The document provides an overview of updates to the 2013 Massachusetts prehospital treatment protocols effective June 15, 2013. Key changes include:
- Routing medication administration to reflect national standards and address shortages.
- Clarifying when EMS should begin interventions based on the receiving facility's capabilities.
- Emphasizing continuous chest compressions and delayed intubation for cardiac arrest.
- Recommending titrated oxygen use and avoiding hyperoxygenation for certain conditions.
- Adding hydroxocobalamin for suspected cyanide toxicity from smoke inhalation.
- Removing recommendations for hyperventilation in head injuries.
- Clarifying tourniquet use for hemorrhage control.
Preoperative pulmoanary evaluation other than lung resection surgeriesPARIKSHIT THAKARE
This document discusses pre-operative pulmonary evaluation for surgeries other than lung resection. It notes that postoperative pulmonary complications contribute significantly to morbidity and mortality, occurring in 5-70% of cases. The goals of pre-operative pulmonary management are to identify high-risk patients and minimize that risk through appropriate interventions. It then discusses various patient-related risk factors like age, obesity, COPD, asthma, pulmonary hypertension, sleep apnea, and immunosuppression, as well as procedure-related risk factors. Pre-operative evaluations and preparations are suggested including pulmonary function tests, chest x-rays, smoking cessation, asthma and COPD control, and inspiratory muscle training.
CPR with ECLS vs conventional CPR in IHCASun Yai-Cheng
Cardiopulmonary Resuscitation with Assisted Extracorporeal Life-Support versus Conventional Cardiopulmonary Resuscitation in Adults with In-Hospital Cardiac Arrest
Lancet 2008; 372:554-561
The Cardiopulmonary Exercise Test (CPET) is a non-invasive stress test that assesses how well the heart, lungs, and muscles work individually and together during exercise. It measures oxygen use, carbon dioxide production, breathing, and electrocardiogram responses. A CPET can detect various cardiac and pulmonary conditions that limit exercise capacity, such as heart failure, ischemia, and lung disorders. It involves wearing a face mask and EKG stickers while exercising on a treadmill or bike according to a protocol, with monitoring of vital signs throughout. Results provide information on functional capacity and can guide medical management and exercise prescription.
This slide presentation covers areas about physiology of respiratory system related to surgery and anaesthesia, definition of postoperative pulmonary complications (PPCs), risk of PPCs, screening for PPC risk and specific management for patients with increased risk.
Strategies to reduce postoperative pulmonary complicationsTerry Shaneyfelt
This document discusses strategies to reduce postoperative pulmonary complications for a 67 year old female smoker undergoing upper abdominal surgery who has COPD. It recommends that she use incentive spirometry and selective use of a nasogastric tube postoperatively. Intensifying bronchodilators and steroids is not recommended. Multiple studies have found that smoking cessation reduces postoperative pulmonary complications compared to current smokers. Incentive spirometry is likely better than no lung expansion but not clearly superior to other techniques. Routine use of nasogastric tubes may increase complications.
Mvss part v weaning & liberation from mechanical ventilationSanti Silairatana
Slides accompanying the Lecture/Review Mechanical Ventilatory support series part V/V: Weaning and liberation from mechanical ventilatory support. For medical students and residents in Internal medicine. Contents are including rationale of weaning, predictors of weaning success and failure, methods of weaning, and detection and management of weaning failure
ACLS 2015 Updates - The Malaysian PerspectiveChew Keng Sheng
This set of slide was presented during the Kelantan Resuscitation Update 22 Nov 2015 in accordance to the latest ACLS/ILCOR 2015 Guidelines. However, I have emphasized on certain important aspects relevant within the Malaysian context. Nonetheless, in general, there are no major changes for this year 2015
Preoperative pulmoanary evaluation other than lung resection surgeriesPARIKSHIT THAKARE
This document discusses pre-operative pulmonary evaluation for surgeries other than lung resection. It notes that postoperative pulmonary complications contribute significantly to morbidity and mortality, occurring in 5-70% of cases. The goals of pre-operative pulmonary management are to identify high-risk patients and minimize that risk through appropriate interventions. It then discusses various patient-related risk factors like age, obesity, COPD, asthma, pulmonary hypertension, sleep apnea, and immunosuppression, as well as procedure-related risk factors. Pre-operative evaluations and preparations are suggested including pulmonary function tests, chest x-rays, smoking cessation, asthma and COPD control, and inspiratory muscle training.
CPR with ECLS vs conventional CPR in IHCASun Yai-Cheng
Cardiopulmonary Resuscitation with Assisted Extracorporeal Life-Support versus Conventional Cardiopulmonary Resuscitation in Adults with In-Hospital Cardiac Arrest
Lancet 2008; 372:554-561
The Cardiopulmonary Exercise Test (CPET) is a non-invasive stress test that assesses how well the heart, lungs, and muscles work individually and together during exercise. It measures oxygen use, carbon dioxide production, breathing, and electrocardiogram responses. A CPET can detect various cardiac and pulmonary conditions that limit exercise capacity, such as heart failure, ischemia, and lung disorders. It involves wearing a face mask and EKG stickers while exercising on a treadmill or bike according to a protocol, with monitoring of vital signs throughout. Results provide information on functional capacity and can guide medical management and exercise prescription.
This slide presentation covers areas about physiology of respiratory system related to surgery and anaesthesia, definition of postoperative pulmonary complications (PPCs), risk of PPCs, screening for PPC risk and specific management for patients with increased risk.
Strategies to reduce postoperative pulmonary complicationsTerry Shaneyfelt
This document discusses strategies to reduce postoperative pulmonary complications for a 67 year old female smoker undergoing upper abdominal surgery who has COPD. It recommends that she use incentive spirometry and selective use of a nasogastric tube postoperatively. Intensifying bronchodilators and steroids is not recommended. Multiple studies have found that smoking cessation reduces postoperative pulmonary complications compared to current smokers. Incentive spirometry is likely better than no lung expansion but not clearly superior to other techniques. Routine use of nasogastric tubes may increase complications.
Mvss part v weaning & liberation from mechanical ventilationSanti Silairatana
Slides accompanying the Lecture/Review Mechanical Ventilatory support series part V/V: Weaning and liberation from mechanical ventilatory support. For medical students and residents in Internal medicine. Contents are including rationale of weaning, predictors of weaning success and failure, methods of weaning, and detection and management of weaning failure
ACLS 2015 Updates - The Malaysian PerspectiveChew Keng Sheng
This set of slide was presented during the Kelantan Resuscitation Update 22 Nov 2015 in accordance to the latest ACLS/ILCOR 2015 Guidelines. However, I have emphasized on certain important aspects relevant within the Malaysian context. Nonetheless, in general, there are no major changes for this year 2015
Mr. Lung is a 78-year-old man scheduled for a 4-hour L3-5 laminectomy and fusion who has severe COPD, diabetes, hypertension, and a 40 pack-year smoking history. He takes medications for his COPD and other conditions and is functionally independent but dyspneic with exertion. Preoperative evaluation shows he is at increased risk for postoperative pulmonary complications according to several risk prediction models. Recommendations are made for postoperative lung expansion techniques and monitoring to help mitigate his risks.
- Pulmonary complications are a major cause of postoperative morbidity and mortality. The risk depends on patient-related factors like age, smoking history, COPD, asthma, obesity, sleep apnea, and heart failure as well as procedure-related factors like the surgical site and duration of anesthesia.
- A thorough preoperative evaluation involves reviewing the patient's history, performing a physical exam, and testing like arterial blood gases, chest x-ray, and pulmonary function tests to determine their risk level. Assigning a risk level helps guide risk reduction strategies in high risk patients.
This study analyzed data from over 31,000 orthopedic trauma surgery cases to determine if the time of day of surgery affected mortality and complication rates. The results showed that surgeries performed in the afternoon or at night had significantly higher mortality rates (1.1% in morning vs 2.4% at night) and general complication rates compared to morning surgeries. Higher rates of emergencies, injury severity, and surgeon fatigue after-hours may contribute to these outcomes. While no differences were found for intra- or post-operative complication rates based on surgery time, optimizing patient safety at all times, including surgeon self-awareness, is important.
Gupta indices for postop pulmonary complicationsTerry Shaneyfelt
Gupta and colleagues developed 2 prediction rules that can be used to estimate a patient's risk for postoperative pneumonia or respiratory failure. I also review an older prediction rule and show how it compares to the Gupta rules.
This document discusses exercise electrocardiography (ETT). It covers:
1. Patient preparation for ETT, including refraining from food/caffeine before and dressing appropriately.
2. Technical components of ETT, including monitoring heart rate, blood pressure, ECG and symptoms during exercise and recovery.
3. Interpreting data from ETT, such as functional capacity and identifying abnormalities that may obscure ECG interpretation.
