The prehospital management of pelvic fractures

Pelvic fractures are one of the potentially life-threatening injuries that should be identified during the primary survey in patients sustaining major trauma. Early suspicion, identification and management of a pelvic fracture at the prehospital stage is essential to reduce the risk of death as a result of hypovolaemia and to allow appropriate triage of the patient. The assessment and management of pelvic fractures in the prehospital environment is reviewed here. It is advocated that the pelvis should not be examined by palpation or springing, and that the patient should not be log rolled. Pelvic immobilisation should be used routinely if there is any suspicion of pelvic fracture based on the mechanism of injury, symptoms and clinical findings.     

二维斑点追踪超声心动图观察脓毒性休克患者左心室心肌功能的变化

目的通过分层二维斑点追踪显像技术评价脓毒性休克患者长期预后心肌分层应变的变化趋势。 方法选择2016年1月至2017年2月苏北人民医院重症监护室38例脓毒性休克存活患者（作为脓毒性休克组）进行长期随访跟踪,并选取35例正常对照者作为健康对照组,应用GE vividE9和Echopac工作站的分层斑点追踪技术,比较其左心室总体及左室心肌内膜、中层、外膜的心肌纵向、环向应变结果。 结果（1）与健康对照组比较,脓毒性休克组心率无明显变化,差异无统计学意义（F=1.668,P=0.177）;脓毒性休克组治疗后1个月左心室射血分数（LVEF）无明显变化,差异无统计学意义（P>0.05）,治疗后3、6个月明显降低,差异具有统计学意义（均P<0.05）;治疗后6个月左心室舒张末期容积（LVEDV）明显升高,差异具有统计学意义（P<0.05）;治疗后1、3、6个月舒张早期二尖瓣血流峰值速度/舒张早期二尖瓣环峰值速度（E/Em）明显升高,差异具有统计学意义（均P<0.05）。（2）脓毒性休克组各时间节点组内比较,心率、E/Em无明显变化,差异无统计学意义（P>0.05）;治疗后6个月LVEF、GLS绝对值、GRS绝对值、GCS绝对值明显降低,LVEDV明显升高,差异具有统计学意义（均P<0.05）。（3）脓毒性休克组心内膜下、中层、心外膜下心肌的纵向应变及环向应变均低于健康对照组,差异具有统计学意义（均P<0.05）。 结论脓毒性休克患者左室心肌内膜、中层、外膜三层心肌收缩功能均减弱,分层斑点追踪技术可以发现其心肌收缩功能的改变。且为脓毒性休克患者评估心功能不全提供了无创参数体系,从而指导临床诊疗,改善脓毒性休克患者的预后。     

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.     

超声心动图对心肌淀粉样变的诊断价值

目的 探讨心肌淀粉样变的超声心动图特征.方法回顾分析本院1994～2007年确诊的15例原发性淀粉样变心脏受累患者的超声心动图检查结果.结果 15例心肌淀粉样变患者均有不同程度的室间隔增厚(＞1.3 cm),11例患者左室后壁增厚(＞1.1 cm),8例房间隔增厚(＞0.6 cm).室间隔及左室游离壁心肌回声明显增强,分布不均匀,呈"毛玻璃样"改变,并可见散在颗粒样斑点状强回声.双房增大,左室射血分数减低,舒张功能受损,伴有少量心包积液.结论超声心动图能对心肌淀粉样变进行初步定性诊断和鉴别诊断.     

Pain management in the prehospital environment

Pain measurement and relief is complex and should be a priority for prehospital providers and supervisors. The literature continues to prove that we are poor pain relievers, despite the high prevalence of pain in the out-of-hospital patient population. Lack of education and research, along with agent availability, controlled substance regulation, and many myths given credence by health care providers, hinder our ability to achieve adequate pain assessment and treatment in the prehospital setting. Protocols must be established to help guide providers through proper acknowledgment, measurement, and treatment for prehospital pain. Nonpharmacologic therapies must also be taught and reinforced as important adjuncts to pain management. Finally, formation of quality improvement pain programs that evaluate patient outcomes and provider practice patterns will help EMS systems understand the pain management process and outline areas for improvement. Only through emphasis on pain education, research, protocol and program monitoring development will the quality of pain assessment and management in the prehospital setting improve.     

