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1.
J.A. March M.J. Kiemeney J. De Guzman J.D. Ferguson 《The American journal of emergency medicine》2019,37(3):407-410
Introduction
Cricothyrotomy may be necessary for airway management when a patient's airway cannot be maintained through standard techniques such as oral airway placement, blind insertion airway device, or endotracheal intubation. Wire-guided cricothyrotomy is one of many techniques used to perform a cricothyrotomy. Although there is some controversy over which cricothyrotomy technique is superior, there is no published data regarding long term retention rates. The purpose of this study is to determine whether ground based paramedics can be taught and are able to retain the skills necessary to successfully perform a wire-guided cricothyrotomy.Methods
This retrospective study was performed in a suburban county with a population of 160,000 with 23,000 EMS calls per year. Participants were ground-based paramedics who were taught wire-guided cricothyrotomy as part of a standardized paramedic educational update program. After viewing an instructional video, the paramedics were shown each the steps of the procedure on a simulation model, using a low fidelity task trainer previously developed to train emergency medicine residents. Using a 16 step procedural checklist, participants were allowed open-ended practice using the task trainer. Critical steps in the checklist were marked in bold lettering indicating automatic failure. Each paramedic was then individually supervised performing a minimum of 5 successful simulations. Retention was assessed using the same 16 step checklist 6 to 12?weeks following the initial training.Results
A total of 55 paramedics completed both the initial training and reassessment during the time period studied. During the initial training phase 100% (55 of 55) of the paramedics were successful in performing all 16 steps of the wire-guided cricothyrotomy. During the retention phase, 87.3% (48 of 55) of paramedics retained the skills necessary to successfully perform the wire-guided cricothyrotomy. On the 16 step checklist, most steps were performed successfully by all the paramedics or missed by only 1 of the 55 paramedics. The step involving removal of the needle prior to advancing the airway device over the guide wire was missed by 34.5% (19 of 55) of the participants. This was not an automatic failure since most participants immediately self-corrected and completed the procedure successfully.Conclusion
Paramedics can be taught and can retain the skills necessary to successfully perform a wire-guided cricothyrotomy on a simulator. Future research is necessary to determine if paramedics can successfully transfer these skills to real patients. 相似文献2.
Young Jin Gu Jae Hoon Lee Jung In Seo 《The American journal of emergency medicine》2019,37(3):539-542
Background
Increasing the size of the central veins is required to increase the success rate of central line placement and decrease complication risk. Right-sided approach for the central veins, Valsalva maneuver, and Trendelenburg position have been recommended, but these may not be available for some cases. This study aimed to determine a more convenient patient position that can result in the largest central vein diameter.Methods
Recruited subjects were placed in 60° and 30° upper body elevation, supine position, and 30° and 60° lower body elevation, and lumbar elevation (LE) was consecutively performed, with one position maintained for 10?min. Diameters of the subclavian vein (SCV) and internal jugular vein (IJV) were measured using high-resolution two-dimensional ultrasonography at each position.Results
The most suitable position on the ordinary bed for increasing central vein diameter was LE. The maximum and minimum SCV and IJV diameters in LE were significantly larger than those in the supine position (SCV: coefficients ?0.633 and ?0.863, p?=?0.08 and 0.011, respectively; IJV: coefficients ?1.09 and ?1.15, p?<?0.001 and?=?0.001, respectively). Leg elevation for 10?min failed to dilate the central vein diameter.Conclusion
The LE without leg elevation produced a greater and more significant increase in central vein diameter than the supine position and may be useful for central line placement. 相似文献3.