1. Three key elements must be assessed to determine a patient's surgical risk: underlying medical conditions and diseases, functional status, and type of surgery.
2. The American Society of Anesthesiologists (ASA) Physical Status classification is commonly used but is limited in only considering medical history and does not include other factors like surgery type. Higher ASA classes correlate with increased postoperative complications and mortality.
3. Other tools like the Goldman Cardiac Risk Index and Revised Cardiac Risk Index were developed to better evaluate cardiac risk, but have limitations and may not predict all-cause mortality risk.
Ventilator Management In Different Disease EntitiesDang Thanh Tuan
The document discusses ventilator management in different disease entities. It covers indications for mechanical ventilation in conditions like respiratory failure, ARDS, COPD, chest trauma, and head injury. For ARDS specifically, it summarizes the key findings of the NIH ARDS Network trial which demonstrated that a lower tidal volume strategy of 6 ml/kg predicted body weight reduced mortality compared to the traditional higher tidal volume approach.
Health screening services provide important tests to diagnose diseases and their stages. Primary screening tests are performed when symptoms occur or a physician requests them, while secondary tests are done after diagnosis. These tests, like blood glucose, cholesterol, blood pressure, and ECG measurements, are accurate, affordable, easily available, and can often be done without side effects. Laboratory test results help assess drug effects and determine proper dosing. Regular screening is important for conditions like diabetes and high blood pressure.
Renal denervation is a potential treatment for resistant hypertension that involves ablating the renal nerves to lower blood pressure. The document discusses the epidemiology of hypertension and definitions of resistant hypertension. It then summarizes early clinical trial results from Symplicity HTN-1 and Symplicity HTN-2 that demonstrated reductions in blood pressure out to 3 years with renal denervation. Ongoing studies like the Global SYMPLICITY Registry aim to evaluate real-world outcomes. The document reviews technical considerations for renal denervation and compares various catheter systems for performing the procedure. Long-term data are still needed regarding durability and safety with larger and longer-term studies.
Weaning And Discontinuing Ventilatory Supporthappyneige
This document discusses guidelines for weaning and discontinuing ventilatory support for patients. It recommends that weaning begins as early as possible and involves a two-stage process of first discontinuing mechanical ventilation and then removing the artificial airway. Key criteria for initiating weaning include adequate lung function and gas exchange as well as resolution of the underlying medical condition requiring ventilation. Effective weaning protocols are led by respiratory therapists and can reduce the duration and costs of mechanical ventilation. Trials of spontaneous breathing are used to assess patient readiness and the document outlines parameters to evaluate during the weaning process.
Here are the key points regarding the applicability of the results to your patient:
- The study population matches the description of your patient (AMI complicated by cardiogenic shock for whom early revascularization is planned), so the results should be applicable.
- The treatments (IABP vs medical therapy) are commonly available, so feasibility of the treatments in your setting is likely.
- The results showed no significant difference in mortality between IABP and medical therapy alone. You would need to consider the potential risks and burdens of IABP placement vs continued medical management for your individual patient.
In summary, while the results are applicable based on the population, you'll need to make a judgment call for your specific patient
1) A large clinical trial found no difference in 7-day or 30-day mortality between patients receiving noninvasive ventilation (CPAP or NIPPV) and standard oxygen therapy for acute cardiogenic pulmonary edema.
2) While noninvasive ventilation improved symptoms and physiological measures more than standard oxygen, these benefits did not translate to improved survival.
3) There were also no differences found between CPAP and NIPPV in terms of efficacy, safety, or effects on mortality.
preoperative evaluation for residents of anesthesia part 2mansoor masjedi
This document summarizes key points from a presentation on preoperative evaluation and management of patients with pulmonary and other medical conditions. Some important topics discussed include: evaluating asthma severity and control; differentiating causes of wheezing; COPD diagnosis and management; restrictive lung diseases; dyspnea workup; pulmonary hypertension; smokers and second-hand smoke exposure; diabetes; renal and liver diseases; coagulation disorders; neurologic issues; upper respiratory infections; obesity; allergies; fasting guidelines; postoperative pain management; and components of a thorough preoperative consultation.
This document discusses exercise-induced bronchoconstriction (EIB). It begins with a case presentation and then defines EIB. It reviews the epidemiology, pathophysiology, clinical presentations, diagnosis, and management of EIB. The key points are:
1) EIB is the transient narrowing of the lower airways that occurs after exercise, which can occur in both asthmatic and non-asthmatic individuals.
2) The pathophysiology involves osmotic and thermal mechanisms leading to the release of inflammatory mediators that cause bronchoconstriction.
3) Diagnosis involves objective exercise or surrogate challenge tests to demonstrate a drop in lung function following exercise.
(1) The IABP-SHOCK II trial investigated whether early use of an intraaortic balloon pump (IABP) compared to conventional therapy alone could reduce mortality in patients with cardiogenic shock complicating myocardial infarction who were planned for early revascularization. (2) The trial found no significant difference in 30-day mortality between patients randomized to IABP versus conventional therapy alone. (3) While IABP use led to short-term improvements in organ dysfunction, it did not significantly affect other outcomes like C-reactive protein, lactate levels, or long-term survival.
Mechanical ventilation in obstructive airway diseasesAnkur Gupta
This document discusses mechanical ventilation for patients with obstructive airway diseases like COPD. Some key points:
- Non-invasive ventilation (NIV) should be considered within 60 minutes of hospital arrival for COPD patients with respiratory acidosis, as NIV can reduce intubation and mortality rates.
- Invasive mechanical ventilation aims to rest respiratory muscles, avoid dynamic hyperinflation, and prevent overventilation. Dynamic hyperinflation can increase work of breathing and compromise cardiac function.
- Ventilation strategies differ between asthma and COPD but generally use small tidal volumes, high inspiratory flows, and respiratory rates to minimize hyperinflation. Sedation and analgesia are also important to control distress and pain
This study evaluated the safety of continuing vitamin K antagonists (VKAs) as anticoagulation for patients undergoing pulmonary vein isolation (PVI) to treat atrial fibrillation. 151 patients underwent PVI between January 2010-March 2011. VKAs were continued for all patients before, during, and for 3 months after the procedure. No patients experienced thromboembolic complications before, during, or after the procedure. 4 procedures (2.7%) were complicated by cardiac tamponade requiring drainage. The results support continuing VKAs as a safe anticoagulation strategy to prevent thromboembolic complications during and after PVI.
Pre-oxygenation is: safe, simple, cheap, effective, well-tolerated. This article provides a compelling argument in favour of pre-oxygenation prior to all general anaesthesia.
Apnoeic Oxygenation: Essential in Prehospital RSInswhems
This document discusses apnoeic oxygenation and its importance for prehospital rapid sequence intubation (RSI). It notes that apnoeic oxygenation was first described in 1959 in a study by Frumin et al. and references standards for monitoring during RSI similar to in-hospital anesthesia. The document questions whether a randomized controlled trial is needed and highlights apnoeic oxygenation as just one component of first pass success for difficult airway intubation. It is authored by Cliff Reid, Director of Training for Greater Sydney Area HEMS.
Mr. Lung is a 78-year-old man scheduled for a 4-hour L3-5 laminectomy and fusion who has severe COPD, diabetes, hypertension, and a 40 pack-year smoking history. He takes medications for his COPD and other conditions and is functionally independent but dyspneic with exertion. Preoperative evaluation shows he is at increased risk for postoperative pulmonary complications according to several risk prediction models. Recommendations are made for postoperative lung expansion techniques and monitoring to help mitigate his risks.
- Pulmonary complications are a major cause of postoperative morbidity and mortality. The risk depends on patient-related factors like age, smoking history, COPD, asthma, obesity, sleep apnea, and heart failure as well as procedure-related factors like the surgical site and duration of anesthesia.
- A thorough preoperative evaluation involves reviewing the patient's history, performing a physical exam, and testing like arterial blood gases, chest x-ray, and pulmonary function tests to determine their risk level. Assigning a risk level helps guide risk reduction strategies in high risk patients.
This study analyzed data from over 31,000 orthopedic trauma surgery cases to determine if the time of day of surgery affected mortality and complication rates. The results showed that surgeries performed in the afternoon or at night had significantly higher mortality rates (1.1% in morning vs 2.4% at night) and general complication rates compared to morning surgeries. Higher rates of emergencies, injury severity, and surgeon fatigue after-hours may contribute to these outcomes. While no differences were found for intra- or post-operative complication rates based on surgery time, optimizing patient safety at all times, including surgeon self-awareness, is important.
Gupta indices for postop pulmonary complicationsTerry Shaneyfelt
Gupta and colleagues developed 2 prediction rules that can be used to estimate a patient's risk for postoperative pneumonia or respiratory failure. I also review an older prediction rule and show how it compares to the Gupta rules.
