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0000-0002-2336-1525
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Alfred Health
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Publisher: Wiley
Date: 27-11-2021
Abstract: A supraglottic airway device (SAD) may be utilised for rescue re‐oxygenation following a failed attempt at endotracheal intubation with direct or video laryngoscopy. However, the choice of subsequent method to secure a definitive airway is not clearly established. The aim of the present study was to compare two techniques for securing a definitive airway via the in‐situ SAD. A randomised controlled trial was undertaken. The population studied was emergency physicians (EPs) attending a cadaveric airway course. The intervention was intubation through a SAD using a retrograde intubation technique (RIT). The comparison was intubation through a SAD guided by a flexible airway scope (FAS). The primary outcome was time to intubation. The trial was registered with ANZCTR.org.au (ACTRN12621000995875). Four EPs completed intubations using both methods on four cadavers for a total of 32 experiments. The mean time to intubation was 18.2 s (standard deviation 8.8) in the FAS group compared with 52.9 s (standard deviation 11.7) in the RIT group a difference of 34.7 s (95% confidence interval 27.1–42.3, P 0.001). All intubations were completed within 2 min and there were no equipment failures or evidence of airway trauma. Successful tracheal intubation of cadavers by EPs is achievable, without iatrogenic airway trauma, via a SAD using either a FAS or RIT, but was 35 s quicker with the FAS.
Publisher: Wiley
Date: 02-06-2021
Abstract: In response to COVID‐19, we introduced and examined the effect of a raft of modifications to standard practice on adverse events and first‐attempt success (FAS) associated with ED intubation. An analysis of prospectively collected registry data of all ED intubations over a 3‐year period at an Australian Major Trauma Centre. During the first 6 months of the COVID‐19 pandemic in Australia, we introduced modifications to standard practice to reduce the risk to staff including: aerosolisation reduction, comprehensive personal protective equipment for all intubations, regular low fidelity simulation with ‘sign‐off’ for all medical and nursing staff, senior clinician laryngoscopist and the introduction of pre‐drawn medications. There were 783 patients, 136 in the COVID‐19 era and 647 in the pre‐COVID‐19 comparator group. The rate of hypoxia was higher during the COVID‐19 era compared to pre‐COVID‐19 (18.4% vs 9.6%, P 0.005). This occurred despite the FAS rate remaining very high (95.6% vs 93.8%, P = 0.42) and intubation being undertaken by more senior laryngoscopists (consultant 55.9% during COVID‐19 vs 22.6% pre‐COVID‐19, P 0.001). Other adverse events were similar before and during COVID‐19 (hypotension 12.5% vs 7.9%, P = 0.082 bradycardia 1.5% vs 0.5%, P = 0.21). Video laryngoscopy was more likely to be used during COVID‐19 (95.6% vs 82.5%, P 0.001) and induction of anaesthesia more often used ketamine (66.9% vs 42.3%, P 0.001) and rocuronium (86.8% vs 52.1%, P 0.001). This raft of modifications to ED intubation was associated with significant increase in hypoxia despite a very high FAS rate and more senior first laryngoscopist.
Publisher: BMJ
Date: 14-12-2022
DOI: 10.1136/EMERMED-2021-211280
Abstract: This study explored the perspectives and behaviours of emergency physicians (EPs), regularly involved in resuscitation, to identify the sources and effects of any stress experienced during a resuscitation as well as the strategies employed to deal with these stressors. This was a two-centre sequential exploratory mixed-methods study of EPs consisting of a focus group, exploring the human factors related to resuscitation, and an anonymous survey. Between April and June 2020, the online survey was distributed to all EPs working at Australia’s largest two major trauma centres, both in Melbourne, and investigated sources of stress during resuscitation, impact of stress on performance, mitigation strategies used, impact of the COVID-19 pandemic on stress and stress management training received. Associations with gender and years of clinical practice were also examined. 7 EPs took part in the focus group and 82 responses to the online survey were received (81% response rate). The most common sources of stress reported were resuscitation of an ‘unwell young paediatric patient’ (81%, 95% CI 70.6 to 87.6) or ‘unwell pregnant patient’ (71%, 95% CI 60.1 to 79.5) and ‘conflict with a team member’ (71%, 95% CI 60.1 to 79.5). The most frequently reported strategies to mitigate stress were ‘verbalising a plan to the team’ (84%, 95% CI 74.7 to 90.5), ‘implementing a standardised/structured approach’ (73%, 95% CI 62.7 to 81.6) and ‘asking for help’ (57%, 95% CI 46.5 to 67.5). 79% (95% CI 69.3 to 86.6) of EPs reported that they would like additional training on stress management. Junior EPs more frequently reported the use of ‘mental rehearsal’ to mitigate stress during a resuscitation (62% vs 22% p .01) while female EPs reported ‘asking for help’ as a mitigator of stress more frequently than male EPs (79% vs 47% p=0.01). Stress is commonly experienced by EPs during resuscitation and can impact decision-making and procedural performance. This study identifies the most common sources of stress during a resuscitation as well as the strategies that EPs use to mitigate the effects of stress on their performance. These findings may contribute to the development of tailored stress management training for critical care clinicians.