Pawel Gawlowski Jacek Smereka Marcin Madziala Lukasz Szarpak Michael Frass Oliver Robak 《The American journal of emergency medicine》2017,35(3):484-487
Introduction
Endotracheal intubation (ETI) using a Macintosh laryngoscope (MAC) requires the head to be positioned in a modified Jackson position, slightly reclined and elevated. Intubation of trauma patients with an injured neck or spine is therefore difficult, since the neck usually cannot be turned or is already immobilized in order to prevent further injury. The iGEL supraglottic airway seems optimal for such conditions due to its blind insertion without the need of a modified Jackson position.Methods
Prospective, randomized, crossover study in 46 paramedics. Participants performing standard intubation and blind intubation via iGEL supraglottic airway device in three airway scenarios: Scenario A – normal airway; Scenario B - manual inline cervical immobilization, performed by an independent instructor; scenario C: cervical immobilization using a standard Patriot cervical extraction collar.Results
In Scenario A, nearly all participants performed ETI successfully both with MAC and iGEL (100% vs. 95.7%). The time to intubation (TTI) using the MAC and iGEL amounted to 19 [IQR, 18–21]s vs. 12 [IQR, 11–13]s (P < 0.001). Head extension angle as well as tooth compression were significantly better with the iGEL compared to the MAC (P < 0.001). In scenario B and C, the results with the iGEL were significantly better than with MAC for all analyzed variables (TTI, success of first intubation attempt, head extension angle, tooth compression and VAS scores).Conclusion
We showed that blind intubation with the iGEL supraglottic airway was superior to ETI performed by paramedics in a simulated cervical immobilization scenario in a manikin in terms of success rate, time to definite tube placement, head extension angle, tooth compression, and rating. 相似文献4.
Nalan Kozaci Mustafa Avcı Ertan Ararat Tansu Pinarbasili Muharrem Ozkaya Ibrahim Etli Eda Donertas Omer F. Karakoyun 《The American journal of emergency medicine》2019,37(5):864-868
Objective
In this study, the accuracy of bedside thoracic ultrasonography (TUSG) performed by emergency physicians with patients in the supine position was compared with that of thoracic computed tomography (TCT) for the determination of thoracic injuries due to trauma.Methods
Patients who suffered the multiple traumas, whose thoracic trauma was identified on physical examination or TCT imaging were included in the study. TUSG was performed following a physical examination by the emergency physician who managed the trauma patient. Subcutaneous emphysema, pneumothorax, pulmonary contusions (PCs), hemothorax, pericardial effusion and tamponade, sternal and clavicular fractures and rib fractures were identified by TUSG. TCT imaging was performed after the ultrasonography examination was completed.Results
Eighty-one patients were included in the study. TCT scans showed subcutaneous emphysema in 16 (19.8%) patients, pneumothorax in 21 (25.9%), PCs in 27 (33.3%), hemothorax in 20 (24.7%), sternum and clavicular fractures in 6 (7.4%) and rib fractures in 21 (25.9%). The sensitivity and specificity of ultrasonography varied for detecting the following pathologies: subcutaneous emphysema (56% and 95%), pneumothorax (86% and 97%), hemothorax (45% and 98%), PCs (63% and 91%), sternal fractures (83% and 97%), clavicular fractures (83% and 100%) and rib fractures (67% and 98%), respectively.Conclusion
In conclusion, ultrasound was found to be highly specific but only moderately sensitive for the identification of thoracic injuries. 相似文献5.
Introduction
Transgender and gender non-conforming (TGNC) people in the United States face disproportionate rates of mental health disorders, including suicidality, depression, anxiety, and substance use disorders than the general population. Patients' experiences utilizing mental healthcare is a determinant in their care-seeking behaviors and treatment success.Aim/question
The purpose of this integrative review is to better understand the firsthand mental healthcare experiences of TGNC persons.Method
The authors sought to locate recent English-language articles that described the mental healthcare experiences of TGNC persons. To do so, only articles that conducted data collection with a TGNC sample were considered for review.Results
Seven articles met criteria for review. Four themes emerged that depicted experiences of health promotion (welcoming environments, staff knowledge and response) and health prevention (enacted stigma, racial disparities and intersectional insensitivity).Discussion
Themes indicated that TGNC persons have mixed experiences (excellent to harmful/damaging) when receiving mental healthcare. There is room for healthcare provider growth in skills to increase TGNC cultural competency.Implications for practice
Mental healthcare providers and nurses would benefit from interventions to promote TGNC culturally competent care, including in-service training or continuing education for the current work force as well as incorporating TGNC content into pre-licensure educational curricula. 相似文献6.
7.
