Management of Respiratory Distress and Failure in Morbidly and Super Obese Patients During Critical Care Transport.

Morbidly and super obese patients are a unique patient population that presents critical care transport providers with unique clinical and logistical challenges in the setting of respiratory distress and failure. These patients are more likely to have chronic respiratory issues at baseline, unique anatomic and physiologic abnormalities, and other comorbidities that leave them poorly able to tolerate respiratory illness or injury. This requires specialized understanding of their respiratory mechanics as well as how to tailor standard treatment modalities, such as noninvasive ventilation, to meet their needs. Also, careful and deliberate planning is required to address the specific anatomic and physiologic characteristics of this population if intubation and mechanical ventilation are needed. Finally, their dimensions and weight also have distinct consequences on transport vehicle considerations. This article reviews the pathophysiology, management, and critical care transport considerations for this unique patient population in respiratory distress and failure.

Feasibility of a Modified Strategy for 2-Rescuer Cardiopulmonary Resuscitation.

BACKGROUND: Cardiopulmonary resuscitation (CPR) requires effective chest compressions and ventilations to circulate and oxygenate blood. It has been established that a 2-handed mask seal is superior when providing bag-valve-mask (BVM) ventilations. However a 1-handed technique remains the standard with which health care providers are trained to perform 2-rescuer CPR. OBJECTIVES: We sought to determine if a modified 2-rescuer CPR technique that incorporates a 2-handed mask seal during ventilations can be accomplished without compromising chest compression quality during a simulated cardiac arrest. METHODS: Medical student volunteers were divided into an "intervention" arm, with 1 rescuer creating a 2-handed mask seal and the second rescuer performing chest compressions followed by that second rescuer squeezing the BVM bag to deliver ventilations during compression pauses, and a "control" arm, in which standard 2-rescuer CPR was performed. Both arms received a brief CPR refresher following a standard script. The 2 rescuer teams then performed 2 rounds of CPR on a manikin while being video recorded. Data were collected from real-time evaluation and post hoc video analysis. RESULTS: Forty-seven pairs of students enrolled in the study. There were no statistically significant differences between the intervention and control arms for median (interquartile range [IQR]) compression fraction (72% [69.5-75.7%] vs. 73.2% [69.1-76.1%]; p = 1.0), median time to complete 2 rounds of CPR (207.8 s [198.5-222.9 s] vs. 214.7 s [201.3-219.5 s]; p = 0.625), median hands-off time (49.8 s [46.2-63.0 s] vs. 55.4 s [50.4-65.2 s]; p = 0.278), or median time for 30 compressions (15.2 s [14.3-15.9 s] vs. 15.4 s [14.6-16.3 s]; p = 0.452). CONCLUSION: Two-rescuer CPR incorporating a 2-handed face mask seal can be performed effectively without impacting chest compression quality during simulated cardiac arrest.

The King laryngeal tube: a mimic of esophageal intubation in the emergency department.

The King Airway is a temporary airway device used primarily in the pre-hospital setting and typically exchanged for an endotracheal tube upon arrival to the emergency department. Since this usually occurs before imaging, many radiologists are unfamiliar with the King Airway. This lack of familiarity can have important consequences for the patient and treating team. The purpose of this article is to raise awareness of the King Airway among radiologists, emphasize appropriate positioning, and review the imaging complications of incorrect positioning.

Modified cadaver technique to simulate contaminated airway scenarios to train medical providers in suction-assisted laryngoscopy and airway decontamination.

Simulation training plays a vital role in modern medical education, fostering safe skill development. Task-trainer manikin and cadaveric airway management training (CAMT) offer realistic airway management practice. Simulation allows learners the opportunity to manage high-risk, low-frequency scenarios, including difficult airways and massive airway contamination, common in emergent airway management. The suction-assisted laryngoscopy and airway decontamination (SALAD) technique was developed to address massive airway contamination. This paper describes two methods to simulate massive airway contamination utilizing cadavers. We detail our techniques for both esophageal and nasopharyngeal delivery of simulated airway contaminant. Nasopharyngeal delivery was less invasive and required less time to set up. Utilizing cadavers to simulate massive airway contamination in CAMT provides learners with tools to manage airway complications effectively, enhancing readiness for complex airway challenges while promoting patient safety in clinical practice.

Rapid response system adaptations at 40 US hospitals during the COVID-19 pandemic.

BACKGROUND: Management of patients with acute deterioration from novel coronavirus disease of 2019 (COVID-19) has posed a particular challenge for rapid response systems (RRSs) due to increased hospital strain and direct risk of infection to RRS team members. OBJECTIVE: We sought to characterize RRS structure and protocols adaptions during the COVID-19 pandemic. DESIGN SETTING AND PARTICIPANTS: Internet-based cross-sectional survey of RRS leaders, physicians, and researchers across the United States. RESULTS: Clinicians from 46 hospitals were surveyed, 40 completed a baseline survey (87%), and 19 also completed a follow-up qualitative survey. Most reported an increase in emergency team resources during the COVID-19 pandemic. The number of sites performing simulation training sessions decreased from 88% before COVID-19 to 53% during the pandemic. CONCLUSIONS: Most RRSs reported pandemic-related adjustments, most commonly through increasing resources and implementation of protocol changes. There was a reduction in the number of sites that performed simulation training.

Differences in Outcomes After Anesthesia-Related Adverse Events in Older and Younger Patients.