Publisher: Wiley
Date: 26-05-2022
Abstract: The present study aimed to determine the difference in force required to puncture simulated pleura comparing Kelly cl s to fine artery forceps. The treatment of symptomatic traumatic pneumothorax and haemothorax involves puncture of the parietal pleura to allow decompression. This is usually performed using Kelly cl s or fine artery forceps. Over‐puncture pulmonary injury risk increases with the force used. An experienced single operator performed puncturing of simulated parietal pleura on a thoracic mannequin while wearing a force sensor under gloves. The force imparted at the device tip onto the parietal pleura was estimated by subtracting the force required to hold the device from the total force. Outcome variables were the total maximum force and force imparted by the device. There were 11 simulated procedures completed, seven using Kelly cl s and four using fine artery forceps. After subtracting the force required to hold the chosen forceps, the median value of pleural puncture force using Kelly cl s was 52.91 N (IQR 36.68–63.56) and 10.70 N (IQR 7.64–26.56) using fine artery forceps ( P = 0.006). A significantly increased force was required to puncture simulated parietal pleura using Kelly cl s compared to fine artery forceps. This higher puncture force will be associated with increased instrument acceleration at the time of pleural puncture, which may result in an increased risk of injury to the underlying lung. Based on these data, clinicians may reduce the risk of pulmonary injury by using fine artery forceps rather than Kelly cl s when performing pleural decompression.
Publisher: Wiley
Date: 17-11-2021
Publisher: Elsevier BV
Date: 11-2019
DOI: 10.1016/J.RESUSCITATION.2019.09.023
Abstract: During resuscitation decisions are made frequently and based on limited information in a stressful environment. This systematic review aimed to identify human factors affecting decision-making in challenging or stressful situations in resuscitation. The secondary aim was to identify methods of improving decision-making performance under stress. The databases PubMed, EMBASE and The Cochrane Library were searched from their commencement to the 13th of April 2019. MeSH terms and key words were combined (Stress* OR "human factor") AND Decision. Articles were included if they involved decision makers in medicine where decisions were made under challenging circumstances, with a comparator group and an outcome measure relating to change in decision-making performance. 22,368 records in total were initially identified, from which 82 full text studies were reviewed and 16 finally included. The included studies ranged from 1995 to 2018 and included a total of 570 participants. The studies were conducted in several different countries and settings, with participants of varying experience and backgrounds. Of the 16 studies, 5 were randomised controlled trials, 3 of which were deemed to have a high risk of bias. The stressors identified were (i) illness severity (ii) socio-evaluative, (iii) noise, (iv) fatigue. The mitigators identified were (i) cognitive aids including checklists, (ii) stress management training and (iii) meditation. Human factors contributing to decision-making during resuscitation are identified and can be mitigated by tailored stress training and cognitive aids. Understanding these factors may have implications for clinician education and the development of decision-support tools.
