急诊SARS患者初诊时血常规特点分析

目的 :探讨严重急性呼吸综合征 (SARS)与急性呼吸道感染 (ARI)患者发病初期血常规特点 ,为早期鉴别诊断提供参考。方法 :采集急诊 SARS与 ARI患者初诊时的血常规检验指标 ,建立数据库 ,运用描述性分析及推断性分析 (χ2检验和 u检验 )方法 ,对两组患者的血常规指标进行对照分析。结果 :早期 SARS患者的白细胞计数、淋巴细胞计数、中性粒细胞计数、血小板计数、血小板容积比均低于 ARI患者 (P均 <0 .0 5 ) ;两组的中性粒细胞比例与淋巴细胞比例差异无显著性 (P均 >0 .0 5 )。结论 :血常规检查是急诊初诊时临床诊断 SARS的重要依据之一。     

The effect of severe acute respiratory syndrome (SARS) on emergency airway management

From early March 2003 to late May 2003, severe acute respiratory syndrome (SARS) was detected in Singapore. The increase in workload and new infection control procedures were thought to affect resuscitation and airway management. Our aim was to study the effects of wearing of personal protective equipment (PPE) and powered air-purifying respirator (PAPR) and the restriction in the number of resuscitation personnel on airway management during the SARS crisis. Data was collected prospectively through an ongoing emergency airway registry. The data was divided into three periods: (1) before PPE was instituted from 1 November 2002 to 31 March 2003; (2) during SARS (when PPE use was mandatory) from 1 April to 31 July 2003; (3) post-SARs (when PPE use was non-mandatory but encouraged) from 1 August to 31 March 2004. There was no change in patient demographics during the three periods. There were significant increases in the proportion of resuscitation cases and airway interventions during the SARS period compared to the pre-SARS period. The resident medical officer intubation rate decreased from 45.1% pre-SARS to 35.2% during SARS and 17.7% post-SARS. The complication rates were 10.5%, 9.9% and 9.4% in periods 1-3, respectively. Restriction in the number of healthcare staff attending to each patient may have influenced the department's decision to allow only the most confident or experienced personnel to manage the airway. The exposure of junior medical officers in emergency airway management during SARS and the immediate post-SARS period was decreased. This trend should be monitored further and intervention may be necessary should it continue to decline.     

Out-of-hospital medication storage temperatures:: a review of the literature and directions for the future

The United States Pharmacopeia (USP) National Formulary prescribes the packaging, storage, and distribution of medications. Most of the medications commonly used by emergency medical services (EMS) are intended for storage at “controlled room temperature.” The USP definition of controlled room temperature is multifaceted and complex, and cannot be easily described as a simple range of acceptable temperatures, or even as an average temperature. The out-of-hospital environment is notoriously uncontrolled, and one of the uncontrolled aspects of that environment is temperature. This report reviews and summarizes the past 15 years of published research relating to out-of-hospital medication temperature exposures. Although the evidence is clear that EMS medication storage is not consistent with the USP definition of controlled room temperature, the impact of EMS medication storage on medication stability and potency remains unclear. Further research is needed to determine the true extent of the EMS medication storage problem, and to develop and validate appropriate solutions.     

Accuracy of arrhythmia recognition in paramedic treatment of paroxysmal supraventricular tachycardia: : A ten-year review

Objectives

To examine trends in paramedic rhythm misidentification rates in the use of adenosine for presumed paroxysmal supraventricular tachycardia (PSVT) over a ten-year period, and to determine variables associated with rhythm misidentification.

Methods

The authors conducted a retrospective analysis of all cases in which paramedics treated presumed PSVT with adenosine from 1993 to 2002. Rhythm strips were categorized as narrow or wide-complex and regular or irregular. Appropriate use of adenosine was defined as narrow-complex regular tachycardia with no visible P waves and rate greater than 140 beats/min.

