成人危重症患者气道管理的最佳证据总结

目的 遴选并获取国内外成人危重症患者气道管理的相关证据,为临床实践管理提供依据。方法 按照PIPOST模式确定循证问题,使用计算机检索Up To Date、Cochrane Library、BMJ、NGC、PubMed、SCCM、NICE、JBI、CINAHL、Medline、CNKI、CBM和万方数据库,选出符合纳入标准的文献,由2名循证研究员独立对纳入的文献进行质量评价,结合专业人士的判断提取及综合证据。结果 共纳入25篇文献,其中高级临床决策支持1篇、指南7篇、系统评价8篇、证据总结5篇、专家共识4篇。最佳证据分别从气道评估、气道吸引时机、气囊管理、气道湿化、气道吸引、气管切开造口护理、口腔护理7个方面进行总结,共44条最佳证据。结论 临床实践中医务人员需加强气道管理循证知识的培训,动态评估患者气道情况,把握气道吸引时机,重视气囊管理和气道湿化,明确气道吸引注意事项,规范气管切开造口护理流程,加强患者口腔护理,根据临床实际情况,有针对性的选择证据。     

Near hanging

Abstract Objectives: To review the literature on near hanging, focusing on the pathophysiology, and relating this to the clinical features and management. Methods: English language articles published in the past 15 years and major textbooks of emergency and forensic medicine were searched. Eight case series and six relevant single case reports were identified. Only articles concerned with non-judicial near hanging were reviewed. Data concerning the incidence of cervical spine injury, laryngeal injury, pulmonary complications and mortality were extracted. Not the case series documented the presence or absence of all these factors, resulting in differing total patient numbers in each category. Unusual complications of near hanging were documented from case reports. Results: Cervical spine injury occurred in four of 689 patients (0.6%). Pulmonary complications occurred in 15 of 133 patients (11%). The in-hospital mortality rate was 23% (29 deaths of 128). No clinically significant laryngeal injuries were reported. Unusual complications documented included hyperthermia, status epilepticus, carotid artery dissection, subarachnoid haemorrhage and pneumoperitoneum. Conclusions: Cervical spine injury, although uncommon, does occur in near hanging, and emergent airway management should take this into account. Laryngeal injury sufficiently severe to interfere with endotracheal intubation does not appear to occur. Cerebral oedema, aspiration pneumonia and acute respiratory distress syndrome are the commonest in-hospital complications. Management of near hanging involves establishment of a safe airway, plus treatment of pulmonary and cerebral oedema along standard lines. In-hospital mortality remains high.     

Managing the difficult airway: a survey of residency directors and a call for change

This study examines airway management issues in Emergency Medicine residency programs (EMRP) including; airway adjunct availability and frequency of use, number of pediatric intubations, approach to trauma airways, and teaching methods. Surveys were distributed to all accredited EM program directors, who were asked about these issues. Availability of airway adjuncts among respondents included: cricothyrotomy kits (94.9%), fiberoptic scopes (76.3%), Bougies (69.5%), LMAs (66.1%), intubating LMAs (61.0%), lighted stylets (54.2%), retrograde intubation kits (49.2%), Combitube (45.8%), and esophageal obturator airways (15.3%). Responses indicated that 93.6% of airways were orotracheal intubations. A small percentage of intubations used airway adjuncts. Programs use didactics, mannequins, cadavers, direct care and operating rooms for airway training. Emergency Physicians (EPs) are responsible for trauma airways in 89.9% of programs. Most programs have multiple airway adjuncts available, but they are rarely utilized. EPs must become proficient with airway adjuncts. EMRPs must increase resident exposure by using airway adjuncts during routine intubations.     