Angela Hua Stephen Haight Robert S. Hoffman Alex F. Manini 《The Journal of emergency medicine》2017,52(1):59-65
Background
Drug overdose is the leading cause of injury-related fatality in the United States, and respiratory failure remains a major source of morbidity and mortality.Objectives
We aimed to identify the incidence and risk factors for endotracheal intubation after acute drug overdose.Methods
This secondary data analysis was performed on a 5-year prospective cohort at two urban tertiary-care hospitals. The present study analyzed adult patients with suspected acute drug overdose to derive independent clinical predictors of endotracheal intubation.Results
We analyzed 2497 patients with acute drug overdose, of whom 87 (3.5%) underwent endotracheal intubation. Independent clinical risk factors for endotracheal intubation were: younger age (odds ratio [OR] 0.97, 95% confidence interval [CI] 0.96–0.98), and history of obstructive lung disease (OR 6.6, 95% CI 3.5–12.3); however, heart failure had no association. Patients with obstructive lung disease had significantly more hypercapnia (mean difference 6.8 mm Hg, 95% CI 2.3–11.3) and a higher degree of acidemia (mean pH difference 0.04, 95% CI 0.01–0.07) than patients without obstructive lung disease. Lack of rapid sequence sedative/paralytic was associated with in-hospital fatality. Early complications of endotracheal intubation itself included desaturation (3.4%) and bradycardia (1%).Conclusions
Endotracheal intubation was infrequently performed on patients with acute drug overdose, and complications were rare when performed. Risk factors associated with endotracheal intubation included younger age and prior obstructive lung disease. 相似文献8.
Background
Despite the evidence and available guidelines about endotracheal suction (ETS), a discrepancy between published guidelines and clinical practice persists. To date, ETS practice in the adult intensive care unit (ICU) population across New Zealand and Australia has not been described.Objective
To describe ICU nurses' ETS practice in New Zealand and Australia including the triggers for performing endotracheal suction.Methods
A single day, prospective observational, binational, multicentre point prevalence study in New Zealand and Australian ICUs. All adult patients admitted at 10:00 on the study day were included.Main outcome measures
In addition to patient demographic data, we assessed triggers for ETS, suction canister pressures, use of preoxygenation, measures of oxygenation, and ETS at extubation.Results
There were 682 patients in the ICUs on the study day, and 230 were included in the study. Three of 230 patients were excluded for missing data. A total of 1891 ETS events were performed on 227 patients during the study day, a mean of eight interventions per patient. The main triggers reported were audible (n = 385, 63%) and visible (n = 239, 39%) secretions. Less frequent triggers included following auscultation (n = 142, 23%), reduced oxygen saturations (n = 140, 22%), and ventilator waveforms (n = 53, 9%). Mean suction canister pressure was ?337 mmHg (standard deviation = 189), 67% of patients received preoxygenation (n = 413), and ETS at extubation was performed by 84% of nurses.Conclusion
Some practices were inconsistent with international guidelines, in particular concerning patient assessment for ETS and suction canister pressure. 相似文献9.
Aude Buil Laurence Caeymaex Sophie Mero Carol Sankey Gisèle Apter Emmanuel Devouche 《Journal of neonatal nursing : JNN》2019,25(2):86-92
Purpose
To test the effects of a new skin-to-skin Supported Diagonal Flexion (SDF) positioning on maternal stress, postpartum depression risk and skin-to-skin daily practice, in comparison with the usual Kangaroo Care in Upright positioning, during the first weeks after very premature birth.Design
Thirty-four mothers and their very preterm infants were assigned to one of the two Kangaroo Care positioning, either the Upright (n?=?17) or the SDF positioning (n?=?17). Maternal risk for depression and stress feelings were assessed through questionnaires before the first kangaroo care, 15 days later and at 40 weeks and 3 months corrected age. Data on daily kangaroo care practice was collected during 15 consecutive days starting from the very first skin-to-skin session.Results
The depression risk score was significantly lower in SDF positioning mothers after 15 days of skin-to-skin practice and at 40 weeks and 3 months corrected age. In the SDF group, mothers chose to practice Kangaroo Care during a significantly longer period of time per session.Conclusion
Our results support the hypothesis of a positive impact of SDF Kangaroo positioning on maternal postpartum risk of depression and skin-to-skin practice. 相似文献10.
