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1.
Best Pract Res Clin Anaesthesiol ; 35(3): 377-388, 2021 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-34511226

RESUMO

The Hospital Incident Command System (HICS) is an incident management system specific to hospitals based on the principles of Incident Command System (ICS), and it includes prevention, protection, mitigation, response, and recovery. It plays a crucial role in effective and timely response during the periods of disasters, mass casualties, and public health emergencies. In recent times, hospitals have used a customized HICS structure to coordinate effective responses to public health problems such as the Ebola outbreak in the US and SARS epidemic in Taiwan. The current COVID-19 pandemic has placed unprecedented challenges on the healthcare system, necessitating the creation of HICS that can help in the proper allocation of resources and ineffective utilization of healthcare personnel. The key elements in managing a response to this pandemic include screening and early diagnosis, quarantining affected individuals, monitoring disease progression, delivering appropriate treatment, and ensuring an adequate supply of personal protective equipment (PPE) to healthcare staff.


Assuntos
COVID-19/epidemiologia , Gestão de Recursos da Equipe de Assistência à Saúde/métodos , Serviços Médicos de Emergência/métodos , COVID-19/terapia , Serviços Médicos de Emergência/tendências , Humanos , Incidência , Centros de Informação/tendências
2.
J Trauma Acute Care Surg ; 91(2): 344-351, 2021 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-34397955

RESUMO

BACKGROUND: Hemorrhage with trauma-induced coagulopathy (TIC) and hyperfibrinolysis (HF) increases the mortality risk after severe trauma. While TIC at hospital admission is well studied, little is known about coagulopathy at the incident site. The aim of the study was to investigate coagulation disorders already present on scene. METHODS: In a prospective single-center observational study, blood samples of trauma patients obtained before and at hospital admission were analyzed. Data on rotational thromboelastometry, blood gas analysis, prehospital treatment, injury severity, in-hospital blood transfusions, and mortality were investigated according to the presence of coagulation disorders at the incident site. The patients were divided into three groups according to the presence of coagulation disorders (no coagulopathy, TIC, TIC with HF). In a subgroup analysis, patients with a Trauma-Induced Coagulopathy Clinical Score (TICCS) of ≥10 were investigated. RESULTS: Between August 2015 and February 2018, 148 patients were enrolled in the study. The mean Injury Severity Score was 22.1, and overall mortality was 7.4%. Trauma-induced coagulopathy and HF were already detectable at the incident site in 18.2% and 6.1%, respectively. Patients with HF had significantly altered circulation parameters with significant changes in pH, hemoglobin, lactate, and base excess at the incident site. In patients with TICCS of ≥10 (14.2%), TIC was detected in 47.6% of the cases and HF in 28.6%. Furthermore, in these patients, blood gas parameters significantly changed and the need for blood transfusion and mortality. CONCLUSION: Trauma-induced coagulopathy and HF can be detected in severely injured patients even before medical treatment is started. Furthermore, in patients with HF and TICCS of ≥10, blood gas parameters were significantly changed at the incident site. LEVEL OF EVIDENCE: Prognostic study, level III.


Assuntos
Transtornos da Coagulação Sanguínea/diagnóstico , Serviços Médicos de Emergência/métodos , Hemorragia/diagnóstico , Traumatismo Múltiplo/diagnóstico , Adulto , Idoso , Coagulação Sanguínea , Transtornos da Coagulação Sanguínea/sangue , Transtornos da Coagulação Sanguínea/terapia , Gasometria , Feminino , Hemorragia/sangue , Hemorragia/terapia , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Traumatismo Múltiplo/sangue , Traumatismo Múltiplo/terapia , Estudos Prospectivos , Tromboelastografia , Adulto Jovem
3.
Nurs Clin North Am ; 56(3): 379-388, 2021 09.
Artigo em Inglês | MEDLINE | ID: mdl-34366158

RESUMO

The registered nurse (RN) on a medical-surgical nursing unit may be the first health care professional to encounter a patient with the signs of impending respiratory failure. Importantly, the RN must recognize the signs of respiratory compromise and possess the competence and confidence to intervene without delay. Signs of respiratory deterioration, physical assessment, and respiratory laboratory studies are reviewed. Modes of oxygen therapy, basic airway management techniques, including bag mask ventilation, and use of oropharyngeal and nasopharyngeal airways are discussed. The assembly of equipment and medications frequently used for intubation are also outlined.