Incidence of difficult airway situations during prehospital airway management by emergency physicians—A retrospective analysis of 692 consecutive patients

IntroductionIn the prehospital setting, advanced airway management is challenging as it is frequently affected by facial trauma, pharyngeal obstruction or limited access to the patient and/or the patient's airway. Therefore, incidence of prehospital difficult airway management is likely to be higher compared to the in-hospital setting and success rates of advanced airway management range between 80 and 99%.Methods3961 patients treated by an emergency physician in Zurich, Switzerland were included in this retrospective analysis in order to determine the incidence of a difficult airway along with potential circumstantial risk factors like gender, necessity of CPR, NACA score, GCS, use and type of muscle relaxant and use of hypnotic drugs.Results692 patients underwent advanced prehospital airway management. Seven patients were excluded due to incomplete or incongruent documentation, resulting in 685 patients included in the statistical analysis. Difficult intubation was recorded in 22 patients, representing an incidence of a difficult airway of 3.2%. Of these 22 patients, 15 patients were intubated successfully, whereas seven patients (1%) had to be ventilated with a bag valve mask during the whole procedure.ConclusionIn this physician-led service one out of five prehospital patients requires airway management. Incidence of advanced prehospital difficult airway management is 3.2% and eventual success rate is 99%, if performed by trained emergency physicians. A total of 1% of all prehospital intubation attempts failed and alternative airway device was necessary.     

Review of non‐invasive ventilation in the emergency department: clinical considerations and management priorities

Aims and objectives. We aimed to synthesise evidence from published literature on non‐invasive ventilation to inform nurses involved in the clinical management of non‐invasive ventilation in the emergency department. Background. Non‐invasive ventilation is a form of ventilatory support that does not require endotracheal intubation and is used in the early management of acute respiratory failure in emergency departments. Safe delivery of this intervention requires a skilled team, educated and experienced in appropriate patient selection, available devices and monitoring priorities. Design. Systematic review. Method. A multi‐database search was performed to identify works published in the English language between 1998–2008. Search terms included: non‐invasive ventilation, continuous positive airway pressure and emergency department. Inclusion and exclusion criteria for the review were identified and systematically applied. Results. Terminology used to describe aspects of non‐invasive ventilation is ambiguous. Two international guidelines inform the delivery of this intervention, however, much research has been undertaken since these publications. Strong evidence exists for non‐invasive ventilation for patients with acute exacerbation of congestive heart failure and chronic obstructive pulmonary disease. Non‐invasive ventilation may be delivered with various interfaces and modes; little evidence is available for the superiority of individual interfaces or modes. Conclusions. Early use of non‐invasive ventilation for the management of acute respiratory failure may reduce mortality and morbidity. Though international guidelines exist, specific recommendations to guide the selection of modes, settings or interfaces for various aetiologies are lacking due to the absence of empirical evidence. Relevance to clinical practice. Monitoring of non‐invasive ventilation should focus on assessment of response to treatment, respiratory and haemodynamic stability, patient comfort and presence of air leaks. Complications are related to mask‐fit and high air flows; serious complications are few and occur infrequently. The use of non‐invasive ventilation has resource implications that must be considered to provide effective and safe management in the emergency department.     

Complications of emergency intubation with and without paralysis

Expert and definitive airway management is fundamental to the practice of emergency medicine. In critically ill patients, rapid sedation and paralysis, also known as rapid-sequence intubation, is used to facilitate endotracheal intubation in order to minimize aspiration, airway trauma, and other complications of airway management. An alternative method of emergent endotracheal intubation, intubation minus paralysis, is performed without the use of neuromuscular blocking agents. The present study compared complications of these two techniques in the emergency setting. Sixty-seven intubations minus paralysis were prospectively compared with 166 rapid-sequence intubations. Complications were greater in number and severity in the nonparalyzed group and included aspiration (15%), airway trauma (28%), and death (3%). None of these difficulties were observed in the rapid-sequence group (P < .0001). These results show that rapid-sequence intubation when compared with intubation minus paralysis significantly reduces complications of emergency airway management and should be made available to emergency physicians trained in its use.     