Michelle Ng Jerrold Perrott Sarah Burgess 《The American journal of emergency medicine》2019,37(3):444-449
Introduction
Tranexamic acid (TXA) has been shown to decrease mortality in adult trauma patients with or at significant risk of hemorrhage when administered within 3?h of injury. The use and appropriateness of TXA in adult trauma patients presenting to Royal Columbian Hospital (RCH) was investigated.Methods
This retrospective chart review utilized the British Columbia Trauma Registry to identify 100 consecutive trauma patients that presented to the emergency department at RCH between April 2012 to June 2015 and met the following indications for TXA: systolic blood pressure <90?mm?Hg and/or heart rate >110?bpm and presentation within 8?h of injury. Primary outcomes included: percentage that met indications for TXA, received TXA according to the CRASH-2 protocol, received a pre-hospital dose, and received TXA ≤1, >1 to ≤3, or >3?h from injury.Results
During the given time period, 117 subjects (2.7%) met indications for TXA. 67 patients (57%) received TXA in any dose, with 10 subjects (8.5%) receiving TXA according to the CRASH-2 protocol. Of the 67 patients who received any TXA, 76% did so ≤3?h. 22 patients (19%) received TXA as a pre-hospital dose.Conclusions
<10% of adult trauma patients that met the indication for TXA received it according to the CRASH-2 protocol. Of those patients that received TXA, 76% did so within 3?h. Further inquiry to identify reasons trauma patients are not receiving TXA as well as quality improvement initiatives in trauma care are required.Level of evidence
IIIStudy type
Therapeutic 相似文献11.
Chrysovalantis Stafylis Claire C Bristow Lauren J Natoli Katheryn R Salow Emma Davidson Yancy Granados Mark McGrath Jeffrey D Klausner 《Diagnostic microbiology and infectious disease》2019,93(4):325-328
Introduction
Dual human immunodeficiency virus/syphilis rapid diagnostic devices can play an important role in prevention efforts. The field performance of the INSTI Multiplex HIV-1/HIV-2/Syphilis Antibody Test (Multiplex) was evaluated.Methods
Fingerstick whole blood was tested using the rapid test. A fourth-generation HIV laboratory assay and treponemal-specific laboratory assays were used as reference. Rapid plasma reagin (RPR) was used to stratify treponemal results. Sensitivity and specificity were calculated.Results
Overall, 274 patients participated. Sensitivity of the Multiplex for detection of HIV was 98.8% (95% CI, 93.4–100%), and specificity was 100% (95% CI, 98.1–100%). Sensitivity for detection of syphilis antibodies was 56.8% (95% CI, 44.7–68.2%), and specificity was 98.5% (95% CI, 95.7–99.7%). Sensitivity for treponemal antibodies improved with increasing RPR and was 100% (95% CI, 78.2–100%) among samples with RPR titers ≥1:8.Conclusions
The Multiplex showed excellent performance for detection of HIV antibodies and increasing sensitivity for detection of treponemal antibody with increasing RPR titer. 相似文献12.
Background
Within nursing education research, protection of students as human subjects must be the highest priority. This protection can be provided via student anonymity. A subject-generated identification code, comprised of responses to a series of questions, can link data across time points while protecting student anonymity.Method
Two studies, focused on palliative care education, used a subject-generated identification code to link student data across multiple time points. Refinements to the code were made between studies to further enhance anonymity and response consistency.Results
The subject-generated identification code fostered linking of student responses across three time points in study one and two time points in study two.Conclusion
There are many benefits to utilizing a subject-generated identification code in nursing education studies. Researchers must consider the need for a data management expert and balancing transposition errors and the power to differentiate between responses. 相似文献13.
Birgitte Lerbæk Rikke Jørgensen Jørgen Aagaard Julie Nordgaard Niels Buus 《Archives of Psychiatric Nursing》2019,33(2):174-181
Background
Life expectancy of people with severe mental illness (SMI) is greatly shortened compared to the general population, and despite extensive research, this issue is unsolved. Although it is widely recognised that people with SMI need support from health care services to manage health related issues, profound health inequalities exist within provision of health care. The aim of this study was to examine how mental health care professionals accounted for their actions and responsibilities related to managing physical health issues among people with SMI.Methods
Three focus groups were conducted with 22 mental health care professionals, employed at three mental health care locations. Participants' situated accounts were subjected to discourse analysis.Results
Participants accounted for actions and responsibilities in three typical ways; 1) by positioning people with SMI as difficult to motivate and actively resisting intervention, 2) by positioning people with SMI as so impaired that intervention was futile, and 3) by arguing they are undertreated for physical conditions and might have physical illnesses that staff are not aware of because of prominent mental illness. These discursive strategies seemed to legitimise situations where participants described not responding to physical health issues, and to downplay potential trouble in situations where participants described not succeeding in facilitating lifestyle changes or promoting compliance to treatment of physical conditions.Discussion and conclusion
Mental health care professionals need to increase their awareness of latent discriminating attitudes towards people with SMI. Such attitudes are suggested to reinforce barriers for people with SMI receiving physical health care. 相似文献14.