Assuntos
Manuseio das Vias Aéreas/enfermagem , Competência Clínica/normas , Papel do Profissional de Enfermagem , Tomada de Decisão Clínica/métodos , Serviços Médicos de Emergência/métodos , Humanos
4.
Transfusion ; 61 Suppl 1: S333-S335, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-34269445

RESUMO

Hemorrhage is the most common mechanism of death in battlefield casualties with potentially survivable injuries. There is evidence that early blood product transfusion saves lives among combat casualties. When compared to component therapy, fresh whole blood transfusion improves outcomes in military settings. Cold-stored whole blood also improves outcomes in trauma patients. Whole blood has the advantage of providing red cells, plasma, and platelets together in a single unit, which simplifies and speeds the process of resuscitation, particularly in austere environments. The Joint Trauma System, the Defense Committee on Trauma, and the Armed Services Blood Program endorse the following: (1) whole blood should be used to treat hemorrhagic shock; (2) low-titer group O whole blood is the resuscitation product of choice for the treatment of hemorrhagic shock for all casualties at all roles of care; (3) whole blood should be available within 30 min of casualty wounding, on all medical evacuation platforms, and at all resuscitation and surgical team locations; (4) when whole blood is not available, component therapy should be available within 30 min of casualty wounding; (5) all prehospital medical providers should be trained and logistically supported to screen donors, collect fresh whole blood from designated donors, transfuse blood products, recognize and treat transfusion reactions, and complete the minimum documentation requirements; (6) all deploying military personnel should undergo walking blood bank prescreen laboratory testing for transfusion transmitted disease immediately prior to deployment. Those who are blood group O should undergo anti-A/anti-B antibody titer testing.


Assuntos
Transfusão de Sangue/métodos , Ressuscitação/métodos , Choque Hemorrágico/terapia , Ferimentos e Lesões/terapia , Bancos de Sangue/métodos , Serviços Médicos de Emergência/métodos , Humanos , Medicina Militar , Militares
5.
Medicine (Baltimore) ; 100(27): e26569, 2021 Jul 09.
Artigo em Inglês | MEDLINE | ID: mdl-34232201

RESUMO

ABSTRACT: Previous comparison studies regarding 2 types of transportation, helicopter (HEMS) versus ground emergency medical services (GEMS), have shown underlying heterogeneity as these options have completely different routes and consequent times with reference to one patient. To compare the 2 types of transportation on a case-by-case basis, we analyzed the retrospectively reviewed HEMS and predicted GEMS data using an open-source navigation software.Patients transferred by military HEMS from 2016 to 2019 were retrospectively enrolled. The HEMS records on the time of notification, injury point and destination address, and time required were reviewed. The GEMS data on distance and the predicted time required were acquired using open-source social navigation systems. Comparison analyses between the two types of transportation were conducted. Furthermore, linear logistic regression analyses were performed on the distance and time of the two options.A total of 183 patients were enrolled. There was no statistical difference (P = .3021) in the distance between the 2 types of transportation, and the HEMS time was significantly shorter than that of GEMS (61.31 vs 116.92 minutes, P < .001). The simple linear curves for HEMS and GEMS were separately secured, and two graphs presented the statistical significance (P) as well as reasonable goodness-of-fit (R2). In general, the HEMS graph demonstrates a more gradual slope and narrow distribution compared to that of GEMS.Ideally, HEMS is identified as a better transportation modality because it has a shorter transportation time (56 minutes saved) and a low possibility of potential time delays (larger R2). With a strict patient selection, HEMS can rescue injured or emergent patients who are "out of the golden hour."


Assuntos
Resgate Aéreo/estatística & dados numéricos , Serviços Médicos de Emergência/métodos , Traumatismo Múltiplo/terapia , Pontuação de Propensão , Software , Transporte de Pacientes/métodos , Transporte de Pacientes/estatística & dados numéricos , Humanos , Escala de Gravidade do Ferimento , Traumatismo Múltiplo/diagnóstico , Estudos Retrospectivos , Fatores de Tempo , Centros de Traumatologia
6.
Medicine (Baltimore) ; 100(23): e26261, 2021 Jun 11.
Artigo em Inglês | MEDLINE | ID: mdl-34115019

RESUMO

ABSTRACT: The rapid response system (RRS) was introduced for early stage intervention in patients with deteriorating clinical conditions. Responses to unexpected in-hospital patient emergencies varied among hospitals. This study was conducted to understand the prevalence of RRS in smaller hospitals and to identify the need for improvements in the responses to in-hospital emergencies.A questionnaire survey of 971 acute-care hospitals in western Japan was conducted from May to June 2019 on types of in-hospital emergency response for patients in cardiac arrest (e.g., medical emergency teams [METs]), before obvious deterioration (e.g., rapid response teams [RRTs]), and areas for improvement.We received 149 responses, including those from 56 smaller hospitals (≤200 beds), which provided fewer responses than other hospitals. Response systems for cardiac arrest were used for at least a limited number of hours in 129 hospitals (87%). The absence of RRS was significantly more frequent in smaller hospitals than in larger hospitals (13/56, 23% vs 1/60, 2%; P < .01). METs and RRTs operated in 17 (11%) and 15 (10%) hospitals, respectively, and the operation rate for RRTs was significantly lower in smaller hospitals than in larger hospitals (1/56, 2% vs 12/60, 20%; P < .01). Respondents identified the need for education and more medical staff and supervisors; data collection or involvement of the medical safety management sector was ranked low.The prevalence of RRS or predetermined responses before obvious patient deterioration was ≤10% in small hospitals. Specific education and appointment of supervisors could support RRS in small hospitals.