阻塞性睡眠呼吸暂停综合征咽壁顺应性的定量评估

目的比较阻塞性睡眠呼吸暂停综合征(obstructive sleep apnea syndrome，OSAS)患者和对照组上呼吸道咽壁顺应性的差别。方法经PSG确诊的OSAS患者和正常人各34人，以纤维内窥镜观察平静呼吸和Muller动作时上呼吸道各平面形态的变化，利用图像分析软件计算咽壁顺应性，比较两组间的差别。结果软腭后区和舌后区的咽侧壁、咽前后壁和总咽壁顺应性在对照组和OSAS患者间差异均存在极显著性。无论是对照组还是OSAS患者，其软腭后区的咽壁顺应性均大于舌后区的咽壁顺应性，咽侧壁顺应性均大于咽前后壁顺应性。结论OSAS患者和对照组的上呼吸道咽壁顺应性差别明显，咽壁顺应性增大是OSAS发病的重要因素之一。     

Could bystander first‐aid prevent trauma deaths at the scene of injury?

Objective: To identify potentially preventable prehospital deaths following traumatic cardiac arrest. Methods: Deaths following prehospital traumatic cardiac arrest during 2003 were reviewed in the state of Victoria, Australia. Possible survival with optimal bystander first‐aid and shorter ambulance response times were identified. Injury Severity Scores (ISS) were calculated. Victims with an ISS <50 and signs of life were reviewed for potentially preventable factors contributing to death including signs of airway obstruction, excessive bleeding and/or delayed ambulance response times. Results: We reviewed 112 cases that had full ambulance care records, hospital records and autopsy details in Victoria 2003. Most deaths involved road trauma and 55 victims had an ISS <50. Twelve patients received first‐aid from bystanders. Ambulance response times >10 min might have contributed to five deaths with an ISS <25. Conclusion: Five (4.5%) potentially preventable prehospital trauma deaths were identified. Three deaths potentially involved airway obstruction and two involved excessive bleeding. There is a case for increased awareness of the need for bystander first‐aid at scene following major trauma.     

Evidence-Based Nursing Care for Spinal Nursing Immobilization: A Systematic Review

IntroductionA high degree of suspicion for spinal injury after trauma is commonplace in an emergency department, and spinal immobilization is considered an accepted intervention to prevent the progression of a potential injury. This systematic review was conducted to gain insight into the best research evidence related to nursing interventions for patients with trauma presenting with a suspected spinal injury.MethodsA systematic search of online databases was conducted in April 2019 for relevant research using specific search terms. The studies were selected on the basis of pre-established eligibility criteria, and the quality was appraised using the Critical Appraisal Skills Programme tool.ResultsNineteen included articles were synthesized thematically on the basis of the outcomes from interventions directed at a suspected spinal injury. The main findings were that spinal immobilization may compromise pulmonary function and airway management, cause pain and pressure ulcers, and be inappropriate with penetrating trauma. Furthermore, there was insufficient evidence to support the safety and efficacy of the hard neck collar and long backboard.DiscussionPatients would benefit from a more selective and cautious approach to spinal immobilization. Emergency nurses should use the evidence to facilitate informed decision-making in balancing the benefits of spinal immobilization against harm when considering the needs and values of the patient.     

创伤困难气道评估及辅助工具研究进展

现代化战争中高科技武器使得伤员的伤势严重、伤情复杂、气道管理难度大、风险高，尤其困难气道管理更具挑战性，而及时有效的气道治疗对降低创伤死亡率尤为重要。本文针对创伤困难气道对近年来的气道评估及辅助工具进展情况进行综述，阐述创伤患者困难气道评估及气道管理辅助工具的进展。     

Airway equipment in Scottish emergency departments.

Airway management is the cornerstone of resuscitation. Emergency endotracheal intubation is more likely to be difficult in the accident and emergency (A&E) department setting compared with the operating room. A&E departments must have an appropriate selection of equipment to deal with difficult airway problems. The aim of this study was to determine the type and range of equipment for airway management in A&E departments in Scotland, UK. A two-page postal survey was sent to consultants in charge of 24 A&E departments covering 98% of major trauma patients in Scotland. The response rate was 96% (23/24). Every department had equipment for basic airway management and all had laryngoscopes, stylets, gum elastic bougies and capnography. Ninety-six per cent (22/23) had equipment for performing a surgical airway and 74% (17/23) possessed laryngeal mask airways suitable for adults; only one department did not possess a suitable rescue device. Thirty per cent (7/23) of departments did not use capnography routinely to confirm correct placement of endotracheal tubes. It is concluded that airway equipment in Scottish A&E departments is adequate for basic airway care and endotracheal intubation. Nearly all departments have access to a suitable rescue device for the failed or difficult airway. Capnographic confirmation of tube placement should be mandatory in A&E.     

