going through the document, I could not find the Cruse Visual Criteria. I will be grateful if you can elaborate on this criteria and how it helps in the decision making process.

Regards, raza

A bigger team as you suggested is not cost effective and may delay rather expedite being seen and discharged. Remember, this is triage. A quick assessment and disposition is what should happen. Assign patients where they need to go in the quickest way possible.

Good question; I too am only familiar with the various country / society algorithms. I've never seen evidence that specifically addresses the value of a D.A. checklist.

The issue if diuretics (i.v furosemide) should be routinely used in patients with acute left sided heart failure (i.e. acute pulmonary edema) on the universally accepted basis that these patients are always "fluid overloaded” has been appropriately introduced by Paul MacConachie Middleton.

My contribution to the discussion is based on the experience on 4 patients - 3 men and 1 woman in their eighties - urgently admitted to our Cardiology ward because of acute pulmonary edema unresponsive to, and even worsening after, usual drug treatment, in whom dehydration was identified as the probable initial mechanism responsible of a downstream sequence of events leading to pulmonary congestion despite hypovolemia. The main clinical characteristics of these patients were: 1) a high heart rate (130 to 165 beats/min due to sinus tachycardia or atrial fibrillation), 2) absence of jugular veins distention despite remarkable respiratory distress, 3) a hyperkinetic, hypertrophic, and small left ventricle, with normal-reduced right chambers size at echocardiographic examination, 4) unresponsiveness to usual drug treatment by morphine-nitrates-furosemide administration which on the contrary produced further symptoms and hemodynamic worsening, with severe arterial hypotension and impending shock. After echocardiographic demonstration of a normal, small, and well contracting left ventricle the diagnosis of acute diastolic CHF was made and all patients progressively recovered from pulmonary edema after heart rate reduction below 100 beats/min by intravenous metoprolol administration, immediately followed by tailored (usually rapid at the beginning) intravenous saline solution administration to avoid impending shock due to hypovolemia, hypotension and reduced stroke volume aggravated by usual treatment. Normal or reduced right chambers size was present and none of the patients exhibited a systolic anterior motion of the mitral valve (as expression of LV outflow tract obstruction) at the emergency echocardiogram. Although limited, this experience suggests that the marked reduction of filling time associated with persistent supraventricular tachycardia or tachyarrhythmia may cause pulmonary congestion and pulmonary edema even in presence of hypovolemia in the elderly hypertensive. The hypovolemia-induced tachycardia appears to be the initiating factor in this events cascade. In one patient a previously undetected hyperthyroidism was also found. Controlling the increased heart rate is the first therapeutic approach resulting in prompt relief of pulmonary edema and dyspnea; the hypovolemic state and impending shock must then be treated accordingly by tailored, usually rapid, intravenous saline infusion. From this experience it also follows that progressive clinical and hemodynamic deterioration by usual treatment of acute pulmonary edema in the elderly should prompt immediate echocardiographic examination. Proper identification of this previously unrecognized syndrome was life-saving in four of our five patients.

I believe there is merit in performing EDRT for blunt trauma if vital signs were lost within 5 minutes of arrival, and particularly if ED ultrasound is available and there is any sign of cardiac activity. Clearly the presence of pericardial effusion, cardiac activity and no pulse (tamponade physiology) would merit immediate needle pericardiocentesis if not full-out EDRT. Hope this helps...

Dear Michael, dear Ingo,

thank you both very much for sharing your experience and your preliminary data. It seems more than important to perform prospective multicenter trials in this context. Regarding the possible confounders (e.g., baseline temperature, length of CPR, ...) it would be interesting to know how your results (Michael) are influenced after adjusting the multivariable analysis.

Once again - thank you for your contributions and best regards

Raoul