Assuntos
Serviços Médicos de Emergência , Parada Cardíaca , Equipe de Respostas Rápidas de Hospitais , Hospitais com Baixo Volume de Atendimentos , Deterioração Clínica , Serviços Médicos de Emergência/métodos , Serviços Médicos de Emergência/normas , Pesquisas sobre Serviços de Saúde , Necessidades e Demandas de Serviços de Saúde , Parada Cardíaca/epidemiologia , Parada Cardíaca/terapia , Equipe de Respostas Rápidas de Hospitais/organização & administração , Equipe de Respostas Rápidas de Hospitais/normas , Equipe de Respostas Rápidas de Hospitais/estatística & dados numéricos , Hospitais com Baixo Volume de Atendimentos/organização & administração , Hospitais com Baixo Volume de Atendimentos/estatística & dados numéricos , Humanos , Japão/epidemiologia , Prevalência , Melhoria de Qualidade , Desenvolvimento de Pessoal
7.
West J Emerg Med ; 22(3): 690-695, 2021 Mar 24.
Artigo em Inglês | MEDLINE | ID: mdl-34125048

RESUMO

INTRODUCTION: The intraosseous (IO) route is one of the primary means of vascular access in critically ill and injured patients. The most common sites used are the proximal humerus, proximal tibia, and sternum. Sternal IO placement remains an often-overlooked option in emergency and prehospital medicine. Due to the conflicts in Afghanistan and Iraq the use of sternal IOs have increased. METHODS: The authors conducted a limited review, searching PubMed and Google Scholar databases for "sternal IO," "sternal intraosseous," and "intraosseous" without specific date limitations. A total of 47 articles were included in this review. RESULTS: Sternal IOs are currently FDA approved for ages 12 and older. Sternal IO access offers several anatomical, pharmacokinetic, hemodynamic, and logistical advantages over peripheral intravenous and other IO points of access. Sternal IO use carries many of the same risks and limitations as the humeral and tibial sites. Sternal IO gravity flow rates are sufficient for transfusing blood and resuscitation. In addition, studies demonstrated they are safe during active CPR. CONCLUSION: The sternal IO route remains underutilized in civilian settings. When considering IO vascular access in adults or older children, medical providers should consider the sternum as the recommended IO access, particularly if the user is a novice with IO devices, increased flow rates are required, the patient has extremity trauma, or administration of a lipid soluble drug is anticipated.


Assuntos
Estado Terminal/terapia , Serviços Médicos de Emergência/métodos , Infusões Intraósseas , Esterno , Humanos , Infusões Intraósseas/instrumentação , Infusões Intraósseas/métodos , Medição de Risco
8.
West J Emerg Med ; 22(3): 739-749, 2021 Mar 24.
Artigo em Inglês | MEDLINE | ID: mdl-34125055

RESUMO

INTRODUCTION: Extreme heat is a significant cause of morbidity and mortality, and the incidence of acute heat illness (AHI) will likely increase secondary to anthropogenic climate change. Prompt diagnosis and treatment of AHI are critical; however, relevant diagnostic and surveillance tools have received little attention. In this exploratory cross-sectional and diagnostic accuracy study, we evaluated three tools for use in the prehospital setting: 1) case definitions; 2) portable loggers to measure on-scene heat exposure; and 3) prevalence data for potential AHI risk factors. METHODS: We enrolled 480 patients who presented to emergency medical services with chief complaints consistent with AHI in Ahmedabad, India, from April-June 2016 in a cross-sectional study. We evaluated AHI case definition test characteristics in reference to trained prehospital provider impressions, compared on-scene heat index measured by portable loggers to weather station measurements, and identified AHI behavioral and environmental risk factors using logistic regression. RESULTS: The case definition for heat exhaustion was 23.8% (12.1-39.5%) sensitive and 93.6% (90.9-95.7%) specific. The positive and negative predictive values were 33.5% (20.8-49.0%) and 90.1% (88.5-91.5%), respectively. Mean scene heat index was 6.7°C higher than the mean station heat index (P < 0.001), and station data systematically underestimated heat exposure, particularly for AHI cases. Heat exhaustion cases were associated with on-scene heat index ≥ 49°C (odds ratio [OR] 2.66 [1.13-6.25], P = 0.025) and a history of recent exertion (OR 3.66 [1.30-10.29], P = 0.014), while on-scene air conditioning was protective (OR 0.29 [0.10-0.85], P = 0.024). CONCLUSION: Systematic collection of prehospital data including recent activity history and presence of air conditioning can facilitate early AHI detection, timely intervention, and surveillance. Scene temperature data can be reliably collected and improve heat exposure and AHI risk assessment. Such data may be important elements of surveillance, clinical practice, and climate change adaptation.