The Easytube for airway management in prehospital emergency medicine

Background

Securing the airway in emergency is among the key requirements of appropriate prehospital therapy. The Easytube (Ezt) is a relatively new device, which combines the advantages of both an infraglottic and supraglottic airway.

Aims

Our goal was to evaluate the effectiveness and the safety of use of Ezt by emergency physicians in case of difficult airway management in a prehospital setting with minimal training.

Methods

We performed a prospective multi-centre observational study of patients requiring airway management conducted in prehospital emergency medicine in France by 3 French mobile intensive care units from October 2007 to October 2008.

Results

Data were available for 239 patients who needed airway management. Two groups were individualized: the “easy airway management” group (225 patients; 94%) and the “difficult airway management” group (14 patients; 6%). All patients had a successful airway management. The Ezt was used in eight men and six women; mean age was 64 years. It was used for ventilation for a maximum of 150 min and the mean time was 65 min. It was positioned successfully at first attempt, except for two patients, one needed an adjustment because of an air leak, and in the other patient the Ezt was replaced due to complete obstruction of the Ezt during bronchial suction.

Conclusion

The present study shows that emergency physicians in cases of difficult airway management can use the EzT safely and effectively with minimal training. Because of its very high success rate in ventilation, the possibility of blind intubation, the low failure rate after a short training period. It could be introduced in new guidelines to manage difficult airway in prehospital emergency.     

Review article: Best practice management of low back pain in the emergency department (part 1 of the musculoskeletal injuries rapid review series)

Low back pain (LBP) is a common presentation to the ED, and a frequent cause of disability globally. The ED management is often associated with high rates of imaging, misuse and overuse of pharmacology and subsequent financial implications. Given this, improved quality of care for patients with LBP in ED is essential. This rapid review investigated best practice for the assessment and management of LBP in the ED. PubMed, CINAHL, EMBASE, TRIP and the grey literature, including relevant organisational websites, were searched in 2015. Primary studies, systematic reviews and guidelines were considered for inclusion. English‐language articles published in the past 10 years that addressed acute LBP assessment, management or prognosis in the ED or acute setting were included. Data extraction of included articles was conducted, followed by quality appraisal to rate the level of evidence where possible. The search revealed 1538 articles, of which 38 were included in the review (n = 8 primary articles, n = 13 systematic reviews and n = 17 guidelines). This rapid review provides clinicians managing LBP in the ED a summary of the best available evidence to risk stratify and enhance the quality of care, optimising patient outcomes. Consistent evidence was found to support the use of ‘red flags’ to screen for serious pathologies, diagnostic tests being reserved for use only in the presence of red flags, the judicious prescribing of opioids, identification of psychosocial risk factors as predictors of poorer outcome and promotion of early return to work and function.     

气管切开术后非机械通气患儿早期气道并发症预防的最佳证据总结

目的 检索并总结气管切开术后非机械通气患儿早期气道并发症预防的相关证据,为临床提供参考。 方法 按照PIPOST方法确定循证问题,依据证据的6S模型针对气管切开术后非机械通气患儿早期气道并发症的预防开展系统性检索,包括计算机决策、临床指南、专家共识、证据总结、最佳实践推荐、系统评价。检索时限为从建库至2020年4月1日。由2名研究者分别对文献质量进行评价和证据提取。 结果 共纳入文献11篇,其中指南1篇,证据总结2篇,推荐实践3篇,专家共识5篇;结合专业人员的判断,从患者管理、气管造瘘口的维护、固定带的更换、气道吸引、气道湿化、气管套管的更换6个方面进行证据总结,汇总了37条最佳证据。 结论 临床管理者应该重视对气管切开术后患儿的管理,制定儿科气管切开术后非机械通气期间早期气道护理的标准化方案,并对所有医护人员进行培训,规范气道护理操作,降低气道并发症的发生率。     

Advanced Trauma Life Support (ATLS): necessary for emergency physicians?