This document discusses exercise electrocardiography (ETT). It covers:
1. Patient preparation for ETT, including refraining from food/caffeine before and dressing appropriately.
2. Technical components of ETT, including monitoring heart rate, blood pressure, ECG and symptoms during exercise and recovery.
3. Interpreting data from ETT, such as functional capacity and identifying abnormalities that may obscure ECG interpretation.
1. Three key elements must be assessed to determine a patient's surgical risk: underlying medical conditions and diseases, functional status, and type of surgery.
2. The American Society of Anesthesiologists (ASA) Physical Status classification is commonly used but is limited in only considering medical history and does not include other factors like surgery type. Higher ASA classes correlate with increased postoperative complications and mortality.
3. Other tools like the Goldman Cardiac Risk Index and Revised Cardiac Risk Index were developed to better evaluate cardiac risk, but have limitations and may not predict all-cause mortality risk.
Ventilator Management In Different Disease EntitiesDang Thanh Tuan
The document discusses ventilator management in different disease entities. It covers indications for mechanical ventilation in conditions like respiratory failure, ARDS, COPD, chest trauma, and head injury. For ARDS specifically, it summarizes the key findings of the NIH ARDS Network trial which demonstrated that a lower tidal volume strategy of 6 ml/kg predicted body weight reduced mortality compared to the traditional higher tidal volume approach.
Health screening services provide important tests to diagnose diseases and their stages. Primary screening tests are performed when symptoms occur or a physician requests them, while secondary tests are done after diagnosis. These tests, like blood glucose, cholesterol, blood pressure, and ECG measurements, are accurate, affordable, easily available, and can often be done without side effects. Laboratory test results help assess drug effects and determine proper dosing. Regular screening is important for conditions like diabetes and high blood pressure.
Renal denervation is a potential treatment for resistant hypertension that involves ablating the renal nerves to lower blood pressure. The document discusses the epidemiology of hypertension and definitions of resistant hypertension. It then summarizes early clinical trial results from Symplicity HTN-1 and Symplicity HTN-2 that demonstrated reductions in blood pressure out to 3 years with renal denervation. Ongoing studies like the Global SYMPLICITY Registry aim to evaluate real-world outcomes. The document reviews technical considerations for renal denervation and compares various catheter systems for performing the procedure. Long-term data are still needed regarding durability and safety with larger and longer-term studies.
Weaning And Discontinuing Ventilatory Supporthappyneige
This document discusses guidelines for weaning and discontinuing ventilatory support for patients. It recommends that weaning begins as early as possible and involves a two-stage process of first discontinuing mechanical ventilation and then removing the artificial airway. Key criteria for initiating weaning include adequate lung function and gas exchange as well as resolution of the underlying medical condition requiring ventilation. Effective weaning protocols are led by respiratory therapists and can reduce the duration and costs of mechanical ventilation. Trials of spontaneous breathing are used to assess patient readiness and the document outlines parameters to evaluate during the weaning process.
Here are the key points regarding the applicability of the results to your patient:
- The study population matches the description of your patient (AMI complicated by cardiogenic shock for whom early revascularization is planned), so the results should be applicable.
- The treatments (IABP vs medical therapy) are commonly available, so feasibility of the treatments in your setting is likely.
- The results showed no significant difference in mortality between IABP and medical therapy alone. You would need to consider the potential risks and burdens of IABP placement vs continued medical management for your individual patient.
In summary, while the results are applicable based on the population, you'll need to make a judgment call for your specific patient
1) A large clinical trial found no difference in 7-day or 30-day mortality between patients receiving noninvasive ventilation (CPAP or NIPPV) and standard oxygen therapy for acute cardiogenic pulmonary edema.
2) While noninvasive ventilation improved symptoms and physiological measures more than standard oxygen, these benefits did not translate to improved survival.
3) There were also no differences found between CPAP and NIPPV in terms of efficacy, safety, or effects on mortality.
preoperative evaluation for residents of anesthesia part 2mansoor masjedi
This document summarizes key points from a presentation on preoperative evaluation and management of patients with pulmonary and other medical conditions. Some important topics discussed include: evaluating asthma severity and control; differentiating causes of wheezing; COPD diagnosis and management; restrictive lung diseases; dyspnea workup; pulmonary hypertension; smokers and second-hand smoke exposure; diabetes; renal and liver diseases; coagulation disorders; neurologic issues; upper respiratory infections; obesity; allergies; fasting guidelines; postoperative pain management; and components of a thorough preoperative consultation.
This document discusses exercise-induced bronchoconstriction (EIB). It begins with a case presentation and then defines EIB. It reviews the epidemiology, pathophysiology, clinical presentations, diagnosis, and management of EIB. The key points are:
1) EIB is the transient narrowing of the lower airways that occurs after exercise, which can occur in both asthmatic and non-asthmatic individuals.
2) The pathophysiology involves osmotic and thermal mechanisms leading to the release of inflammatory mediators that cause bronchoconstriction.
3) Diagnosis involves objective exercise or surrogate challenge tests to demonstrate a drop in lung function following exercise.
(1) The IABP-SHOCK II trial investigated whether early use of an intraaortic balloon pump (IABP) compared to conventional therapy alone could reduce mortality in patients with cardiogenic shock complicating myocardial infarction who were planned for early revascularization. (2) The trial found no significant difference in 30-day mortality between patients randomized to IABP versus conventional therapy alone. (3) While IABP use led to short-term improvements in organ dysfunction, it did not significantly affect other outcomes like C-reactive protein, lactate levels, or long-term survival.
Mechanical ventilation in obstructive airway diseasesAnkur Gupta
This document discusses mechanical ventilation for patients with obstructive airway diseases like COPD. Some key points:
- Non-invasive ventilation (NIV) should be considered within 60 minutes of hospital arrival for COPD patients with respiratory acidosis, as NIV can reduce intubation and mortality rates.
- Invasive mechanical ventilation aims to rest respiratory muscles, avoid dynamic hyperinflation, and prevent overventilation. Dynamic hyperinflation can increase work of breathing and compromise cardiac function.
- Ventilation strategies differ between asthma and COPD but generally use small tidal volumes, high inspiratory flows, and respiratory rates to minimize hyperinflation. Sedation and analgesia are also important to control distress and pain
This study evaluated the safety of continuing vitamin K antagonists (VKAs) as anticoagulation for patients undergoing pulmonary vein isolation (PVI) to treat atrial fibrillation. 151 patients underwent PVI between January 2010-March 2011. VKAs were continued for all patients before, during, and for 3 months after the procedure. No patients experienced thromboembolic complications before, during, or after the procedure. 4 procedures (2.7%) were complicated by cardiac tamponade requiring drainage. The results support continuing VKAs as a safe anticoagulation strategy to prevent thromboembolic complications during and after PVI.
Pre-oxygenation is: safe, simple, cheap, effective, well-tolerated. This article provides a compelling argument in favour of pre-oxygenation prior to all general anaesthesia.
Apnoeic Oxygenation: Essential in Prehospital RSInswhems
This document discusses apnoeic oxygenation and its importance for prehospital rapid sequence intubation (RSI). It notes that apnoeic oxygenation was first described in 1959 in a study by Frumin et al. and references standards for monitoring during RSI similar to in-hospital anesthesia. The document questions whether a randomized controlled trial is needed and highlights apnoeic oxygenation as just one component of first pass success for difficult airway intubation. It is authored by Cliff Reid, Director of Training for Greater Sydney Area HEMS.
A central venous access device (CVAD) is a catheter inserted into the central venous system to deliver fluids, medications, blood products, and nutrition either short-term or long-term. CVADs are commonly used when peripheral access is limited or for ongoing home therapy. There are several types of CVADs including tunneled catheters, nontunneled catheters, PICCs, and implanted ports. Proper care and maintenance of CVADs includes regular dressing changes using aseptic technique, flushing the catheter with saline to maintain patency, and locking catheters with saline or low-dose heparin between uses.
CVAD Management, Care and Maintenance (Radiology Nursing)Sarah Cox
Central venous access devices (CVADs) require careful management to prevent complications. There are two main types of CVADs - external and internal. External devices are short-term while internal devices like ports can remain for years. Proper infection control including hand hygiene is essential to prevent catheter-related bloodstream infections. Nurses must regularly assess the CVAD site and dressing and know how to properly access, flush, and secure the device. Occlusions and tip migration are potential complications that require monitoring and troubleshooting.
Capnography measures ventilation by detecting exhaled carbon dioxide (CO2) and provides a graphical waveform that can be interpreted. Pulse oximetry measures oxygenation by detecting oxygen levels in the blood. Capnography is useful for confirming endotracheal tube placement, detecting tube displacement, assessing chest compressions during CPR, and detecting return of spontaneous circulation. It also helps evaluate and monitor respiratory conditions, hypoventilation states, and low perfusion states in intubated and non-intubated patients.