Assuntos
Diagnóstico Precoce , Serviços Médicos de Emergência/métodos , Transtornos de Estresse por Calor , Temperatura Alta/efeitos adversos , Adaptação Fisiológica , Adulto , Mudança Climática , Estudos Transversais , Intervenção Médica Precoce , Feminino , Transtornos de Estresse por Calor/diagnóstico , Transtornos de Estresse por Calor/epidemiologia , Transtornos de Estresse por Calor/etiologia , Transtornos de Estresse por Calor/terapia , Humanos , Índia/epidemiologia , Masculino , Medição de Risco
9.
Sci Rep ; 11(1): 12985, 2021 06 21.
Artigo em Inglês | MEDLINE | ID: mdl-34155299

RESUMO

This study aimed to determine the association between cardiopulmonary resuscitation (CPR) under the coronavirus 2019 (COVID-19) safety protocols in our hospital and the prognosis of out-of-hospital cardiac arrest (OHCA) patients, in an urban area, where the prevalence of COVID-19 infection is relatively low. This was a single-center, retrospective, observational, cohort study conducted at a tertiary critical care center in Kyoto City, Japan. Adult OHCA patients arriving at our hospital under CPR between January 1, 2019, and December 31, 2020 were included. Our hospital implemented a revised resuscitation protocol for OHCA patients on April 1, 2020 to prevent COVID-19 transmission. This study defined the conventional CPR period as January 1, 2019 to March 31, 2020, and the COVID-19 safety protocol period as April 1, 2020 to December 31, 2020. Throughout the prehospital and in-hospital settings, resuscitation protocols about wearing personal protective equipment and airway management were revised in order to minimize the risk of infection; otherwise, the other resuscitation management had not been changed. The primary outcome was hospitalization survival. The secondary outcomes were return of spontaneous circulation after hospital arrival and 1-month survival after OHCA occurrence. The adjusted odds ratios with 95% confidence intervals (CI) were calculated for outcomes to compare the two study periods, and the multivariable logistic model was used to adjust for potential confounders. The study analyzed 443 patients, with a median age of 76 years (65-85), and included 261 men (58.9%). The percentage of hospitalization survivors during the entire research period was 16.9% (75/443 patients), with 18.7% (50/267) during the conventional CPR period and 14.2% (25/176) during the COVID-19 safety protocol period. The adjusted odds ratio for hospitalization survival during the COVID-19 safety protocol period was 0.61 (95% CI 0.32-1.18), as compared with conventional CPR. There were no cases of COVID-19 infection among the staff involved in the resuscitation in our hospital. There was no apparent difference in hospitalization survival between the OHCA patients resuscitated under the conventional CPR protocol compared with the current revised protocol for controlling COVID-19 transmission.


Assuntos
COVID-19/epidemiologia , COVID-19/prevenção & controle , Reanimação Cardiopulmonar/métodos , Serviços Médicos de Emergência/métodos , Parada Cardíaca Extra-Hospitalar/terapia , SARS-CoV-2 , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , COVID-19/virologia , Feminino , Hospitalização , Humanos , Japão/epidemiologia , Masculino , Pessoa de Meia-Idade , Razão de Chances , Estudos Retrospectivos , Resultado do Tratamento , Adulto Jovem
10.
Scand J Trauma Resusc Emerg Med ; 29(1): 85, 2021 Jun 29.
Artigo em Inglês | MEDLINE | ID: mdl-34187538