A survey was conducted to determine differences in perspective towards Advanced Trauma Life Support (ATLS) between emergency medicine (EM) physicians and other specialties (OS), assess its value in the management of acute trauma, and identify areas in the course which could be revised or updated. The survey was devised and completed by physicians after ATLS. Of 26 course participants, there were 11 EM physicians (42%), four family practitioners (15%), four surgeons (15%), four internists (15%), two paediatricians (8%), and one anaesthesiologist (4%). Both groups found ATLS useful and relevant, and reported little deviation from their prior management of acute trauma. Unclear topics identified were airway, spine trauma, and burns/cold injury for EM, and head, abdominal, and paediatric trauma for OS. Significant differences were noted for the following: 91% EM vs. 13% OS felt ATLS could be shortened into a one-day course (p = 0.002), 64% EM vs. 7% OS thought the laboratory could be omitted (p = 0.003), and all (100%) EM vs. 60% OS believed the course could be taught by EM physicians as effectively as surgeons (p = 0.02). EM disagreed with OS over the proposed requirement that all EM physicians be required to take ATLS (2.0 +/- 0.2 vs. 3.5 +/- 0.4, p = 0.03). The EM group reported doing > 20 per year of airway, vascular, and thoracostomy procedures in their own practice, whereas OS did significantly fewer. ATLS may not be useful for EM practitioners actively involved in trauma care. Proposed changes from the EM perspective include shortening ATLS to one day, increased use of EM instructors, clarifying certain portions of the manual, and omitting the laboratory section or making it optional.     

气道管理设备的应用特点

目的:总结几类气道管理设备:喉罩通气、食道气道双腔导管、纤维光学导丝喉镜、视频Mac喉镜气管插管系统以及GlideScope9视频喉镜的优缺点以及应用前景。资料来源:检索Medline 1990-01/2006-02与气道管理设备相关的文献,检索词“airway management”,限定文献语言种类为英文。资料选择:对资料进行初审,选择与应用喉罩通气、食道气道双腔导管、纤维光学导丝喉镜、视频Mac喉镜气管插管系统以及GlideScopeK视频喉镜进行气管插管研究插管成功率、插管相关并发症发生率有关的文献。纳入标准:①对成年病例的随机对照研究。②临床研究实验或者病例报告。③包括对一般气道或者困难气道的研究。排除标准:①对儿童插管的研究。②重复性研究。数据提炼:共收集到有关喉罩通气、食道气道双腔导管、纤维光学导丝喉镜、视频Mac喉镜气管插管系统以及GlideScopeK视频喉镜的文章86篇,36篇符合纳入标准,排除的50篇为对儿童插管研究或重复性研究。资料综合:正确的喉罩置入不会影响声带功能,患者戴喉罩时可以发声。其成功率在90%以上。其优点在于无论麻醉师的经验是否足够均可以快速而又容易的置入喉罩,降低咳嗽发生的频率和置入后的咽喉炎发生率。食道气道双腔导管可获得有效通气,其在急救情况下的应用十分成功。缺点是只有成人型号。纤维光学导丝喉镜的灵活性使其在应用时不需要调整患者头部和颈部的位置,主要缺点是视野有限及高昂的购买和维护费用。视频Mac喉镜气管插管系统的观察和操作可在一个轴上完成。GlideScopeK视频喉镜可以在屏幕上提供一个更为清晰的喉视野,插管可以根据图像指示进行调整,而不是只凭操作者的肉眼所见进行调整。结论:这些新型的气道管理设备都在不同程度上降低了插管难度,提高了插管成功率,相对减少了插管相关并发症的发生。在现代麻醉医师培养中应加入对这些新设备特征的介绍,以及掌握基本操作方法。     

Self-management education for adults with type 2 diabetes: a meta-analysis of the effect on glycemic control