Publisher: AMPCo
Date: 05-2020
DOI: 10.5694/MJA2.50598
Publisher: Wiley
Date: 11-08-2023
Abstract: Haemorrhagic shock is a life‐threatening complication of trauma, but remains a preventable cause of death. Early recognition of retroperitoneal haemorrhage (RPH) is crucial in preventing deleterious outcomes including mortality. Injury to the 9–11th intercostal arteries (i.e. arteries of the lower thoracic region) are complicit in RPH. However, the associated injuries, implications and management of such bleeds remain poorly characterised. We performed a retrospective review of the medical records of patients diagnosed with RPH who presented to our level‐1 trauma centre (2009–2019). We described the associated injuries, management and outcomes relating to RPH of the lower thoracic region (the 9–11th intercostal arteries) from this cohort to identify potential predictors and evaluate the impact of early identification and management of non‐cavitary bleeds. Haemorrhage of the lower intercostal arteries (LIA) into the retroperitoneal space is associated with an increased number of posterior lower rib fractures and pneumothorax/haemothorax. A higher proportion of patients in the LIA group required massive transfusion, angioembolisation or surgical ligation when compared to other causes of RPH. The present study highlights the importance of injury patterns, particularly posterior lower rib fractures, as predictors for early recognition and management of RPH in the prevention of deleterious patient outcomes. RPH secondary to bleeding of the LIA may require early and aggressive management of haemorrhage through massive transfusion, and angioembolisation or surgical ligation when compared to RPH because of other causes.
Publisher: AMPCo
Date: 25-01-2022
DOI: 10.5694/MJA2.50889
Publisher: Springer Science and Business Media LLC
Date: 05-08-2007
DOI: 10.1007/S00213-007-0885-X
Abstract: The antisaccade task provides a powerful tool with which to investigate the cognitive and neural systems underlying goal-directed behaviour, particularly in situations when the correct behavioural response requires the suppression of a prepotent response. Antisaccade errors (failures to suppress reflexive prosaccades towards sudden-onset targets) are increased in patients with damage to the dorsolateral prefrontal cortex, and in patients with schizophrenia. Nicotine has been found to improve antisaccade performance in patients with schizophrenia and healthy controls. This performance enhancing effect may be due to direct effects on the cholinergic system, but there has been no test of this hypothesis. In a double blind, double dummy, placebo-controlled design, we compared the effect of nicotine and modafinil, a putative indirect noradrenergic agonist, on antisaccade performance in healthy non-smokers. Both compounds reduced latency for correct antisaccades, although neither reduced antisaccade errors. These findings are discussed with reference to the pharmacological route of performance enhancement on the antisaccade task and current models of antisaccade performance.
Publisher: Informa UK Limited
Date: 30-08-2022
Publisher: BMJ
Date: 17-06-2020
DOI: 10.1136/EMERMED-2019-208935
Abstract: Endotracheal intubation (ETI) is a commonly performed but potentially high-risk procedure in the emergency department (ED). Requiring more than one attempt at intubation has been shown to increase adverse events and interventions improving first-attempt success rate should be identified to make ETI in the ED safer. We introduced and examined the effect of a targeted bundle of airway initiatives on first-attempt success and adverse events associated with ETI. This prospective, interventional cohort study was conducted over a 2-year period at an Australian Major Trauma Centre. An online airway registry was established at the inception of the study to collect information related to all intubations. After 6 months, we introduced a bundle of initiatives including monthly audit, monthly airway management education and an airway management checklist. A time series analysis model was used to compare standard practice (ie, first 6 months) to the postintervention period. There were 526 patients, 369 in the intervention group and 157 in the preintervention comparator group. A total of 573 intubation attempts were performed. There was a significant improvement in first-attempt success rates between preintervention and postintervention groups (88.5% vs 94.6%, relative risk 1.07 95% CI 1.00 to 1.14, p=0.014). After the introduction of the intervention the first-attempt success rate increased significantly, by 13.4% (p=0.006) in the first month, followed by a significant increase in the monthly trend (relative to the preintervention trend) of 1.71% (p .001). The rate of adverse events were similar preintervention and postintervention (hypoxia 8.3% vs 8.9% (p=0.81) hypotension 8.3% vs 7.0% (p=0.62) any complication 27.4% vs 23.6% (p=0.35)). This bundle of airway management initiatives was associated with significant improvement in the first-attempt success rate of ETI. The introduction of a regular education programme based on the audit of a dedicated airway registry, combined with a periprocedure checklist is a worthwhile ED quality improvement initiative.