Results

The authors studied 224 patients with a mean age of 60 years (range, 15-94 years); 157 (70%) were female and predominantly white. The majority (54%) of patients had initial heart rates of 161-200 beats/min. Forty-nine percent of the patients had a previous history of PSVT. Inappropriate use of adenosine occurred in 45 (20%) cases. Misidentification rates per year ranged from 9% to 31% with the lowest rate occurring after a targeted education program on tachydysrhythmias. An initial heart rate of <160 beats/min (χ² = 14.81, p<0.001) and absence of a medical history of either fast heart rate or palpitations (χ² = 11.35, p = 0.001) were associated with inappropriate use of adenosine.

Conclusion

Paramedics in this emergency medical services system are more likely to use adenosine appropriately for patients with initial heart rates of >160 beats/min and a history of rapid heart rate or palpitations. Further studies are required to identify factors associated with rhythm interpretation errors in the prehospital setting as well as to evaluate error reduction strategies.     

恢复期SARS患者康复治疗疗效分析

目的:观察SARS患者恢复期康复治疗效果。方法:9例恢复期肺弥散功能异常的SARS确诊患者,平均年龄为(31.44±11.53)岁,在平均病程为(73±4.97)天时接受为期3周的康复治疗,主要包括呼吸操、有氧运动及肺部物理因子治疗。在治疗前后进行肺功能、呼吸困难程度及静息心率等方面评定,将结果进行统计学分析。结果:恢复期SARS患者经康复治疗后,7例肺弥散功能正常,1例明显改善但仍低于正常标准,1例未复查。平均肺弥散率较治疗前有极显著性提高(P<0.01),呼吸困难程度和静息心率也有显著性改善(P<0.01和P<0.05)。与同期未绎康复治疗的对照组相比,康复治疗组患者的呼吸困难程度明显低于对照组,差异具有极显著性意义(P<0.01),但两组静息心率差异无显著性意义,均属正常范围。结论:以深呼吸运动、有氧运动和物理因子治疗为主的康复治疗有助于恢复期SARS患者肺弥散功能的改善,减轻呼吸困难症状,提高活动耐力。     

急诊SARS患者中医证候特点分析

目的：探讨急诊严重急性呼吸综合征(SARS)的中医证候分布特点。方法：利用急诊初诊SARS患者的中医证候信息采集表，构建证候四诊指标信息数据库，运用描述性分析及聚类分析方法，统计61例急诊SARS患者的中医证型情况。结果：61例急诊SARS患者，初诊的中医证候四诊指标聚类主要为疫毒侵袭、卫气同病和毒蕴肺胃、湿浊阻遏两型。其中疫毒侵袭、卫气同病占77．05％(47例)，毒蕴肺胃、湿浊阻遏型占22．95％(14例)。结论：SARS中医病名属温疫，为感受时邪疫毒所致；早期疫毒侵袭上中二焦，以卫气同病和毒蕴肺胃、湿浊阻遏多见，治疗以疏表清里、卫气同治以及芳香宣化，分消走泄为法。     

严重急性呼吸综合征患者的临床特征

目的 分析急诊科严重急性呼吸综合征(severe acute respiratory syndrome，SARS)或称传染性非典型肺炎(infeclive atypical pneumonia，IAP)患者的临床资料，了解其特征。方法 统计SARS患者的年龄分布和总体发病趋势；以社区获得性肺炎患者为对照，分析SARS患者的临床特点。结果 本组64例SARS患者中21～40岁年龄段占43．75％。在出现SARS疫情后31～50d病例数达高峰，全过程约4个月。SARS患者临床表现的前3位为发热、咳嗽和咯稀白痰，约2／3患者无肺部体征。X线胸片病变进展较快，外周血白细胞计数正常或降低，淋巴细胞计数降低以及具有传染性为SARS的临床特点。结论 SARS患者在年龄分布、发病趋势、临床表现、X线胸片、外周血白细胞和淋巴细胞计数以及传染性等方面与社区获得性肺炎患者有所不同，掌握这些特点有利于在急诊科对本病的临床诊断。     