OBJECTIVE: To evaluate the efficacy of self-management education on GHb in adults with type 2 diabetes. RESEARCH DESIGN AND METHODS: We searched for English language trials in Medline (1980-1999), Cinahl (1982-1999), and the Educational Resources Information Center database (ERIC) (1980-1999), and we manually searched review articles, journals with highest topic relevance, and reference lists of included articles. Studies were included if they were randomized controlled trials that were published in the English language, tested the effect of self-management education on adults with type 2 diabetes, and reported extractable data on the effect of treatment on GHb. A total of 31 studies of 463 initially identified articles met selection criteria. We computed net change in GHb, stratified by follow-up interval, tested for trial heterogeneity, and calculated pooled effects sizes using random effects models. We examined the effect of baseline GHb, follow-up interval, and intervention characteristics on GHb. RESULTS: On average, the intervention decreased GHb by 0.76% (95% CI 0.34-1.18) more than the control group at immediate follow-up; by 0.26% (0.21% increase - 0.73% decrease) at 1-3 months of follow-up; and by 0.26% (0.05-0.48) at > or = 4 months of follow-up. GHb decreased more with additional contact time between participant and educator; a decrease of 1% was noted for every additional 23.6 h (13.3-105.4) of contact. CONCLUSIONS: Self-management education improves GHb levels at immediate follow-up, and increased contact time increases the effect. The benefit declines 1-3 months after the intervention ceases, however, suggesting that learned behaviors change over time. Further research is needed to develop interventions effective in maintaining long-term glycemic control.     

Trauma Airway Management

Background

Airway management in a trauma patient can be particularly challenging when both a difficult airway and the need for rapid action collide. The provider must evaluate the trauma patient for airway difficulty, develop an airway management plan, and be willing to act quickly with incomplete information.

Discussion

Thorough knowledge of airway management algorithms will assist the emergency physician in providing optimal care and offer a rapid and effective treatment plan.

Conclusions

Using a case-based approach, this article reviews initial trauma airway management strategies along with the rationale for evidence-based treatments.     

Ⅱ代引流型喉管与Proseal喉罩在择期手术中应用评价

目的：评价Ⅱ代引流型喉管（LTSⅡ）和Proseal喉罩（PLMA）在择期手术中应用效果。方法：检索了Cochrane图书馆（2009年第3期）、Pubmed（1950～2009）、EMBase（1989～2009）、CNKI（1979～2009）、VIP（1989～2009）、CBM（1978～2009）中相关Ⅱ代引流型喉管（LTSⅡ）和Proseal喉罩在择期手术中应用的随机对照试验（RCT）,同时筛检纳入文献的参考文献。由2名研究者对文献质量进行严格评价和资料提取,根据指标相应异质性进行描述性分析或Meta分析（RevMan 5.0）。结果：共纳入3个RCT,共244例研究对象,文献质量均为B级。3个RCT的结果显示与PLMA相比,LTSⅡ具有相似的首次置入成功率（P=0.45）、术毕即刻上呼吸道损伤发生率（P=1.00）、术后24 h咽痛发生率（P=0.81）、术后24 h吞咽困难发生率（P=0.12）。2个RCT的结果显示两组引流管置入均较容易。1个RCT的结果显示两组的操作者主观评价相近（OR=1.86,95%CI 0.39～8.99）。气道封闭效果由于采用方法学差异性较大,指标也不尽相同,尚不能得出准确结果。结论：LTSⅡ在择期手术中用于气道管理具有较好的前景。但是现时仍不宜用于需在择期术中进行控制通气的病人。关于气道封闭效果,尚需采用更合理规范的指标、更高质量的研究设计进一步研究。     

Intubating trauma patients before reaching hospital – revisited

Endotracheal intubation is widely used for airway management in a prehospital setting, despite a lack of controlled trials demonstrating a positive effect on survival or neurological outcome in adult patients. The benefits, in term of outcomes of invasive airway management before reaching hospital, remain controversial. However, inadequate airway management in this patient population is the primary cause of preventable mortality. An increase in intubation failures and in the rate of complications in trauma patients should induce us to improve airway management skills at the scene of trauma. If the addition of emergency physicians to a prehospital setting is to have any influence on outcome, further studies are merited. However, it has been established that sedation with rapid sequence intubation is superior in terms of success, complications and rates of intubation difficulty. Orotracheal intubation with planned neuromuscular blockade and in-line cervical alignment remains the safest and most effective method for airway control in patients who are severely injured.