Rapid sequence intubation (RSI) in the pre-hospital setting can provide a higher level of care for trauma patients with airway compromise or risk of aspiration. While controversial, RSI performed by a trained physician-paramedic team can achieve high first-pass intubation success rates of over 97%. However, pre-hospital RSI also carries risks and has shown mixed results in studies. To mitigate risks, pre-hospital RSI should follow standardized procedures, utilize proper monitoring, and involve rigorous training through simulation to minimize human error and maximize patient safety.
The document outlines different categories of beliefs and knowledge regarding theism, atheism, and related concepts. It defines theism as a belief in the supernatural, and atheism as lacking such a belief. Belief can range from absolutism to deism, and knowledge positions include gnosticism, agnosticism, ignosticism, and apathetic agnosticism. Various combinations of beliefs and knowledge stances are described as existing within these overarching categories.
The Wrong Stuff: Prehospital Dogma - Cliff Reid SMACC Conference
The Wrong Stuff: Prehospital Dogma
Summary by: Cliff Reid
The master of Dogmalysis himself, Cliff Reid, challenges current practices in prehospital and emergency medicine. Warning listeners to be skeptical, Cliff dissects the dogma of acute crush injuries and spinal immobilization. He also explores the false dichotomy of “scoop and run vs. stay and play”. Cliff reminds us that “not to challenge current practice is intellectually lazy”.
2. central venous access devices (cvads)ChartwellPA
Central venous catheters can be categorized into four groups based on their design: peripherally inserted central catheters, temporary central venous catheters, permanent tunneled central venous catheters, and implantable ports. It is the nurse's responsibility to understand the design, purpose, and care of each type of catheter and educate patients. PICC lines are long, flexible tubes inserted into a peripheral vein and threaded into the central circulation. They are commonly used for short or long-term therapies and have a lower risk of complications than other central lines. Implantable ports are implanted subcutaneously and consist of a portal body and catheter, providing vascular access without an external component.
Central Venous Access Devices Made Incredibly Easy!Cathy Lewis
Target audience: RNs during New Hire Orientation and nurses needing additional training on identifying, assessing, and maintaining central lines.
Developed in conjunction with subject matter experts (SMEs) from IV Team. Principles based on practice at this particular institution.
The document discusses a clinical trial that evaluated the effects of treating ARDS patients with the neuromuscular blocking agent (NMBA) cisatracurium for 48 hours. The randomized, double-blind study of 340 ARDS patients found that those receiving cisatracurium had improved oxygenation and a decreased trend in ICU mortality compared to controls. However, the primary outcome of reduced 90-day mortality was not statistically significant between the groups. The authors conclude that NMBAs may provide clinical benefits for ARDS, but further research is still needed.
Weaning from mechanical ventilation is the process of gradually transferring breathing from the ventilator to the patient. It must be individualized and involves assessing patient readiness using criteria like clinical stability, adequate oxygenation and pulmonary function. Weaning success means unassisted breathing for 48 hours after removal from the ventilator. Patients are classified as having simple, difficult or prolonged weaning based on time to successful extubation. Factors that can cause weaning failure include increased airway resistance, decreased lung compliance, and respiratory muscle fatigue due to conditions like cardiac dysfunction, diaphragm weakness or endocrine abnormalities.
journal club and critical appraisal checklist
intensive recruitment versus moderate recruitment strategy in postop cardiac surgery patients to avaoid postop pulmonary complications
refactory hypoxemia and status Asthmaticus.pptxsanikashukla2
The patient has refractory hypoxemia and status asthmaticus after 10 days in the ICU on mechanical ventilation. For refractory hypoxemia, therapies include recruitment maneuvers, prone positioning, neuromuscular blockade, inhaled pulmonary vasodilators, ECMO, and HFOV. Management of status asthmaticus focuses on standard treatment with oxygen, inhaled bronchodilators, and corticosteroids, as well as additional therapies like antibiotics, magnesium, methylxanthines, and epinephrine if needed. Ventilator strategies aim to reduce work of breathing and dynamic hyperinflation while treating the underlying inflammation.
1. The document discusses discontinuation of ventilatory support and weaning from mechanical ventilation in critically ill patients. It focuses on challenges in determining the optimal time for withdrawal of ventilation support and strategies to improve weaning outcomes.
2. Weaning from mechanical ventilation is a complex process that requires evaluation of respiratory, cardiac, muscular and cognitive factors. Approximately 20-30% of patients who are deemed ready for weaning trials will fail the initial spontaneous breathing test and require resumed mechanical ventilation.
3. The document reviews various approaches and considerations for evaluating patient readiness, managing weaning, and preventing extubation failure. It emphasizes the need for further research to identify high risk patients and improve weaning techniques.
The initial resuscitation of the burn patient in icuGhaleb Almekhlafi
This document discusses advances in burn care over the last 50 years that have improved survival rates and reduced morbidity and mortality. Key factors contributing to improved outcomes include developments in resuscitation protocols, respiratory support, infection control, early burn wound closure, and early enteral nutrition. The document then provides guidance on various aspects of burn patient management and treatment, including vascular access, monitoring, resuscitation formulas and endpoints, wound management, pain management, and nutrition.
This document provides an overview of a seminar on advanced cardiovascular life support (ACLS) algorithms and interventions for cardiac arrest. The seminar will cover rhythms that can cause cardiac arrest, monitoring during CPR, establishing vascular access, advanced airways, medications for arrest rhythms, and interventions not recommended for routine use. Key points include: the importance of high-quality CPR and timely defibrillation to increase return of spontaneous circulation and survival; using vasopressors, amiodarone, or lidocaine for refractory rhythms; monitoring end-tidal CO2, coronary perfusion pressure, and central venous oxygen saturation to guide CPR quality; and avoiding routines use of atropine, calcium,
Enhanced external counterpulsation (eecp) role inMonir zaman
Enhanced external counterpulsation (EECP) involves the use of inflatable cuffs wrapped around the lower extremities that are synchronized with the cardiac cycle to improve coronary perfusion. A study investigated EECP in patients with heart failure and found it improved exercise duration but not peak oxygen consumption compared to medical therapy alone. While EECP appears safe, more research is still needed to determine its efficacy in treating heart failure.
The document discusses guidelines and recommendations for weaning patients from mechanical ventilation and discontinuing ventilator support. Some key points covered include:
- Weaning involves gradually reducing ventilatory support as a patient's condition improves to avoid complications of prolonged ventilation.
- Readiness for weaning depends on recovery from the underlying medical issues, overall clinical condition, and psychological state.
- Spontaneous breathing trials are recommended to assess a patient's ability to breathe independently without ventilator support.
- Factors like ventilator mode, oxygen needs, airway protection, and non-respiratory medical conditions must be considered during the weaning process.
- Protocols and guidelines aim to standard
anaesthesia for Lung resection surgeriesJunaid Arif
This document discusses anaesthesia considerations for lung resection surgeries. It outlines key points about pre-operative evaluation including assessing respiratory function via tests like FEV1, DLCO and VO2 max to determine risk. Concurrent medical conditions like cardiac disease, pulmonary hypertension, renal dysfunction and COPD are also evaluated. Thresholds for increased risk are outlined for various tests to guide surgical risk stratification and optimization.
1) The documents discuss several ongoing and planned clinical trials investigating optimal post-resuscitation care and targets for oxygen, carbon dioxide, temperature management, and other factors after return of spontaneous circulation (ROSC) following cardiac arrest.
2) The TAME Cardiac Arrest Trial will investigate whether targeted therapeutic mild hypercapnia improves outcomes compared to standard normocapnia care.
3) The TTM-2 Trial will compare outcomes between post-cardiac arrest patients treated with targeted temperature management at 33°C versus 37.5°C.
4) Together these trials and others aim to establish best practices for multisystem organ support after cardiac arrest to optimize survival and neurological outcomes.
1) Pre-intubation hypotension and hypoxemia are significant risk factors for cardiac arrest during intubation, especially in critically ill children.
2) Techniques to improve hemodynamics and oxygenation prior to intubation include IV fluids, push dose epinephrine, adjusting induction/paralytic doses, apneic oxygenation, and awake intubation if possible.
3) Metabolic acidosis also increases risk, so consider delaying intubation with brief non-invasive ventilation if acidosis can be corrected.
This document discusses bronchial thermoplasty, a non-pharmacological treatment for moderate-to-severe asthma. It works by delivering radiofrequency energy to the airways to reduce airway smooth muscle, which should decrease bronchoconstriction and asthma exacerbations. The procedure involves using a catheter with an expandable electrode array that is inserted via bronchoscope to deliver the radiofrequency energy in a timed manner over three sessions. Potential short term side effects include wheezing, coughing and chest discomfort that typically resolve within a week.