RESUMO

BACKGROUND: Noninvasive ventilation (NIV) is recognized as first line ventilatory support for the management of acute pulmonary edema (APE) and chronic obstructive pulmonary disease (COPD) exacerbations. We aimed to study the prehospital management of patients in acute respiratory distress with an indication for NIV and whether they received it or not. METHODS: This retrospective study included patients ≥18 years old who were cared for acute respiratory distress in a prehospital setting. Indications for NIV were oxygen saturation (SpO2) <90% and/or respiratory rate (RR) >25/min with a presumptive diagnosis of APE or COPD exacerbation. Study population characteristics, initial and at hospital vital signs, presumptive and definitive diagnosis were analyzed. For patients who received NIV, dyspnea level was evaluated with a dyspnea verbal ordinal scale (D-VOS, 0-10) and arterial blood gas (ABG) values were obtained at hospital arrival. RESULTS: Among the 187 consecutive patients included in the study, most (n = 105, 56%) had experienced APE or COPD exacerbation, and 56 (30%) received NIV. In comparison with patients without NIV, those treated with NIV had a higher initial RR (35 ± 8/min vs 29 ± 10/min, p < 0.0001) and a lower SpO2 (79 ± 10 vs 88 ± 11, p < 0.0001). The level of dyspnea was significantly reduced for patients treated with NIV (on-scene D-VOS 8.4 ± 1.7 vs 4.4 ± 1.8 at admission, p < 0.0001). Among the 131 patients not treated with NIV, 41 (31%) had an indication. In the latter group, initial SpO2 was 80 ± 10% in the NIV group versus 86 ± 11% in the non-NIV group (p = 0.0006). NIV was interrupted in 9 (16%) patients due to either discomfort (n = 5), technical problem (n = 2), persistent desaturation (n = 1), or vomiting (n = 1). CONCLUSIONS: The results of this study contribute to a better understanding of the prehospital management of patients who present with acute respiratory distress and an indication for NIV. NIV was started on clinically more severe patients, even if predefined criteria to start NIV were present. NIV allows to improve vital signs and D-VOS in those patients. A prospective study could further elucidate why patients with a suspected diagnosis of APE and COPD are not treated with NIV, as well as the clinical impact of the different strategies. TRIAL REGISTRATION: The study was approved by our institutional ethical committee ( CER-VD 2020-01363 ).


Assuntos
Serviços Médicos de Emergência/métodos , Hospitais/estatística & dados numéricos , Ventilação não Invasiva/métodos , Síndrome do Desconforto Respiratório/terapia , Adolescente , Idoso , Feminino , Humanos , Masculino , Estudos Retrospectivos
11.
West J Emerg Med ; 22(3): 750-755, 2021 Mar 24.
Artigo em Inglês | MEDLINE | ID: mdl-34125056

RESUMO

INTRODUCTION: Thoracic ultrasound is frequently used in the emergency department (ED) to determine the etiology of dyspnea, yet its use is not widespread in the prehospital setting. We sought to investigate the feasibility and diagnostic performance of paramedic acquisition and assessment of thoracic ultrasound images in the prehospital environment, specifically for the detection of B-lines in congestive heart failure (CHF). METHODS: This was a prospective observational study of a convenience sample of adult patients with a chief complaint of dyspnea. Paramedics participated in a didactic and hands-on session instructing them how to use a portable ultrasound device. Paramedics assessed patients for the presence of B-lines. Sensitivity and specificity for the presence of bilateral B-lines and any B-lines were calculated based on discharge diagnosis. Clips archived to the ultrasound units were reviewed and paramedic interpretations were compared to expert sonologist interpretations. RESULTS: A total of 63 paramedics completed both didactic and hands-on training, and 22 performed ultrasounds in the field. There were 65 patients with B-line findings recorded and a discharge diagnosis for analysis. The presence of bilateral B-lines for diagnosis of CHF yielded a sensitivity of 80.0% (95% confidence interval [CI], 51.4-94.7%) and specificity of 72.0% (95% CI, 57.3-83.3), while presence of any B-lines was 93.3% sensitive (95% CI, 66.0-99.7%), and 50% specific (95% CI, 35.7-64.2%) for CHF. Paramedics archived 117 ultrasound clips of which 63% were determined to be adequate for interpretation. Comparison of paramedic and expert sonologist interpretation of images showed good inter-rater agreement for detection of any B-lines (k = 0.60; 95% CI, 0.36-0.84). CONCLUSION: This observational pilot study suggests that prehospital lung ultrasound for B-lines may aid in identifying or excluding CHF as a cause of dyspnea. The presence of bilateral B-lines as determined by paramedics is reasonably sensitive and specific for the diagnosis of CHF and pulmonary edema, while the absence of B lines is likely to exclude significant decompensated heart failure. The study was limited by being a convenience sample and highlighted some of the difficulties related to prehospital research. Larger funded trials will be needed to provide more definitive data.