Publisher: Elsevier BV
Date: 02-2006
Publisher: Springer Science and Business Media LLC
Date: 16-04-2008
DOI: 10.1038/NPP.2008.50
Abstract: There is growing preclinical evidence for the involvement of glutamate in the behavioral actions of nicotine. The aim of this study, was to investigate the role of N-methyl-D-aspartate (NMDA) receptors in the cognitive and subjective effects of smoking in humans. Sixty regular smokers took part in this double-blind placebo controlled study, that investigated the effect of the NMDA-antagonist memantine (40 mg) and the nicotinic-receptor antagonist mecamylamine (10 mg) on smoking-induced improvement in performance of a task of sustained attention and on smoking-induced changes in subjective effects and craving. Increases in subjective ratings of 'buzzed' following smoking were reversed by memantine, but not by mecamylamine. In contrast, improvement on a Rapid Visual Information Processing task by smoking was opposed by mecamylamine, but not by memantine. Smoking reduced craving for cigarettes, but neither drug altered this effect. Our results suggest that glutamatergic mechanisms may have differential involvement in the subjective and cognitive actions of smoking. Further investigations using different ligands are warranted to fully characterize the role of glutamate underlying the consequences of smoking behavior.
Publisher: Wiley
Date: 27-02-2022
Abstract: The wide‐spread use of an initial ‘Glasgow Coma Scale (GCS) 8 or less’ to define and dichotomise ‘severe’ from ‘mild’ or ‘moderate’ traumatic brain injury (TBI) is an out‐dated research heuristic that has become an epidemiological convenience transfixing clinical care. Triaging based on GCS can delay the care of patients who have rapidly evolving injuries. Sole reliance on the initial GCS can therefore provide a false sense of security to caregivers and fail to provide timely care for patients presenting with GCS greater than 8. Nearly 50 years after the development of the GCS – and the resultant misplaced clinical and statistical definitions – TBI remains a heterogeneous entity, in which ‘best practice’ and ‘prognoses’ are poorly stratified by GCS alone. There is an urgent need for a paradigm shift towards more effective initial assessment of TBI.
Publisher: Wiley
Date: 15-02-2017
DOI: 10.1111/ANAE.13809
Abstract: Following the return of spontaneous circulation after out-of-hospital cardiac arrest, neurological dysfunction, airway or ventilatory compromise can impede transport to early percutaneous coronary intervention, necessitating pre-hospital or emergency department anaesthesia to facilitate this procedure. There are no published reports of the ideal induction agents in these patients. We sought to describe haemodynamic changes associated with induction of anaesthesia using a midazolam (0.1 mg.kg
Publisher: JMIR Publications Inc.
Date: 29-03-2020
Abstract: elemedicine offers a unique opportunity to improve coordination and administration for urgent patient care remotely. In an emergency setting, it has been used to support first responders by providing telephone or video consultation with specialists at hospitals and through the exchange of prehospital patient information. This technological solution is evolving rapidly, yet there is a concern that it is being implemented without a demonstrated clinical need and effectiveness as well as without a thorough economic evaluation. ur objective is to systematically review whether the clinical outcomes achieved, as reported in the literature, favor telemedicine decision support for medical interventions during prehospital care. his systematic review included peer-reviewed journal articles. Searches of 7 databases and relevant reviews were conducted. Eligibility criteria consisted of studies that covered telemedicine as data- and information-sharing and two-way teleconsultation platforms, with the objective of supporting medical decisions (eg, diagnosis, treatment, and receiving hospital decision) in a prehospital emergency setting. Simulation studies and studies that included pediatric populations were excluded. The procedures in this review followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. The Risk Of Bias In Non-randomised Studies–of Interventions (ROBINS-I) tool was used for the assessment of risk of bias. The results were synthesized based on predefined aspects of medical decisions that are made in a prehospital setting, which include diagnostic decision support, receiving facility decisions, and medical directions for treatment. All data extractions were done by at least two reviewers independently. ut of 42 full-text reviews, 7 were found eligible. Diagnostic support and medical direction and decision for treatments were often reported. A key finding of this review was the high agreement between prehospital diagnoses via telemedicine and final in-hospital diagnoses, as supported by quantitative evidence. However, a majority of the articles described the clinical value of having access to remote experts without robust quantitative data. Most telemedicine solutions were evaluated within a feasibility or short-term preliminary study. In general, the results were positive for telemedicine use however, biases, due to preintervention confounding factors and a lack of documentation on quality assurance and protocol for telemedicine activation, make it difficult to determine the direct effect on patient outcomes. he information-sharing capacity of telemedicine enables access to remote experts to support medical decision making on scene or in prolonged field care. The influence of human and technology factors on patient care is poorly understood and documented.