Journal Presentation on article Comparative efficacy of different combination...Shubham Jain
Journal Presentation on article Comparative efficacy of different combinations of acapella, active cycle of breathing technique, and external diaphragmatic pacing in perioperative patients with lung cancer
The document summarizes updates from the 2015 CPR and ECC guidelines developed by the International Liaison Committee on Resuscitation (ILCOR). Key changes included emphasizing high-quality chest compressions, use of automated external defibrillators, and early defibrillation for cardiac arrest. The guidelines were informed by reviews of over 250 studies and recommendations were made using the GRADE methodology. Updates were provided for defibrillation, airway management, drug administration including epinephrine timing, and post-cardiac arrest care such as targeted temperature management.
This document summarizes trends and developments in the management of acute coronary syndromes (ACS). It discusses improvements in pre-hospital care like early ECGs that aid diagnosis and direct transport to catheterization labs. In-hospital, point-of-care testing of biomarker panels can safely rule out heart attacks within 90 minutes and allow more patients to be discharged earlier from emergency departments. Adherence to guidelines for evidence-based medical therapies and quality improvement standards is associated with better outcomes for ACS patients.
PowerPoint presentation on ECMO (Extracorporeal Membrane Oxygenation). Part 2 focuses on Monitoring ECMO patients
Ventilatory strategies, Sedation and pain control, Weaning, Complications and recent advances in ECMO. For better understanding please have a look at ECMO part 1 before going through part 2.
This document discusses airway secretion clearance techniques in the ICU, including mechanical insufflation-exsufflation (MIE). It provides a timeline of MIE devices including the CoughAssist. A case study describes how MIE was used successfully via face mask in an 18-year-old post-op patient to avoid intubation. Typical treatment protocols for the CoughAssist E-70 are outlined. Studies show MIE can improve respiratory parameters and allow extubation of restrictive patients to noninvasive ventilation. The evidence suggests MIE is safe and effective for both obstructive and restrictive lung diseases.
Based on the details provided, the results of this study appear to be applicable and helpful for guiding treatment decisions for patients similar to those enrolled in the trial - namely, patients with moderate PE who are ineligible for full-dose thrombolysis. The treatment appears feasible and significantly reduced important clinical outcomes. As with any intervention, the risks and benefits for an individual patient should be considered.
The skin is the largest organ and its health plays a vital role among the other sense organs. The skin concerns like acne breakout, psoriasis, or anything similar along the lines, finding a qualified and experienced dermatologist becomes paramount.
How to Control Your Asthma Tips by gokuldas hospital.Gokuldas Hospital
Respiratory issues like asthma are the most sensitive issue that is affecting millions worldwide. It hampers the daily activities leaving the body tired and breathless.
The key to a good grip on asthma is proper knowledge and management strategies. Understanding the patient-specific symptoms and carving out an effective treatment likewise is the best way to keep asthma under control.
Histololgy of Female Reproductive System.pptxAyeshaZaid1
Dive into an in-depth exploration of the histological structure of female reproductive system with this comprehensive lecture. Presented by Dr. Ayesha Irfan, Assistant Professor of Anatomy, this presentation covers the Gross anatomy and functional histology of the female reproductive organs. Ideal for students, educators, and anyone interested in medical science, this lecture provides clear explanations, detailed diagrams, and valuable insights into female reproductive system. Enhance your knowledge and understanding of this essential aspect of human biology.
- Video recording of this lecture in English language: https://youtu.be/Pt1nA32sdHQ
- Video recording of this lecture in Arabic language: https://youtu.be/uFdc9F0rlP0
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Osvaldo Bernardo Muchanga-GASTROINTESTINAL INFECTIONS AND GASTRITIS-2024.pdfOsvaldo Bernardo Muchanga
GASTROINTESTINAL INFECTIONS AND GASTRITIS
Osvaldo Bernardo Muchanga
Gastrointestinal Infections
GASTROINTESTINAL INFECTIONS result from the ingestion of pathogens that cause infections at the level of this tract, generally being transmitted by food, water and hands contaminated by microorganisms such as E. coli, Salmonella, Shigella, Vibrio cholerae, Campylobacter, Staphylococcus, Rotavirus among others that are generally contained in feces, thus configuring a FECAL-ORAL type of transmission.
Among the factors that lead to the occurrence of gastrointestinal infections are the hygienic and sanitary deficiencies that characterize our markets and other places where raw or cooked food is sold, poor environmental sanitation in communities, deficiencies in water treatment (or in the process of its plumbing), risky hygienic-sanitary habits (not washing hands after major and/or minor needs), among others.
These are generally consequences (signs and symptoms) resulting from gastrointestinal infections: diarrhea, vomiting, fever and malaise, among others.
The treatment consists of replacing lost liquids and electrolytes (drinking drinking water and other recommended liquids, including consumption of juicy fruits such as papayas, apples, pears, among others that contain water in their composition).
To prevent this, it is necessary to promote health education, improve the hygienic-sanitary conditions of markets and communities in general as a way of promoting, preserving and prolonging PUBLIC HEALTH.
Gastritis and Gastric Health
Gastric Health is one of the most relevant concerns in human health, with gastrointestinal infections being among the main illnesses that affect humans.
Among gastric problems, we have GASTRITIS AND GASTRIC ULCERS as the main public health problems. Gastritis and gastric ulcers normally result from inflammation and corrosion of the walls of the stomach (gastric mucosa) and are generally associated (caused) by the bacterium Helicobacter pylor, which, according to the literature, this bacterium settles on these walls (of the stomach) and starts to release urease that ends up altering the normal pH of the stomach (acid), which leads to inflammation and corrosion of the mucous membranes and consequent gastritis or ulcers, respectively.
In addition to bacterial infections, gastritis and gastric ulcers are associated with several factors, with emphasis on prolonged fasting, chemical substances including drugs, alcohol, foods with strong seasonings including chilli, which ends up causing inflammation of the stomach walls and/or corrosion. of the same, resulting in the appearance of wounds and consequent gastritis or ulcers, respectively.
Among patients with gastritis and/or ulcers, one of the dilemmas is associated with the foods to consume in order to minimize the sensation of pain and discomfort.
Co-Chairs, Val J. Lowe, MD, and Cyrus A. Raji, MD, PhD, prepared useful Practice Aids pertaining to Alzheimer’s disease for this CME/AAPA activity titled “Alzheimer’s Disease Case Conference: Gearing Up for the Expanding Role of Neuroradiology in Diagnosis and Treatment.” For the full presentation, downloadable Practice Aids, and complete CME/AAPA information, and to apply for credit, please visit us at https://bit.ly/3PvVY25. CME/AAPA credit will be available until June 28, 2025.
Breast cancer: Post menopausal endocrine therapyDr. Sumit KUMAR
Breast cancer in postmenopausal women with hormone receptor-positive (HR+) status is a common and complex condition that necessitates a multifaceted approach to management. HR+ breast cancer means that the cancer cells grow in response to hormones such as estrogen and progesterone. This subtype is prevalent among postmenopausal women and typically exhibits a more indolent course compared to other forms of breast cancer, which allows for a variety of treatment options.
Diagnosis and Staging
The diagnosis of HR+ breast cancer begins with clinical evaluation, imaging, and biopsy. Imaging modalities such as mammography, ultrasound, and MRI help in assessing the extent of the disease. Histopathological examination and immunohistochemical staining of the biopsy sample confirm the diagnosis and hormone receptor status by identifying the presence of estrogen receptors (ER) and progesterone receptors (PR) on the tumor cells.
Staging involves determining the size of the tumor (T), the involvement of regional lymph nodes (N), and the presence of distant metastasis (M). The American Joint Committee on Cancer (AJCC) staging system is commonly used. Accurate staging is critical as it guides treatment decisions.
Treatment Options
Endocrine Therapy
Endocrine therapy is the cornerstone of treatment for HR+ breast cancer in postmenopausal women. The primary goal is to reduce the levels of estrogen or block its effects on cancer cells. Commonly used agents include:
Selective Estrogen Receptor Modulators (SERMs): Tamoxifen is a SERM that binds to estrogen receptors, blocking estrogen from stimulating breast cancer cells. It is effective but may have side effects such as increased risk of endometrial cancer and thromboembolic events.
Aromatase Inhibitors (AIs): These drugs, including anastrozole, letrozole, and exemestane, lower estrogen levels by inhibiting the aromatase enzyme, which converts androgens to estrogen in peripheral tissues. AIs are generally preferred in postmenopausal women due to their efficacy and safety profile compared to tamoxifen.
Selective Estrogen Receptor Downregulators (SERDs): Fulvestrant is a SERD that degrades estrogen receptors and is used in cases where resistance to other endocrine therapies develops.