Assuntos
Pessoal Técnico de Saúde/normas , Dispneia , Serviços Médicos de Emergência/métodos , Pulmão/diagnóstico por imagem , Testes Imediatos , Ultrassonografia/métodos , Diagnóstico Diferencial , Dispneia/diagnóstico , Dispneia/etiologia , Serviços Médicos de Emergência/estatística & dados numéricos , Estudos de Viabilidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Sensibilidade e Especificidade
12.
Epilepsia Open ; 6(2): 331-338, 2021 06.
Artigo em Inglês | MEDLINE | ID: mdl-34033243

RESUMO

OBJECTIVE: To determine whether the portable Ceribell® electroencephalograph (EEG) (Mountain View, CA) used for suspected status epilepticus (SE) can reduce time to diagnosis and on-call workforce demands and whether it can be applied to patients in respiratory isolation. METHODS: A multidisciplinary team developed a protocol for the use of the Ceribell EEG. The staff deploying the device, the attending physician, and the interpreting neurologist completed evaluation tools for each patient. Data maintained for quality and resource planning of 18-channel electroencephalography ordered for suspected SE were used as controls. Times to diagnosis were compared by application of Welch-Satterthwaite tests and workforce call-in demands by Fisher's exact t test. We evaluated qualitative data related to the use of the EEG in COVID-19 isolation rooms and on its technical aspects and acceptance by staff members. RESULTS: The Ceribell EEG reduced diagnosis time (P = .0000006) and on-call workforce demand (P = .02). The device can be used at any time of day in any hospital care area and has advantages in respiratory isolation rooms. SIGNIFICANCE: Compared with a standard 18-channel EEG, the Ceribell device allowed earlier diagnosis of SE and non-SE conditions and reduced workforce demands. Due to the ease of its use and its simple components, which can be readily disinfected, it is advantageous for COVID-19 patients in isolation.


Assuntos
COVID-19 , Eletroencefalografia , Serviços Médicos de Emergência , Controle de Infecções , Estado Epiléptico/diagnóstico , Tempo para o Tratamento/normas , Serviços de Atendimento/instrumentação , COVID-19/epidemiologia , COVID-19/prevenção & controle , COVID-19/terapia , Diagnóstico Precoce , Eletroencefalografia/instrumentação , Eletroencefalografia/métodos , Serviços Médicos de Emergência/métodos , Serviços Médicos de Emergência/organização & administração , Serviços Médicos de Emergência/normas , Pesquisa sobre Serviços de Saúde , Mão de Obra em Saúde , Hospitalização , Humanos , Controle de Infecções/métodos , Controle de Infecções/organização & administração , Estudo de Prova de Conceito , Melhoria de Qualidade , SARS-CoV-2 , Gestão da Segurança , Estado Epiléptico/terapia
13.
Diabetes Metab Syndr ; 15(3): 1039-1045, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34015627

RESUMO

BACKGROUND AND AIMS: Initially, novel severe acute respiratory syndrome coronavirus (SARS-CoV-2) was considered primarily a respiratory pathogen. However, with time it has behaved as a virus with the potential to cause multi-system involvement, including neurological manifestations. Cerebral venous sinus thrombosis (CVT) has increasingly been reported in association with coronavirus infectious disease of 2019 (COVID-19). Here, we have shed light upon CVT and its possible mechanisms in the backdrop of the ongoing COVID-19 pandemic. METHODS: In this review, data were collected from PubMed, EMBASE and Web of Science, until March 30, 2021, using pre-specified searching strategies. The search strategy consisted of a variation of keywords of relevant medical subject headings and keywords, including "COVID-19", "SARS-CoV-2", "coronavirus", and "cerebral venous sinus thrombosis". RESULTS: COVID-19 has a causal association with a plethora of neurological, neuropsychiatric and psychological effects. CVT has gained particular importance in this regard. The known hypercoagulable state in SARS-CoV-2 infection is thought to be the main mechanism in COVID-19 related CVT. Other plausible mechanisms may include vascular endothelial dysfunction and altered flow dynamics. CONCLUSIONS: Although there are no specific clinical characteristics, insidious or acute onset headache, seizures, stroke-like, or encephalopathy symptoms in a patient with, or who has suffered COVID-19, should prompt the attending physician to investigate for CVT. The treatment of COVID-19 associated CVT does not differ radically from the therapy of CVT without the infection, i.e. urgent initiation of parenteral unfractionated heparin or low molecular weight heparin followed by conventional or mostly newer oral anticoagulants.


Assuntos
COVID-19/complicações , COVID-19/terapia , Trombose Intracraniana/etiologia , Trombose Intracraniana/terapia , Anticoagulantes/uso terapêutico , COVID-19/epidemiologia , Serviços Médicos de Emergência/métodos , Heparina/uso terapêutico , Humanos , Trombose Intracraniana/epidemiologia , Pandemias , SARS-CoV-2/fisiologia
14.
Am J Emerg Med ; 47: 248-252, 2021 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-33964547