Publisher: SAGE Publications
Date: 24-07-2021
DOI: 10.1177/10249079211034272
Abstract: After failed endotracheal intubation, using direct laryngoscopy, rescued using a supraglottic airway device, the choice of subsequent method to secure a definitive airway is not clearly determined. The aim of this study was to compare the time to intubation using a fibre-optic airway scope, to guide an endotracheal tube through the supraglottic airway device, with a more conventional approach using a hyperangulated video laryngoscope. A single-centre randomised controlled trial was undertaken. The population studied were emergency physicians working in an adult major trauma centre. The intervention was intubation through a supraglottic airway device guided by a fibre-optic airway scope. The comparison was intubation using a hyperangulated video laryngoscope. The primary outcome was time to intubation. The trial was registered with ANZCTR.org.au (ACTRN12621000018819). Four emergency physicians completed intubations using both of the two airway devices on four cadavers for a total of 32 experiments. The mean time to intubation was 14.0 s (95% confidence interval = 11.1–16.8) in the hyperangulated video laryngoscope group compared with 29.2 s (95% confidence interval = 20.7–37.7) in the fibre-optic airway scope group a difference of 15.2 s (95% confidence interval = 8.7–21.7, p 0.001). All intubations were completed within 2 min, and there were no equipment failures or evidence of airway trauma. Successful intubation of the trachea without airway trauma by emergency physicians in cadavers is achievable by either fibre-optic airway scope via a supraglottic airway device or hyperangulated video laryngoscope. Hyperangulated video laryngoscope was statistically but arguably not clinically significantly faster than fibre-optic airway scope via supraglottic airway device.
Publisher: Wiley
Date: 11-12-2020
Publisher: Springer Science and Business Media LLC
Date: 28-07-2021
DOI: 10.1186/S13049-021-00925-Y
Abstract: In the ‘can’t intubate can’t oxygenate’ scenario, techniques to achieve front of neck access to the airway have been described in the literature but there is a lack of guidance on the optimal method for securing the tracheal tube (TT) placed during this procedure. The aim of this study was to compare three different methods of securing a TT to prevent extubation following a surgical cricothyroidotomy. A randomised controlled trial was undertaken. The population studied were emergency physicians (EPs) attending a cadaveric airway course. The intervention was securing a TT placed via a surgical cricothyroidotomy by suture. The comparison was securing the TT using fabric tape with two different tying techniques. The primary outcome was the force required to extubate the trachea. The trial was registered with ANZCTR.org.au (ACTRN12621000320853). 17 emergency physicians completed intubations using all three of the securing methods on 12 cadavers for a total of 51 experiments. The mean extubation force was 6.54 KG (95 % CI 5.54–7.55) in the suture group compared with 2.28 KG (95 % CI 1.91–2.64) in the ‘Wilko tie’ group and 2.12 KG (95 % CI 1.63–2.60) in the ‘Lark’s foot tie’ group The mean difference between the suture and fabric tie techniques was significant ( p 0.001). Following a surgical cricothyroidotomy in cadavers, EPs were able to effectively secure a TT using a suture technique, and this method was superior to tying the TT using fabric tape.
Publisher: JMIR Publications Inc.
Date: 08-12-2020
DOI: 10.2196/18959
Abstract: Telemedicine offers a unique opportunity to improve coordination and administration for urgent patient care remotely. In an emergency setting, it has been used to support first responders by providing telephone or video consultation with specialists at hospitals and through the exchange of prehospital patient information. This technological solution is evolving rapidly, yet there is a concern that it is being implemented without a demonstrated clinical need and effectiveness as well as without a thorough economic evaluation. Our objective is to systematically review whether the clinical outcomes achieved, as reported in the literature, favor telemedicine decision support for medical interventions during prehospital care. This systematic review included peer-reviewed journal articles. Searches of 7 databases and relevant reviews were conducted. Eligibility criteria consisted of studies that covered telemedicine as data- and information-sharing and two-way teleconsultation platforms, with the objective of supporting medical decisions (eg, diagnosis, treatment, and receiving hospital decision) in a prehospital emergency setting. Simulation studies and studies that included pediatric populations were excluded. The procedures in this review followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. The Risk Of Bias In Non-randomised Studies–of Interventions (ROBINS-I) tool was used for the assessment of risk of bias. The results were synthesized based on predefined aspects of medical decisions that are made in a prehospital setting, which include diagnostic decision support, receiving facility decisions, and medical directions for treatment. All data extractions were done by at least two reviewers independently. Out of 42 full-text reviews, 7 were found eligible. Diagnostic support and medical direction and decision for treatments were often reported. A key finding of this review was the high agreement between prehospital diagnoses via telemedicine and final in-hospital diagnoses, as supported by quantitative evidence. However, a majority of the articles described the clinical value of having access to remote experts without robust quantitative data. Most telemedicine solutions were evaluated within a feasibility or short-term preliminary study. In general, the results were positive for telemedicine use however, biases, due to preintervention confounding factors and a lack of documentation on quality assurance and protocol for telemedicine activation, make it difficult to determine the direct effect on patient outcomes. The information-sharing capacity of telemedicine enables access to remote experts to support medical decision making on scene or in prolonged field care. The influence of human and technology factors on patient care is poorly understood and documented.