Combination Therapies
Combining endocrine therapy with other treatments enhances efficacy. Examples include:
Endocrine Therapy with CDK4/6 Inhibitors: Palbociclib, ribociclib, and abemaciclib are CDK4/6 inhibitors that, when combined with endocrine therapy, significantly improve progression-free survival in advanced HR+ breast cancer.
Endocrine Therapy with mTOR Inhibitors: Everolimus, an mTOR inhibitor, can be added to endocrine therapy for patients who have developed resistance to aromatase inhibitors.
Chemotherapy
Chemotherapy is generally reserved for patients with high-risk features, such as large tumor size, high-grade histology, or extensive lymph node involvement. Regimens often include anthracyclines and taxanes.
Test bank for karp s cell and molecular biology 9th edition by gerald karp.pdfrightmanforbloodline
Test bank for karp s cell and molecular biology 9th edition by gerald karp.pdf
Test bank for karp s cell and molecular biology 9th edition by gerald karp.pdf
Test bank for karp s cell and molecular biology 9th edition by gerald karp.pdf
NAVIGATING THE HORIZONS OF TIME LAPSE EMBRYO MONITORING.pdfRahul Sen
Time-lapse embryo monitoring is an advanced imaging technique used in IVF to continuously observe embryo development. It captures high-resolution images at regular intervals, allowing embryologists to select the most viable embryos for transfer based on detailed growth patterns. This technology enhances embryo selection, potentially increasing pregnancy success rates.
“Psychiatry and the Humanities”: An Innovative Course at the University of Mo...Université de Montréal
“Psychiatry and the Humanities”: An Innovative Course at the University of Montreal Expanding the medical model to embrace the humanities. Link: https://www.psychiatrictimes.com/view/-psychiatry-and-the-humanities-an-innovative-course-at-the-university-of-montreal
1. 2013 OEMS Prehospital2013 OEMS Prehospital
Protocol UpdateProtocol Update
Amy Gutman MD
EMS Medical Director
prehospitalmd@gmail.com / www.teaems.com
May 2013
2. ObjectivesObjectives
• Inform Massachusetts
pre-hospital providers of
updates to the OEMS
Pre-hospital Treatment
protocols effective as of
June 15, 2013
• Review evidence-based
literature rationale behind
the changes
www.mass.gov/dph/oems
3. Medication ChangesMedication Changes
• Majority of changes are
route-related or provide
alternatives during
medication shortages
• Updated wording reflects
national standards, for
example removing “trailing
zeros” from medication
dosing in all protocols,
appendixes & drug
references
www.jointcommission.org
Rationale: Joint Commission safety recommendation, consistent with
national patient care practices
4. General Principles for Specific SkillsGeneral Principles for Specific Skills
• EMS crews should not begin or administer interventions that
require further medical assessment if the patient is being
transported to an environment where the intervention will not
be provided / monitored
– i.e. Giving IV narcotics to patient not being transported to a medical facility
• This principle does not apply to giving medications if the
patient is being transported to a facility where personnel are
available to assess the patient, such as a physician’s office or a
skilled nursing facility
Rationale: Clarification of role of EMS as medical providers
5. General Principles for Specific SkillsGeneral Principles for Specific Skills
• Recent advances in resuscitation science have increased potential for
survival in out-of-hospital cardiac arrest (OOHCA)
• Some MA EMS systems monitor their OOHCA survival rates with
excellent results comparable to national norms. Ideally every EMS
system should monitor & strive to improve their OOHCA survival rates
• For services not currently monitoring & taking steps to improve their
OOHCA outcomes the following is recommended:
– EMD instructions to provide hands-only CPR if patient unconscious & not
breathing normally
– Emphasis on continuous compressions to maintain 80% compression fraction
– Delay intubation to after 1st
8 minutes of CPR in primary cardiac arrest to avoid
interrupting compressions
– Field initiated followed by in-hospital hypothermia for ROSC
– Rapid 12-lead EKG after ROSC to determine if STEMI POE should be used
Rationale: Monitoring out-of-hospital cardiac arrest care
6. Ewy GA, Sanders AB. Alternative approach to improving
survival of patients with out-of-hospital primary cardiac
arrest (OOHCA). J Am Coll Cardiol. 2013. Jan 15;61(2):113-8
• Cardiocerebral resuscitation (CCR) significantly improved survival of
OOHCA patients in 2 Wisconsin counties from 15% to 39%, and in 60
Arizona EMS departments to 38% over one year. Using CCR, over a
five year period, survival from primary cardiac arrest in Arizona
increased from 18% to 33%
• Conclusions: Advocating bystander compression only CPR for
patients with primary OOHCA, and encouraging EMS CCR vs prior
CPR guidelines which included emphasis on ventilations and early
airway management
7. Ewy GA, Kern KB. Recent advances in cardiopulmonary
resuscitation: cardiocerebral resuscitation. J Am Coll
Cardiol. 2009 Jan 13;53(2):149-57
• CCR advocates continuous compressions without mouth-to-mouth
ventilations for witnessed cardiac arrest
• For bystanders with AED access & EMS arriving in electrical (1st
4-5
minutes) phase of VF, prompt defibrillation recommended
• For EMS arriving in circulatory phase of VF arrest (>5 minutes) when
fibrillating myocardium has used up energy stores, compressions
mandatory prior to & immediately after defibrillation
• Recommendations: delayed endotracheal intubation, avoid excessive
ventilations, & utilize early epinephrine
8. Clemmensen P, et al. Diversion of STEMI patients for primary
angioplasty (pPCI) based on wireless prehospital 12-lead ECG
transmission directly to cardiologist's handheld computer: a
progress report. J Electrocardiol. 2005 Oct;38:194-8
• Time to reperfusion critical in STEMI patients. Transfer from receiving
hospital to a catheterization center can cause unacceptable delays
• Prehospital ECGs transmitted for 408 CP patients (success 93%).
Cardiologists receiving ECG recommended 113 patients (28%)
diverted for pPCI
• Results: EMS scene time increased by 7 minutes when ECG
transmitted to cardiologist compared to control group. Time from ECG
to ED arrival 25 minutes. Hospital treatment time significantly reduced
for diverted patients - ED arrival to pPCI 40 minutes vs. 94 minutes in
control group
9. Wenzel V, et al. Comments on the 2010 guidelines on
cardiopulmonary resuscitation of the European
Resuscitation Council. Anaesthesist. 2010 Dec;59(12):1105-23
• Chest compressions minimum 100/min, 5 cm depth at ratio of 30:2
with ventilation. Avoid interruptions in compressions to ventilate
• After every defibrillation attempt (initially biphasic 120-200J,
monophasic 360J, subsequently with respective highest energy),
compressions immediately reinitiated for 2 minutes independent of
rhythm
• ETI performed only by experienced providers during ongoing
compressions with a maximum interruption of 10 sec to pass ETT
through vocal cords. Supraglottic airways are alternatives to ETI
• Active compression-decompression & inspiratory threshold valve are
not superior to good standard CPR
10. Wenzel V, et al. Comments on the 2010 guidelines on
cardiopulmonary resuscitation of the European
Resuscitation Council. Anaesthesist. 2010 Dec;59(12):1105-23
• Pediatric BLS:
– Initially 5 rescue breaths, followed by compressions (100-
120/min depth 1/3chest diameter), compression-ventilation
ratio 15:2
– Foreign body airway obstruction with insufficient cough:
alternate back blows & compressions (infants), or
abdominal compressions (>1 yo)
• Pediatric ALS:
– Epinephrine 10 ug/kg IV or IO every 3-5 minutes.
Defibrillation (4 J/kg) followed by 2 minutes CPR, then ECG
& pulse check
11. 1.5 ACS, 1.6 ROSC, 3.11 Acute Stroke1.5 ACS, 1.6 ROSC, 3.11 Acute Stroke
• Added: Avoid hyperoxygenation, administer
oxygen using the appropriate delivery device
as clinically indicated
• If pulse oximetry available, give
supplemental oxygen only if oxygen
saturation level <94% on room air
Rationale: Hyperoxygenation causes coronary & systemic
vasoconstriction, resulting in decreased coronary blood flow, increased
coronary vascular resistance & free radical formation
12. Ranchord AM, et al. High-concentration versus titrated
oxygen therapy in STEMI: a pilot randomized controlled
trial. Am Heart J. 2012 Feb;163(2):168-75
• Methods: 136 STEMI patients uncomplicated by cardiogenic shock or
hypoxia randomized to receive high-concentration (>6 L/min) or titrated
O2 (to achieve O2 saturation 93%-96%) for 6 hrs. Outcomes were 30-day
mortality & infarct size assessed by troponin level at 72 hrs. Secondary
outcomes: meta-analysis of mortality data from previous trials, &
infarct size assessed by MRI at 4 - 6 weeks
• Conclusions: No benefit or harm from high-concentration O2 compared
with titrated O2 in uncomplicated STEMI. Because meta-analysis data
had a large confidence interval (meaning, data uncertainty) larger
randomized studies required to resolve any clinical uncertainty
13. Shi J, et al. A new idea about reducing reperfusion injury
in ischemic stroke: Gradual reperfusion. Med Hypotheses.