Nancy Hoffart Thomas P. McCoy Lynne P. Lewallen Shemeka Thorpe 《Journal of Professional Nursing》2019,35(2):93-100
Background
The New Careers in Nursing (NCIN) program provided scholarships and other supports to accelerated degree students at 130 nursing schools and collected data from the scholars at three time-points.Purpose
The NCIN database was analyzed to identify gender-based differences in scholars' profile characteristics, program experiences, and post-graduation outcomes.Method
An adaptation of Jeffreys's Nursing Universal Retention and Success Model guided the analysis. Gender differences were assessed after multiplicity adjustments for false positive rates.Results
Differences based on gender were found for profile characteristics, student affective factors, academic factors, professional integration factors, environmental factors, as well as academic, psychological and NCIN program outcomes. Results suggest that males were influenced by economic factors more than females when choosing nursing as a career. They had fewer concerns about financial aspects associated with being a student again yet secured employment sooner after graduation than female scholars. They did not view support services as important as did female students. They expressed confidence in their leadership competence more than their female counterparts.Conclusion
Efforts are needed to better understand and address the nuanced gender-based perceptions and needs of nursing students who are male. 相似文献15.
Gloria McKee-Lopez Leslie Robbins Elias Provencio-Vasquez Hector Olvera 《Journal of Professional Nursing》2019,35(2):112-119
Background
Research evidence strongly suggests that Adverse Childhood Experiences (ACEs) predispose individuals to development of an increased sensitivity to stress and negative physical and mental health outcomes in adulthood.Purpose
To determine if there was a relationship between the number of ACEs reported by first semester BSN students and their reported level of Burnout and Depression.Methods
211 students enrolled in the first semester of upper division courses of their BSN program completed self-report questionnaires which measured the number of ACEs, the level of Depression and the level of Burnout.Results
The number of reported ACEs by participants had a significant relationship on the levels of burnout and severity of depressive symptoms. Female students with a higher number of ACEs were more likely to report higher levels of Burnout A (Emotional Exhaustion) and Burnout B (Depersonalization), and higher depression severity scores compared to males.Conclusion
Nursing programs should educate faculty concerning the frequency and range of adverse experiences that students may have had prior to admission to the nursing program, and the possible relationship with Burnout and Depression. Faculty can provide early information on counseling and support services. 相似文献16.
Catherine A. Marco Robert P. Wahl James D. Thomas Ramon W. Johnson O. John Ma Anne L. Harvey Earl J. Reisdorff 《The American journal of emergency medicine》2019,37(5):859-863
Objective
The ABEM ConCert Examination is a summative examination that ABEM-certified physicians are required to pass once in every 10-year cycle to maintain certification. This study was undertaken to identify practice settings of emergency physicians, and to determine if there was a difference in performance on the 2017 ConCert between physicians of differing practice types and settings.Methods
This was a mixed methods cross sectional-study, using a post-examination survey and test performance data. All physicians taking the 2017 ConCert Examination who completed three survey questions pertaining to practice type, practice locations, and teaching were included. These three questions address different aspects of academia: self-identification, an academic setting, and whether the physician teaches.Results
Among 2796 test administrations of the 2017 ConCert Examination, 2693 (96.3%) completed the three survey questions about practice environment. The majority (N?=?2054; 76.3%) self-identified as primarily being a community physician, 528 (19.6%) as academic, and 111 (4.1%) as other. The average ConCert Examination score for community physicians was 83.5 (95% CI, 83.3–83.8); the academic group was 84.8 (95% CI, 84.3–85.3); and the other group was 82.3 (95% CI, 81.1–83.6). After controlling for initial ability as measured by the Qualifying Examination score, there was no significant difference in performance between academic and community physicians (p?=?.10).Conclusions
Academic emergency physicians and community emergency physicians scored similarly on the ConCert. Working at a community teaching hospital was associated with higher examination performance. Teaching medical learners, especially non-emergency medicine residents, was also associated with better examination performance. 相似文献17.