Publisher: Wiley
Date: 09-2022
Abstract: Inconsistency in the structure and function of team‐based major trauma reception and resuscitation is common. A standardised trauma team training programme was initiated to improve quality and consistency among trauma teams across a large, mature trauma system. The aim of this manuscript is to outline the programme and report on the initial perception of participants. The Alfred Trauma Team Reception and Resuscitation Training (TTRRT) programme commenced in March 2019. Participants included critical care and surgical craft group members commonly involved in trauma teams. Training was site‐specific and included rural, urban and tertiary referral centres. The programme consisted of prescribed pre‐learning, didactic lectures, skill stations and simulated team‐based scenarios. Participant perceptions of the programme were collected before and after the programme for analysis. The TTRRT was delivered to 252 participants and 120 responses were received. Significant improvement in participant‐reported confidence was identified across all key topic areas. There was also a significant increase in both confidence and clinical exposure to trauma team leadership roles after participation in the programme (from 53 [44.2%] to 74 [61.7% P = 0.007]). This finding was independent of clinician experience. A team‐based trauma reception and resuscitation education programme, introduced in a large, mature trauma system led to positive participant‐reported outcomes in clinical confidence and real‐life team leadership participation. Wider implementation combined with longitudinal data collection will facilitate correlation with patient and staff‐centred outcomes.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 16-11-2020
DOI: 10.1097/TA.0000000000003027
Abstract: During hemorrhagic shock and subsequent resuscitation, pathways reliant upon calcium such as platelet function, intrinsic and extrinsic hemostasis, and cardiac contractility are disrupted. The objective of this systematic review was to examine current literature for associations between pretransfusion, admission ionized hypocalcemia, and composite outcomes including mortality, blood transfusion requirements, and coagulopathy in adult trauma patients. This review was reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. We searched Ovid MEDLINE and grey literature from database inception till May 3, 2020. Case series and reports were excluded. Reference lists of appraised studies were also screened for articles that the aforementioned databases might not have captured. The Newcastle-Ottawa Scale was used to assess study quality. A total of 585 abstracts were screened through database searching and alternative sources. Six unique full-text studies were reviewed, of which three were excluded. Admission ionized hypocalcemia was present in up to 56.2% of the population in studies included in this review. Admission ionized hypocalcemia was also associated with increased mortality in all three studies, with increased blood transfusion requirements in two studies, and with coagulopathy in one study. Hypocalcemia is a common finding in shocked trauma patients. While an association between admission ionized hypocalcemia and mortality, blood transfusion requirements, and coagulopathy has been identified, further prospective trials are essential to corroborating this association. Systematic review, level III.
Publisher: Wiley
Date: 14-03-2017
DOI: 10.1111/ANAE.13852
Abstract: Pre-oxygenation before tracheal intubation aims to increase safe apnoea duration by denitrogenation of the functional residual capacity of the lungs, and increasing oxygen stores at the onset of apnoea. Pre-oxygenation options in the pre-hospital environment are limited due to oxygen availability and equipment portability. The aim of this study was to evaluate the effectiveness of strategies available in this setting. This was a prospective, randomised, crossover study of 30 healthy volunteers who underwent 3-min periods of pre-oxygenation by tidal volume breathing with a non-rebreather mask, a bag-valve-mask and a portable ventilator. The primary outcome measure was fractional expired oxygen concentration of the first exhaled breath after each technique. The secondary outcome measure was ease of breathing, assessed using a visual analogue scale. The mean (95%CI) fractional expired oxygen concentrations achieved with the non-rebreather mask were 64 (60-68)%, bag-valve-mask 89 (86-92)% and portable ventilator 95 (94-96)%. Pre-oxygenation efficacy with the non-rebreather mask was significantly worse than with either the bag-valve-mask (p < 0.001) or ventilator (p < 0.001). No significant difference in ease of breathing was identified between the bag-valve-mask and ventilator, but both were perceived as being significantly more difficult to breathe through than the non-rebreather mask. We conclude that, in healthy volunteers, the effectiveness of pre-oxygenation by bag-valve-mask and portable ventilator was superior to pre-oxygenation with a non-rebreather mask, although the non-rebreather mask was easier to breathe through than the other pre-oxygenation devices.