Because more older adults undergo surgical procedures, it is incumbent on us to learn how to provide them with the safest possible perioperative care. We conducted a retrospective cohort study at a large tertiary care center to determine whether outcomes after anesthesia-related adverse events differed between patients aged 65 years and older versus patients under age 65. One thousand four hundred twenty-four cases were referred to the Performance Improvement committee of the Department of Anesthesiology from the years 2007-2015. After exclusions of cases that were not anesthesia-related, could not be identified, or were duplicates, 747 cases with anesthesia-related adverse events were included in the study. Two hundred eighty-six were aged 65 years and older and 461 were under age 65. Anesthesia-related adverse events occurred more commonly in the postoperative period in older patients relative to younger patients (37.7% vs. 21.9%, p = .001), and older patients had a greater incidence of mortality compared with a propensity-matched group of younger patients (adjusted odds ratio 1.87 [1.14-3.12], p < .05). We concluded that older patients have a greater likelihood of mortality as a result of suffering an anesthesia-related adverse event and may benefit from increased vigilance in the postoperative period.

Suction Assisted Laryngoscopy and Airway Decontamination (SALAD): A technique for improved emergency airway management.

Emergency airway management is often complicated by the presence of blood, emesis or other contaminants in the airway. Traditional airway management education has lacked task-specific training focused on mitigating massive airway contamination. The Suction Assisted Laryngoscopy and Airway Decontamination (SALAD) technique was developed in order to address the problem of massive airway contamination both in simulation training and in vivo. We review the evidence describing the dangers associated with airway contamination, and describe the SALAD technique in detail.

Multidisciplinary approach to the management of pulmonary embolism patients: the pulmonary embolism response team (PERT).

Pulmonary embolism (PE) is a potentially fatal disease with a broad range of treatment options that spans multiple specialties. The rapid evolution and expansion of novel therapies to treat PE make it a disease process that is well suited to a multidisciplinary approach. In order to facilitate a rapid, robust response to the diagnosis of PE, some hospitals have established multidisciplinary pulmonary embolism response teams (PERTs). The PERT model is based on existing multidisciplinary teams such as heart teams and rapid response teams. A PERT is composed of clinicians from the range of specialties involved in the treatment of PE, including pulmonology critical care, interventional radiology, cardiology, and cardiothoracic surgery among others. A PERT is a 24/7 consult service that is able to provide expert advice on the initial management of PE patients and convene in real time to develop a consensus treatment plan specifically tailored to the needs of a particular patient and consistent with the capabilities of the institution. In this review, we discuss the rationale for establishing a PERT and its potential benefits. We discuss considerations in forming a PERT and present case studies of several PERTs currently in operation at different institutions. We also discuss potential difficulties in forming a PERT and review evidence that has been generated by some of the PERTs that have been in operation the longest.

Acute pulmonary embolism: endovascular therapy.

Pulmonary embolism (PE) is a leading cause of morbidity and mortality worldwide. PE is a complex disease with a highly variable presentation and the available treatment options for PE are expanding rapidly. Anticoagulation (AC), systemic lysis, surgery, and catheter-directed thrombolysis (CDT) play important roles in treating patients with PE. Thus, a multidisciplinary approach to diagnosis, risk stratification, and therapy is required to determine which treatment option is best for a given patient with this complex disease.

Loop formation in unfolded polypeptide chains on the picoseconds to microseconds time scale.

Intrachain loop formation allows unfolded polypeptide chains to search for favorable interactions during protein folding. We applied triplet-triplet energy transfer between a xanthone moiety and naphthylalanine to directly measure loop formation in various unfolded polypeptide chains with loop regions consisting of polyserine, poly(glycine-serine) or polyproline. By combination of femtosecond and nanosecond laserflash experiments loop formation could be studied over many orders of magnitude in time from picoseconds to microseconds. The results reveal processes on different time scales indicating motions on different hierarchical levels of the free energy surface. A minor (<15%) very fast reaction with a time constant of approximately 3 ps indicates equilibrium conformations with donor and acceptor in contact at the time of the laserflash. Complex kinetics of loop formation were observed on the 50- to 500-ps time scale, which indicate motions within a local well on the energy landscape. Conformations within this well can form loops by undergoing local motions without having to cross major barriers. Exponential kinetics observed on the 10- to 100-ns time scale are caused by diffusional processes involving large-scale motions that allow the polypeptide chain to explore the complete conformational space. These results indicate that the free energy landscape for unfolded polypeptide chains and native proteins have similar properties. The presence of local energy minima reduces the conformational space and accelerates the conformational search for energetically favorable local intrachain contacts.

A conformational two-state peptide model system containing an ultrafast but soft light switch.

Combining an azobenzene chromophore with the bis-cysteinyl active-site sequence of the protein disulfide isomerase (PDI) we constructed a simple but promising model for allosteric conformational rearrangements. Paralleling cellular signaling events, an external trigger, here absorption of a photon, leads to a structural change in one part of the molecule, namely the azobenzene-based chromophore. The change in geometry translates to the effector site, in our case the peptide sequence, where it modifies covalent and nonbonded interactions and thus leads to a conformational rearrangement. NMR spectroscopy showed that the trans-azo and cis-azo isomer of the cyclic PDI peptide exhibit different, but well-defined structures when the two cystine residues form a disulfide bridge. Without this intramolecular cross-link conformationally more variable structural ensembles are obtained that again differ for the two isomeric states. Ultrafast UV/Vis spectroscopy confirmed that the rapid isomerization of azobenzene is not significantly slowed down when incorporated into the cyclic peptides, although the amplitudes of ballistic and diffusive pathways are changed. The observation that most of the energy of an absorbed photon is dissipated to the solvent in the first few picoseconds when the actual azo-isomerization takes place is important. The conformational rearrangement is weakly driven due to the absence of appreciable excess energy and can be described as biased diffusion similar to natural processes.