Background
There is limited information about the careers, roles and views of doctor of nursing practice (DNP) graduates.Method
This study describes the labor participation, post-graduation work activities, and perceptions of 1,308 DNP members of three professional nursing organizations who completed a 2017 survey (32% response rate).Findings
More than 70% of respondents reported substantial improvements in quality improvement, evidenced based practice and leadership abilities. Twenty-two percent of respondents noted the degree was required by their employer and most of these held educational positions. Postgraduate participation in activities associated with DNP education, assessment of personal impact and degree necessity varied by position title and organization membership.Discussion
These differences have implications for nursing associations and professional solidarity. 相似文献18.
Charles W. Hwang Desmond E. Fitzpatrick Torben K. Becker Jason M. Jones 《The American journal of emergency medicine》2019,37(3):482-485
Background
Freestanding emergency departments (FSED) are equipped to care for most emergencies, but do not have all the resources that hospital-based emergency departments (ED) offer. As the number of FSEDs grows rapidly, emergency medical services (EMS) must routinely determine whether a FSED is an appropriate destination. Inappropriate triage may delay definitive care, potentially increasing morbidity, mortality, and resource utilization. We sought to evaluate paramedics' ability in determining whether a FSED is the most appropriate destination.Methods
We conducted a retrospective study of two county EMS agencies and two FSEDs over a 25-month period in Alachua and Levy County, Florida, USA. Both EMS agencies allow paramedic discretion in determining transport destination. To determine whether paramedics can correctly identify patients that can be cared for fully at a FSED, our primary outcome was the percentage of patients transported to FSEDs by EMS that were discharged without additional hospital-based resources.Results
We identified 1247 EMS patients that had a selected destination of FSED. We excluded patients that did not arrive at their selected FSED destination, left before FSED disposition, or were transferred from the FSED to unaffiliated hospitals. A total of 1184 patients were included for analysis, and 885 (74.7%) did not require additional hospital resources. Comparing the two EMS agencies yielded similar results.Conclusion
In this study, involving two EMS agencies over a 25-month period, we found that 3 out of 4 patients deemed appropriate for transport to a FSED by a paramedic did not require additional hospital-based services. 相似文献19.
Objective
To determine whether prehospital point-of-care lactate (pLA) is associated with mortality, admission, and duration of hospital stay.Design
A retrospective clinical audit, where elevated lactate was defined as ≥2 mmol/L.Setting
The ambulance service and primary referral hospital in the Australian Capital Territory from 1st July 2014 to 30th June 2015.Participants
Adult patients (≥18 years) who had pLA measured and were transported to the primary referral hospital.Main outcome measures
Mortality, admission, and duration of hospital stay.Results
Two hundred fifty-three patients with a median pLA of 2.5 mmol/L (interquartile range [IQR]: 1.5–3.7) were analysed. Overall mortality was 8.3%; 68% were admitted to the hospital; 8.3% to the intensive care unit (ICU). pLA was non-significantly higher in those who died compared to survivors (3.5 [IQR: 2.75–5.85] vs 2.4 [1.5–3.6]; W = 1631.5; p = 0.053). pLA was higher for those admitted to the hospital (2.9 [1.9–3.9] vs 2.0 [1.4–3.1]; W = 5094.5, p = 0.001) and the ICU (3.2 [2.4–5.7] vs 2.4 [1.5–3.6]; W = 1578.5; p = 0.008). There was no relationship between pLA and duration of stay. Considered as a screening tool, at a cut-off of 2.5 mmol/L, pLA had a likelihood ratio+ of 1.61 for mortality and 1.44 for ICU admission; the odds ratio for mortality was 3.76 (95% confidence interval = 1.30, 13.89).Conclusions
Elevated prehospital lactate was associated with significantly increased ICU and hospital admissions. There may be value in pLA as a screening tool. 相似文献20.
Hsieh-Chun Hsieh 《Archives of physical medicine and rehabilitation》2019,100(4):591-597