右室心肌病的超声评价

目的：探讨超声心动图对右室心肌病的诊断价值。材料和方法：对５４例经心血管造影及心肌活检确诊为右室心肌病者进行了超声心动图检查。结果：①９２． １％的患者右室形态发生明显改变 ;②９２． ６％的患者室壁运动出现异常;③９４．５％的患者室壁厚度发生改变;④６６．７％的患者右室功能减低;⑤４４．４％的患者肌小梁排列紊乱,１１．１％的患者乳头肌增粗、肥大。⑥超声心动图诊断右室心肌病的敏感性为９０．７％,假阴性率为９．３％。结论：超声心动图能对右室心肌病作出准确诊断,但应注意排除其他容易发生混淆的心血管疾病。     

Controversies in the prehospital management of major trauma

Many traditional therapies in the prehospital management of major trauma may be of little value or may be even harmful. Little scientific evidence exists to support the use of the pneumatic antishock garment, and some studies have shown it to worsen outcome. The traditional role of intravenous fluid resuscitation also has been questioned and, in situations such as penetrating truncal trauma, it may be associated with comparatively worse outcomes. Although some infusion may be appropriate in severe haemorrhage, the clear priority in such patients is evacuation to definitive surgical intervention. Airway control and establishment of intravenous access are recommended en route. Endotracheal intubation may be capable of prolonging the ability to tolerate circulatory arrest, but overzealous ventilation may further compromise cardiac output where there is severe haemodynamic instability. If these procedures delay patient transport, any benefit they may offer could be outweighed by delaying definitive care. Many of the paradigms of prehospital trauma care should be reconsidered and carefully evaluated in future randomized controlled trials.     

超声心动图联合右心声学造影在卵圆孔未闭诊断中的价值探讨

目的:探讨经食道超声心动图(transesophageal echocardiography,TEE)、右心声学造影(contrast transthoracic echocardiography,cTTE)在卵圆孔未闭(patent foramen ovale,PFO)诊断中的应用价值.方法:本研究选取2019年8月...     

主肺动脉间隔缺损的超声心动图诊断价值

目的总结超声心动图对主肺动脉间隔缺损(APSD)的诊断经验,提高超声诊断的准确率。方法11例主肺动脉间隔缺损的患者,男性8例,女性3例,术前超声心动图检查结果与心导管检查及术后结果对照。结果术前超声心动图检查确诊8例,Ⅰ型1例,Ⅱ型3例,Ⅲ型4例,漏诊3例,其中心导管证实1例为Ⅱ型,2例为Ⅲ型。9例患者合并其他心内畸形。结论应用合理的临床思维、特殊的超声切面及方法,超声心动图可作为一种无创、安全、可重复的检查手段,对此病做出正确的诊断及分型。     

超声心动图在诊断单心室中的价值

目的 探讨单心室的超声诊断价值,分析其超声表现类型.方法 回顾性分析66例单心室患者的经胸超声心动图表现,并结合文献分析超声表现类型.结果 66例患者根据单心室的超声表现分为三型:①A型(左室型)19例,单心室为左室形态,其前方有一发育不良的残余心室;②B型(右室型)38例,单心室为右室形态,其后方有一发育不良的残余心室;③C型(不定型)9例,只有单个心室腔,无合并发育不良的残余心室.66例单心室患者中,31例经手术证实,5例经MRI或心血管造影证实,分型诊断正确率为100%.其合并的畸形中,1例混合型完全性肺静脉畸形引流误诊为心上型完全性肺静脉畸形引流(APVD),降主动脉局限性缩窄并动脉导管未闭(PDA)漏诊1例,其余诊断完全正确.结论 经胸超声心动图能准确诊断单心室分型及其合并畸形,为手术提供准确可靠的信息,是术前诊断的必要检查方法.     