无创正压通气治疗SARS的临床评价

目的 :分析无创正压通气 (NIPPV)对严重急性呼吸综合征 (SARS)患者的氧合作用 ,并初步探讨机械通气时机把握问题。方法 :对 2 5例 SARS合并呼吸功能不全而使用 NIPPV治疗 2 4 h后患者的生理指标和氧合功能进行分析 ,然后再将他们分为生存组与死亡组 ,比较两组患者 NIPPV前后急性生理学与慢性健康状况 (APACHE )评分、改良呼吸指数 (PO2 / Fi O2 ,MRI)的变化。结果 :虽然 NIPPV 2 4 h内多数患者呼吸困难有不同程度缓解、心率 (HR)和呼吸频率 (RR)明显减慢 (P均 <0 .0 5 )、脉搏容积血氧饱和度 (Sp O2 )和 MRI显著升高 (P均 <0 .0 5 ) ,但死亡组患者从发病到 NIPPV治疗的平均时间明显晚于生存组患者 ,且死亡组患者经NIPPV2 4 h后 APACHE 、RR仍显著高于生存组 (P均 <0 .0 5 ) ;Sp O2 、MRI明显低于生存组 (P均 <0 .0 5 )。结论 :对重症 SARS患者而言 ,NIPPV是机械通气的选择方式 ,但它无法替代有创机械通气治疗。治疗 SARS时不能错过 NIPPV或有创机械通气治疗时机 ,且绝不能拘泥于现行的无创或有创通气指征。     

Helicopter emergency medical services transport outcomes literature:: Annotated Review of Articles Published 2000-2003

Helicopter emergency medical services (HEMS) and its possible association with outcomes improvement continues to be a subject of debate. As is the case with other scientific endeavors, debate over HEMS usefulness should be framed around an evidence-based assessment of the relevant literature. In an effort to facilitate the academic pursuit of assessment of HEMS utility, in late 2000 the National Association of EMS Physicians' Air Medical Committee prepared annotated bibliographies of the HEMS-related outcomes literature. As a result of that work, two review articles—one covering HEMS use in nontrauma and the other in trauma—published in 2002 in Prehospital Emergency Care surveyed HEMS outcomes-related literature published between 1980 and mid-2000. Given the broad interest in the earlier reviews, and the increasing rate of publication of HEMS studies, the current project was executed with the intent of updating the annotated HEMS outcomes-related bibliography, covering a three-year time interval (through 2003) since the prior reviews.     

Endotracheal intubation and esophageal tracheal combitube insertion by regular ambulance attendants: : A comparative trial

Objective

Recent cardiac arrest resuscitation guidelines have recommended the esophageal tracheal Combitube (ETC) as an advanced airway management alternative for individuals who infrequently perform endotracheal intubation (ETI). This study attempted to analyze basic (nonparamedic) ambulance attendant success rates at ETI and ETC insertion as well as their continuing skill competency over time and whether ongoing practice on mannequins improved skill performance.

Methods

Three hundred fifty-seven adult patients in cardiorespiratory arrest were treated by 81 basic ambulance attendants. Original study design called for the analysis of two treatment options in three patient groups: ETC insertion, ETI insertion with mannequin practice (ETI-MP), and ETI insertion without mannequin practice (ETI-NMP). The main outcome measures were:

(1)

successful insertion and ventilation with ETC or ETI, assessed by receiving physicians; and

(2)

differences in successful insertion/ventilation between the MP and NMP groups.

Results

Successful insertion (intent-to-treat) for the ETI-NMP group was 70 of 111 (63%; 95% confidence interval [CI], 54-73%); ETI-MP success was 105 of 139 (76%; 95% CI, 67-84%); ETC-NMP success was 26 of 42 (62%; 95% CI, 49-75%); and ETC-MP success was 36 of 53 (68%; 95% CI, 54-82%). Continuing mannequin practice appeared to improve ETI success (as-treated): MP 75% versus NMP 61% (odds ratio, 2.1; 95% CI, 1.11-3.94).

Conclusions

There were similar rates of successful insertion/ventilation with the ETC and ETI. ETI insertion success was lower without mannequin practice. ETI skill erosion was partially mitigated by additional field experience.