RESUMO

BACKGROUND: Expediting the measurement of serum troponin by leveraging EMS blood collection could reduce the diagnostic time for patients with acute chest pain and help address Emergency Department (ED) overcrowding. However, this practice has not been examined among an ED chest pain patient population in the United States. METHODS: A prospective observational cohort study of adults with non-traumatic chest pain without ST-segment elevation myocardial infarction was conducted in three EMS agencies between 12/2016-4/2018. During transport, paramedics obtained a patient blood sample that was sent directly to the hospital core lab for troponin measurement. On ED arrival HEART Pathway assessments were completed by ED providers as part of standard care. ED providers were blinded to troponin results from EMS blood samples. To evaluate the potential impact on length of stay (LOS), the time difference between EMS blood draw and first clinical ED draw was calculated. To determine the safety of using troponin measures from EMS blood samples, the diagnostic performance of the HEART Pathway for 30-day major adverse cardiac events (MACE: composite of cardiac death, myocardial infarction (MI), coronary revascularization) was determined using EMS troponin plus arrival ED troponin and EMS troponin plus a serial 3-h ED troponin. RESULTS: The use of EMS blood samples for troponin measures among 401 patients presenting with acute chest pain resulted in a mean potential reduction in LOS of 72.5 ± SD 35.7 min. MACE at 30 days occurred in 21.0% (84/401), with 1 cardiac death, 78 MIs, and 5 revascularizations without MI. Use of the HEART Pathway with EMS and ED arrival troponin measures yielded a NPV of 98.0% (95% CI: 89.6-100). NPV improved to 100% (95% CI: 92.9-100) when using the EMS and 3-h ED troponin measures. CONCLUSIONS: EMS blood collection used for core lab ED troponin measures could significantly reduce ED LOS and appears safe when integrated into the HEART Pathway.


Assuntos
Dor no Peito/sangue , Serviços Médicos de Emergência/métodos , Tempo de Internação , Troponina/sangue , Adulto , Idoso , Dor no Peito/diagnóstico , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/diagnóstico , Estudos Prospectivos , Método Simples-Cego
15.
Scand J Trauma Resusc Emerg Med ; 29(1): 62, 2021 May 07.
Artigo em Inglês | MEDLINE | ID: mdl-33962682

RESUMO

BACKGROUND: Helicopter Emergency Medical Services (HEMS) respond to serious trauma and medical emergencies. Geographical disparity and the regionalisation of trauma systems can complicate accurate HEMS dispatch. We sought to evaluate HEMS dispatch sensitivity in older trauma patients by analysing critical care interventions and conveyance in a well-established trauma system. METHODS: All trauma patients aged ≥65 years that were attended by the Air Ambulance Kent Surrey Sussex over a 6-year period from 1 July 2013 to 30 June 2019 were included. Patient characteristics, critical care interventions and hospital disposition were stratified by dispatch type (immediate, interrogate and crew request). RESULTS: 1321 trauma patients aged ≥65 were included. Median age was 75 years [IQR 69-89]. HEMS dispatch was by immediate (32.0%), interrogation (43.5%) and at the request of ambulance clinicians (24.5%). Older age was associated with a longer dispatch interval and was significantly longer in the crew request category (37 min [34-39]) compared to immediate dispatch (6 min [5-6] (p = .001). Dispatch by crew request was common in patients with falls < 2 m, whereas pedestrian road traffic collisions and falls > 2 m more often resulted in immediate dispatch (p = .001). Immediate dispatch to isolated head injured patients often resulted in pre-hospital emergency anaesthesia (PHEA) (39%). However, over a third of head injured patients attended after dispatch by crew request received PHEA (36%) and a large proportion were triaged to major trauma centres (69%). CONCLUSIONS: Many patients who do not fulfil the criteria for immediate HEMS dispatch need advanced clinical interventions and subsequent tertiary level care at a major trauma centre. Further studies should evaluate if HEMS activation criteria, nuanced by age-dependant triggers for mechanism and physiological parameters, optimise dispatch sensitivity and HEMS utilisation.


Assuntos
Aeronaves , Cuidados Críticos/métodos , Emergências , Despacho de Emergência Médica/métodos , Serviços Médicos de Emergência/métodos , Triagem/métodos , Acidentes de Trânsito , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino
16.
Scand J Trauma Resusc Emerg Med ; 29(1): 69, 2021 May 22.
Artigo em Inglês | MEDLINE | ID: mdl-34022933