The need for standardized data reporting for prehospital airway management

Despite a widespread belief in the value of aggressive prehospital airway management, the therapeutic benefits of early tracheal intubation (TI) remain unclear. In fact, most attempts to elucidate the benefits of prehospital TI on outcome from traumatic brain injury and cardiopulmonary arrest have documented an increase in mortality associated with the procedure. While some degree of selection bias is likely present in these studies, the inherent adverse physiological effects of intubation and a high incidence of desaturation and subsequent hyperventilation may indicate a harmful effect of the procedure. This uncertainty regarding such a fundamental resuscitation procedure as TI underscores the need for standardized data reporting in prehospital airway management research. To this end, the Utstein prehospital airway conference proposed a set of variables that would move us in that direction. However, the present article by Lossius and colleagues documents how far we still have to travel before such standardization can be achieved. Only through these efforts can we elucidate the true benefits - or harm - of advanced airway management during critical resuscitation.     

超声心动图在经胸小切口房间隔缺损封堵术中的应用价值

目的：探讨超声心动图在经胸小切口房间隔缺损（ASD）封堵术中的应用价值。方法：对38例ASD患者,术前采用经胸超声筛选合适的病例及封堵器型号;术中采用经胸超声指导封堵术,经右心房插入特制推送器,将封堵器嵌入ASD处;术后即刻及3个月随访观察封堵器的位置及有无分流。结果：38例患者中,36例封堵术成功,2例失败。术后3个月随访,无一例发生严重并发症。结论：超声心动图在ASD介入治疗的术前选择病例、确定封堵器型号、术中监测以及术后随诊方面均具有重要的临床价值。     

实时三维超声心动图在主动脉瓣成形术中的应用价值

目的 初步探讨实时三维超声心动图在保留瓣叶的主动脉瓣成形术中的应用价值.方法 对11例主动脉瓣中重度关闭不全患者在术前、术后进行常规超声心动图、实时三维超声心动图(RT-3DE)及彩色实时三维超声心动图(color RT-3DE)检查.结果 11例患者术前及术后RT-3DE、color RT-3DE均能立体观察主动脉瓣的形态及对合情况,5例患者术前color RT-3DE能立体观察室间隔缺损部位、形态、大小及空间关系,而且RT-3DE测量主动脉瓣环直径、窦部直径、窦干部直径、升主动脉直径及室间隔缺损大小基本上与手术中的测值呈线性相关.结论 RT-3DE能快速、准确地测量主动脉瓣环、窦部、窦干部及升主动脉的直径,同时能立体显示主动脉瓣的形态和功能及主动脉瓣反流的程度.     

新生儿先天性心脏病临床筛查及超声心动图的应用价值

目的分析我院2006年7月1日至2007年6月30日出生的新生儿先天性心脏病的发病情况,探讨临床检查及超声心动图对新生儿先天性心脏病临床筛查的应用价值。方法选择我院2006年7月1日至2007年6月30日出生全部新生儿共5581例,住院期间每日均予体格检查、详细心脏听诊,出生第2天进行心电图检查,对有病理性杂音、皮肤青紫、气促等不能用呼吸神经等疾病解释及心电图提示先天性心脏病患儿,进一步行超声心动图检查,出院随访至出生后6个月。结果筛查5581例新生儿,发现听诊异常51例,其中超声心动图确诊为先天性心脏病29例,未闭动脉导管12例,9例瓣膜反流及1例假腱索;256例新生儿检测了经皮血氧饱和度,62例经皮血氧饱和度降低,其中8例排除了肺、脑等心外因素,超声心动图均证实先天性心脏病存在;4例新生儿心电图提示先天性心脏病,均确诊。超声心动图确诊先天性心脏病31例,包括室间隔缺损15例(48.4%),房间隔缺损10例(32.2%),完全性内脏反位及镜像右位心2例,原发性肺动脉高压、法洛四联症、三尖瓣下移畸形、完全型房室隔缺损合并永存动脉干各1例。结论彩色多普勒超声心动图结合临床症状、体征、血氧饱和度测定及心电图等检查,可使新生儿先天性心脏病早期诊断的准确性明显提高。