2013 Feb;80(2):134-6
• Occlusion of intracranial arteries leads to direct cell death with cell
functional impairment surrounding dead core (ischemic penumbra).
Opening the occluded artery to limit ischemic penumbra size is aim of
thrombolysis therapy, but reperfusion induced injury counteracts
potential benefits of thrombolysis
• Conclusions: Gradual reperfusion reduces reperfusion injury by
reducing free radical production; free radicals come from reperfusion
penumbra & respiration cycle which is unregulated during ischemia.
Once reperfusion occurs, respiratory chain enzymes need only normal
amount of O2 & glucose to avoid producing free radical intermediates.
Gradual reperfusion reduces free radical production by limiting O2 &
glucose provided to the respiratory chain
14. 3.4 Bronchospasm/ Respiratory Distress3.4 Bronchospasm/ Respiratory Distress
• Added to ALS-P Standing Orders:
In patient with known asthma or COPD,
without history or findings significant for
CHF give Hydrocortisone 100 mg IV, IM, IO
or Methylprednisolone 125 mg IV, IM or IO
• In patients <40 yo Epinephrine 0.15-0.3 mg
IM* by autoinjector only as 1 time dose,
contact medical control for additional
dosing
• Added to MCO: “BY AUTOINJECTOR
ONLY” for additional dosing
Rationale: Therapy for severe distress by reducing inflammation
associated with bronchospasm; Effective treatment to patients <40 yo
in treatment of bronchospasm/respiratory distress due to asthma;
safety reminder regarding dosing device
www.hubpages.com
15. 4.2 Burns / Inhalation Injuries4.2 Burns / Inhalation Injuries
• Added to ALS-P Standing
Orders:
In patient with hypotension,
AMS, or indications of
cyanide toxicity who may
have experienced smoke
inhalation, consider
Hydroxocobalamin 5gm IV
over 15 minutes (adult), or 70
mg/kg (to max 5 gm) IV over
15 minutes (pediatric)
Rationale: Effective treatment for acute cyanide poisoning
sanatate.bzi.ro
16. O’Brien DJ, et al. Empiric management of cyanide
toxicity associated with smoke inhalation. Prehosp
Disaster Med. 2011. Oct;26(5):374-82
• Closed-space smoke inhalation 5th
most common cause of US
unintentional injury deaths. Cyanide is a toxin in many cases of smoke
inhalation but it’s presence cannot be rapidly confirmed
• Findings suggesting cyanide toxicity include: closed-space fire with
likely smoke inhalation; oropharyngeal soot or carbonaceous
expectorations; altered LOC, otherwise inexplicable hypotension
• Prehospital studies demonstrate feasibility & safety of empiric
treatment with FDA-approved hydroxocobalamin for patients with
suspected smoke inhalation cyanide toxicity. Based on literature
review & on-site observation of the Paris Fire Brigade, prehospital
protocols to guide empiric & early hydroxocobalamin administration in
smoke inhalation victims with high-risk presentations recommended
17. 4.3 Head Trauma &4.3 Head Trauma &
4.7 Spinal Column / Cord Injuries4.7 Spinal Column / Cord Injuries
4.3 Head Trauma
• Removed: “Hyperventilation may help
brain injury by reducing intracranial
pressure. Hyperventilate patient in
suspected cases of herniation
syndrome (e.g. decorticate posturing,
decerebrate posturing, fixed, dilated
pupils, etc.)”
• Removed: “Consider hyperventilation
if clinically appropriate with a
significant closed head injury & signs
of herniation syndrome”
4.7 Spinal Column / Cord Injuries
• Removed: “Consider hyperventilation
with 100% oxygen with BVM if
associated with a significant closed
head injury & signs of herniation
syndrome”
Rationale: Hyperventilation causes increased ICP & decreased
peripheral blood flow, worsening patient outcomes
18. Dumont TM, et al. Inappropriate prehospital ventilation in
severe traumatic brain injury increases in-hospital
mortality. J Neurotrauma. 2010. Jul;27(7):123-41
• In traumatic brain injury (TBI), hyperventilation to reduce ICP may be life-
saving. However, undue use of hyperventilation may increase incidence of
secondary brain injury through direct reduction of cerebral blood flow
• Methods: TBI patients with GCS <8 (n = 65) sorted into hypocarbic (Pco2
<35 mmHg), normocarbic (Pco2 35-45 mmHg), & hypercarbic (Pco2 >45
mmHg). Survival related to admission Pco2 in TBI patients requiring ETI.
Patients with normocarbia had in-hospital mortality of 15%, significantly
improved over patients presenting with hypocarbia (77% mortality) or
hypercarbia (61% mortality).
• Conclusions: Abnormal Pco2 on presentation after TBI correlated with
increased in-hospital mortality and advocate prehospital normoventilation
19. 4.6 Soft Tissue / Crush Injury4.6 Soft Tissue / Crush Injury
• Removed: under Basic Procedures words
“direct pressure”, “pressure points”
• Added: “If suspect severe crushing injury /
compartment syndrome, if injury permits”
Rationale: To avoid contradicting new changes for hemorrhage control
(direct pressure followed by tourniquet). Allows use of tourniquet if no
other way to stop hemorrhage
20. 4.7 Spinal Column / Cord Injuries4.7 Spinal Column / Cord Injuries
• Added: “Evidence of non-penetrating trauma
above the clavicles” when considering spinal
immobilization
Note: Patients with penetrating trauma who
were immobilized had worse overall
outcomes
Rationale: Immobilized patients with penetrating trauma have worse
outcomes than non-immobilized patients
21. Paiva WS, et al. Spinal cord injury and its association with
blunt head trauma. Int J Gen Med. 2011;4:613-5
• What are risk factors for spine trauma plus traumatic brain injury (TBI)?
• Results: 180 pts with moderate or severe TBI had cervical spine x-ray
and CT. Most common causes of TBI were pedestrians struck by
vehicles (31%), MVC (28%) & falls (25%). Systemic injuries found in 80
(44%) patients. 53% had severe , & 47% had moderate head trauma. 14
patients (8%) had a spinal cord injury (12 cervical, 1 lumbar, 1 thoracic).
In the elderly, presence of systemic injuries & GCS <9 were significant
risk factors for spine injury
• Conclusions: Spinal cord injury related to moderate & severe brain
trauma usually affects the cervical spine
22. 4.7 Spinal Column / Cord Injuries4.7 Spinal Column / Cord Injuries
• Deleted: “including adult fall from standing”
from the high risk factors for determining
possible spinal injury
• Age <8 years or >65 years still considered
“high risk mechanisms”
Rationale: Fall from standing only a risk in patients >65 years of age
23. Lomoschitz FM, et al. Cervical spine injuries in patients 65
years old & older: epidemiologic analysis regarding the effects
of age & injury mechanism on distribution, type, & stability of
injuries. Am J Roentgenol. 2002 Mar;178(3):573-7
• Methods & Results: 225 cervical spine injuries in 149 patients >65 yo
retrospectively assessed. Mechanism (falls from standing or seated
height vs higher energy mechanisms) & initial neurologic status
recorded. 95 (64%) patients had upper cervical injuries. 59 (40%)
patients had multilevel injuries. Main causes for cervical injuries were
MVCs in "young elderly" (65-75 yo; 61%) & falls from standing or
seated height in "old elderly" (>75yo; 40%). Patients >75 yo
(independent of mechanism), & patients falling from standing height
(independent of age), more likely to injure the upper cervical spine
• Conclusions: Elderly patients in general including those falling from
standing height are more prone to injuries of the cervical spine
24. 4.10 Traumatic Amputations4.10 Traumatic Amputations
• Language Added to Basic
Procedures:
– Control/stop any life
threatening hemorrhage
– If other methods cannot
control bleeding apply
appropriate tourniquet
– Document exact time of
tourniquet application
Rationale: ITLS recommends use of tourniquets to control life
threatening bleeding; pressure points & elevation have been removed
www.thefreedictionary.com
25. Kragh JF, et al. Survey of the indications for use of
emergency tourniquets. J Spec Oper Med. 2011
Winter;11(1):30-8
• Optimal tourniquet use in trauma appears to depend on device,
doctrine, training, speedy evacuation, & performance improvement.