Publisher: Wiley
Date: 24-05-2018
Publisher: Elsevier BV
Date: 2023
DOI: 10.1016/J.INJURY.2022.07.041
Abstract: Haemorrhagic shock remains a leading preventable cause of death amongst trauma patients. Failure to identify retroperitoneal haemorrhage (RPH) can lead to irreversible haemorrhagic shock. The arteries of the middle retroperitoneal region (i.e., the 1st to 4th lumbar arteries) are complicit in haemorrhage into the retroperitoneal space. However, predictive injury patterns and subsequent management implications of haemorrhage secondary to bleeding of these arteries is lacking. We performed a retrospective cohort study of patients diagnosed with retroperitoneal haemorrhage who presented to our Level-1 Trauma Centre (2009-2019). We described the associated injuries, management and outcomes relating to haemorrhage of lumbar arteries (L1-4) from this cohort to assess risk and management priorities in non-cavitary haemorrhage compared to RPH due to other causes. Haemorrhage of the lumbar arteries (LA) is associated with a higher proportion of lumbar transverse process (TP) fractures. Bleeding from branches of these vessels is associated with lower systolic blood pressure, increased incidence of massive transfusion, higher shock index, and a higher Injury Severity Score (ISS). A higher proportion of patients in the LA group underwent angioembolisation when compared to other causes of RPH. This study highlights the injury patterns, particularly TP fractures, in the prediction, early detection and management of haemorrhage from the lumbar arteries (L1-4). Compared to other causes of RPH, bleeding of the LA responds to early, aggressive haemorrhage control through angioembolisation. These injuries are likely best treated in Level-1 or Level-2 trauma facilities that are equipped with angioembolisation facilities or hybrid theatres to facilitate early identification and management of thoracolumbar bleeds.
Publisher: Wiley
Date: 11-07-2017
DOI: 10.1111/ANAE.13954
Publisher: Wiley
Date: 17-02-2016
DOI: 10.1111/ACEM.12889
Abstract: Preoxygenation prior to intubation aims to increase the duration of safe apnea by causing denitrogenation of the functional residual capacity, replacing this volume with a reservoir of oxygen. In the operating room (OR) the criterion standard for preoxygenation is an anesthetic circuit and well-fitting face mask, which provide a high fractional inspired oxygen concentration (FiO2 ). Outside of the OR, various strategies exist to provide preoxygenation. The objective was to evaluate the effectiveness of commonly used preoxygenation strategies outside of the OR environment. This was a prospective randomized unblinded study of 30 healthy staff volunteers from a major trauma center emergency department (ED) in Sydney, Australia. The main outcome measure is fractional expired oxygen concentration (FeO2 ) measured after a 3-minute period of tidal volume breathing with seven different preoxygenation strategies. The mean FeO2 achieved with the anesthetic circuit was 81.0% (95% confidence interval [CI] = 78.3% to 83.6%), bag-valve-mask (BVM) 80.1% (95% CI = 76.5% to 83.6%), BVM with nasal cannula (NC) 74.8% (95% CI = 72.0% to 77.6%), BVM with positive end-expiratory pressure valve (PEEP) 78.9% (95% CI = 75.4% to 82.3%), BVM + NC + PEEP 75.5% (95% CI = 72.2% to 78.9%), nonrebreather mask (NRM) 51.6% (95% CI = 48.8% to 54.4%), and NRM + NC 57.1% (95% CI = 52.9% to 61.2%). Preoxygenation efficacy with BVM strategies was significantly greater than NRM strategies (p < 0.01) and noninferior to the anesthetic circuit. In healthy volunteers, the effectiveness of BVM preoxygenation was comparable to the anesthetic circuit (criterion standard) and superior to preoxygenation with NRM. The addition of NC oxygen, PEEP, or both did not improve the efficacy of the BVM device.
No related grants have been discovered for Christopher Groombridge.