Challenges remain in estimation of blood loss & injury lethality
• Methods: Data on emergency tourniquet use analyzed from a clinical
study of 728 casualties with 953 tourniqueted limbs. Authors compared
known prior datasets to this clinical study
• Recommendations: Current indication for emergency tourniquet use is
any compressible limb wound that provider assesses as having
possibly lethal hemorrhage. This indication has shown good outcomes
only when devices, training, doctrine, evacuation & research optimized
26. Appendix D Emergent AirwayAppendix D Emergent Airway
• Appendix renamed “Difficult Airway Protocol”
Rationale: More representative of when process should be utilized
27. Appendix T Nerve Agent Dosing &Appendix T Nerve Agent Dosing &
Reference TableReference Table
• Added: Duodote to Appendix T
• Mark I kits & Duodote not approved
for routine pediatric use, however
should be used as initial therapy for
children with life-threatening nerve
agent toxicity (in extremis) when IV
therapy not available
• “Assumes” 0.8 inch needle insertion
depth
Rationale: Accepted treatment for children with severe life-threatening
nerve agent toxicity
www.myfirefighternation.com
28. 1.1 Asystole1.1 Asystole
• Added to ALS-P Standing
Orders:
if Epinephrine 1:10,000
unavailable due to drug
shortage,
Vasopressin 40 units may be
substituted & given every 20
minutes IV or IO
Rationale: Handle epinephrine shortages
www.drugline.org
29. Wenzel V, et al. A comparison of vasopressin & epinephrine
for out-of-hospital cardiopulmonary resuscitation. NEJM.
2004 Jan 8;350(2):105-13
• Background: Vasopressin is an alternative to epinephrine for
vasopressor therapy during CPR
• Study Methods: Adults with OOHCA received 2 injections of either 40
IU of vasopressin or 1 mg of epinephrine, followed by additional
treatment with epinephrine if needed. Primary end point was survival
to admission; secondary end point was survival to discharge
• Study Conclusions: Effects of vasopressin similar to those of
epinephrine in management of VF and PEA, but vasopressin superior
to epinephrine in patients with asystole. Vasopressin followed by
epinephrine may be more effective than epinephrine alone in
refractory cardiac arrest
30. Protocols / References Involving Morphine andProtocols / References Involving Morphine and
FentanylFentanyl
(1.2, 1.3, 1.4, 1.5, 1.9, 1.11, 3.7, 3.14, 4.2, 5.13)(1.2, 1.3, 1.4, 1.5, 1.9, 1.11, 3.7, 3.14, 4.2, 5.13)
• Standing Orders:
– Deleted “This is a one time dose option”; Replaced with
“Medication dose may be given in divided doses up to the
maximum”
– This includes titrating to pain control for ACS (Protocol 1.5)
• Added:
– Fentanyl linked to drug reference page
– IM route added for Fentanyl
Rationale: Allow pain control titration of under standing orders,
technical fix to text, added administration route
31. Protocols & References InvolvingProtocols & References Involving
Epinephrine (1.4,1.6, 3.2, 5.1, 5.2, 5.3, 5.5)Epinephrine (1.4,1.6, 3.2, 5.1, 5.2, 5.3, 5.5)
• Infusion:
– Administer 1 mcg to 10 mcg /
min IV or IO
– For example: mix 1 mg of
1:1000 Epinephrine in 250 ml
NS
– 15 micro drops/min = 1 mcg /
min
Rationale: Standardized language, administration routes clarified by
adding IV & IO routes
commons.wikimedia.org
32. 1.5 ACS1.5 ACS
• NTG 0.3mg removed
from MCO section
• Standardized dosing
remains the same of
0.4mg under standing
order
Rationale: Standardized language
www.webmed.com
33. Protocols Involving Amiodarone (1.6 & 1.11Protocols Involving Amiodarone (1.6 & 1.11))
• Added: “for example” to
drip information
– Amiodarone 1 mg/min
IV drip for example:
100mg/100ml - 1mg/min
Rationale: Standardize dosing option in ALS-P & MCO
www.rxprescriptionguide.org
34. Allergic Reaction/AnaphylaxisAllergic Reaction/Anaphylaxis
3.2 Adult
• Added:
– IO route to diphenhydramine
• Added to ALS-P Standing Orders:
– Hydrocortisone 100 mg IV, IM, IO
or
– Methylprednisolone 125 mg IV, IM
or IO
• Added to MCO Section:
– Epinephrine “by autoinjector
only” 1:1,000: 0.15-0.3mg IM
5.2 Pediatric
• Added:
– IO route to diphenhydramine
• Added to ALS-P Standing Orders:
– Hydrocortisone 2 mg/k. to
maximum 100 mg IV, IM, IO or
– Methylprednisolone 2 mg/kg to
maximum125 mg IV, IM or IO
Rationale: Appropriate administration & therapy route to rapidly reduce
inflammation; safety reminder
35. 3.13 Toxicology / Poisoning / SA / OD3.13 Toxicology / Poisoning / SA / OD
• Deleted:
– EMT-B procedures
naloxone 0.4mg
– Protocol now reads
“Administer naloxone
2.0mg nasal via atomizer”
Rationale: Correct dosing as under special project waivers
store.airwaycam.com
36. Merlin MA, et al. Intranasal naloxone delivery is an
alternative to intravenous naloxone for opioid overdoses.
Am J EM. 2010. Mar;28(3):296-303
• Proposal that EMS intranasal (IN) naloxone administration preferable
to intravenous (IV) naloxone without risk of needle exposure
• Methods: retrospective chart review of ALS patients performed on
confirmed opioid overdose patients. Initial and final unassisted
respiratory rates & GCS used as indicators of naloxone effectiveness
• Conclusion: IN naloxone statistically as effective as IV naloxone in
reversing effects of opioid overdose with similar average increases in
RR and GCS. IN naloxone is a viable alternative to IV naloxone while
posing less risk of needle stick injury
37. 3.14 Adult Pain & Nausea Management3.14 Adult Pain & Nausea Management
5.13 Pediatric Pain & Nausea Management5.13 Pediatric Pain & Nausea Management
• Added: PO and ODT routes
for Odansetron as a
standing order & treatment
option
Rationale: Reasonable treatment route & formulation without threat of
needlestick injury
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38. SeizuresSeizures
3.9 Adult
• Added To ALS-P Standing Orders:
– Midazolam 2.5-5mg slow IV
push or IM
5.7 Pediatric
• Added To ALS-P Standing Orders:
– Midazolam 0.05 mg/kg IV, IO, IM
to max single dose of 4 mg
Rationale: An option for benzodiazepine therapy shown to work faster
in some studies; addresses medication shortages
39. 5.4 Pediatric Bronchospasm / Respiratory5.4 Pediatric Bronchospasm / Respiratory
DistressDistress
• Added to ALS-P Standing Orders :
– For >2 yo with known diagnosis of asthma;
Hydrocortisone 2 mg/kg to maximum 100 mg IV,
IM, IO or
– Methylprednisolone 2 mg/kg to maximum 125 mg
IV, IM, IO
Rationale: Therapy reduces inflammation associated with bronchospasm
40. Knapp B, Wood C. The prehospital administration of IV
methylprednisolone lowers hospital admission rates for
moderate to severe asthma. PEC. 2003 Oct-Dec;7(4):423-6
• Compare hospital admission rates for patients with moderate to severe
asthma who receive prehospital vs ED methylprednisolone
• Results: 31 moderate to severe asthmatics received prehospital
methylprednisolone. 33 asthmatics transported by EMS & later received
IV methylprednisolone in the ED. Only 13% (4) of patients receiving
prehospital solumedrol were admitted to the hospital vs 33% (11)
receiving solumedrol in the ED
• Conclusions: Patients with moderate to severe asthma receiving
prehospital methylprednisolone have 3 times fewer hospital admissions
41. Summary of Medication ChangesSummary of Medication Changes
• Vasopressin 40 units every 20
minutes IV or IO if Epinephrine
1:10,000 shortage
• Morphine & Fentanyl may be given
in divided doses to the maximum
• IM route added for Fentanyl
42. Summary of Medication ChangesSummary of Medication Changes
• NTG 0.3mg removed from MCO
• IO route added for
Diphenhydramine
• Added Hydrocortisone 100 mg IV,
IM, or IO or Methylprednisolone
125 mg IV, IM or IO
43. Summary of Medication ChangesSummary of Medication Changes
• “By autoinjector only” added to
MCO for Epinephrine 1:1,000, 0.15-
0.3mg IM
• Midazolam 2.5-5mg slow IVP or IM
• Midazolam 0.05 mg/kg IV, IO or IM
to max single dose of 4 mg
(pediatrics)
44. Summary of Medication ChangesSummary of Medication Changes
• PO / ODT as Odansetron
route as a standing order &
a treatment option
45. SummarySummaryprehospitalmd@gmail.com
• This review serves as notification of
the changes to the MA Pre-hospital
Treatment Protocols effective June 15,
2013
• Provide evidence-based information
regarding why changes occurred