RESUMO

BACKGROUND: Assessing and managing the risk of clinical deterioration is a cornerstone of emergency care, commencing at triage and continuing throughout the emergency department (ED) care. The aim of this scoping review was to assess the extent, range and nature of published research related to formal systems for recognising and responding to clinical deterioration in emergency department (ED) patients. MATERIALS AND METHODS: We conducted a scoping review according to PRISMA-ScR guidelines. MEDLINE complete, CINAHL and Embase were searched on 07 April 2021 from their dates of inception. Human studies evaluating formal systems for recognising and responding to clinical deterioration occurring after triage that were published in English were included. Formal systems for recognising and responding to clinical deterioration were defined as: i) predefined patient assessment criteria for clinical deterioration (single trigger or aggregate score), and, or ii) a predefined, expected response should a patient fulfil the criteria for clinical deterioration. Studies of short stay units and observation wards; deterioration during the triage process; system or score development or validation; and systems requiring pathology test results were excluded. The following characteristics of each study were extracted: author(s), year, design, country, aims, population, system tested, outcomes examined, and major findings. RESULTS: After removal of duplicates, there were 2696 publications. Of these 33 studies representing 109,066 patients were included: all were observational studies. Twenty-two aggregate scoring systems were evaluated in 29 studies and three single trigger systems were evaluated in four studies. There were three major findings: i) few studies reported the use of systems for recognising and responding to clinical deterioration to improve care of patients whilst in the ED; ii) the systems for recognising clinical deterioration in ED patients were highly variable and iii) few studies reported on the ED response to patients identified as deteriorating. CONCLUSION: There is a need to re-focus the research related to use of systems for recognition and response to deteriorating patients from predicting various post-ED events to their real-time use to improve patient safety during ED care.


Assuntos
Serviços Médicos de Emergência/métodos , Serviço Hospitalar de Emergência/estatística & dados numéricos , Determinação de Necessidades de Cuidados de Saúde , Triagem/normas , Deterioração Clínica , Humanos , Segurança do Paciente
17.
Anesth Analg ; 133(1): 187-195, 2021 07 01.
Artigo em Inglês | MEDLINE | ID: mdl-33989226

RESUMO

BACKGROUND: Emergency front-of-neck airway rescue is recommended in a can't intubate, can't oxygenate clinical scenario. Cannula cricothyroidotomy has been reported as having a high failure rate. Our primary aim was to estimate the angle of the trachea in relation to the horizontal axis in a simulated emergency front-of-neck airway rescue position. Our secondary aims were to estimate the optimal cannula angle of approach and evaluate the anatomical relationship of the cricothyroid membrane (CTM) to adjacent structures. We also assessed whether the CTM lies above or below the neck midpoint, a point equidistant from the suprasternal notch (SSN), and the chin surface landmarks. All measurements were compared between the male and female subjects. METHODS: Subjects having elective computed tomography of their thorax were consented to have extension of the computed tomography to include their neck. A preliminary radiation dose and risk assessment deemed the additional radiation to be of very low risk (level IIa). Subjects were positioned supinely on the computed tomography table. Standard neck extension was achieved by placing a pillow under the scapulae and a rolled towel under the neck to simulate emergency front-of-neck airway rescue positioning. RESULTS: Fifty-two subjects were included in this study: 31 men and 21 women. The mean angle of the trachea in relation to the horizontal axis was 25.5° (95% confidence interval [CI], 21.8-29.1) in men and 14.0° (95% CI, 11.5-16.5) in women. The mean minimum angles required for hypothetical cannula cricothyroidotomy for men and women were 55.2° (95% CI, 51.8-58.7) and 50.5° (95% CI, 45.4-55.6), respectively. The CTM was located lower in the neck in men compared to women. The CTM was located below the neck midpoint in 30 of 30 (100%) male subjects and 11 of 20 (55%) female subjects (P < .001). CONCLUSIONS: The trachea angulates posteriorly in a simulated emergency front-of-neck airway rescue position in supine subjects and to a greater degree in men compared to women (P < .001). The minimum angle required for hypothetical cannula cricothyroidotomy was >45° in the majority (75%) of subjects studied. A steeper cannula angle of approach may be more reliable and warrants further clinical study. If airway anatomy is indistinct and performing a vertical scalpel cricothyroidotomy, consideration should be given to performing this incision lower in the neck in men compared to women.


Assuntos
Manuseio das Vias Aéreas/métodos , Cartilagem Cricoide/diagnóstico por imagem , Serviços Médicos de Emergência/métodos , Pescoço/diagnóstico por imagem , Cartilagem Tireóidea/diagnóstico por imagem , Tomografia Computadorizada por Raios X/métodos , Idoso , Idoso de 80 Anos ou mais , Cartilagem Cricoide/anatomia & histologia , Cartilagem Cricoide/cirurgia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pescoço/cirurgia , Estudos Prospectivos , Cartilagem Tireóidea/anatomia & histologia , Cartilagem Tireóidea/cirurgia , Traqueia/anatomia & histologia , Traqueia/diagnóstico por imagem , Traqueia/cirurgia
20.
J Am Geriatr Soc ; 69(7): 1713-1721, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-33955546

RESUMO

BACKGROUND/OBJECTIVE: Emergency department (ED) visits have declined while excess mortality, not attributable to COVID-19, has grown. It is not known whether older adults are accessing emergency care differently from their younger counterparts. Our objective was to determine patterns of ED visit counts for emergent conditions during the COVID-19 pandemic for older adults. DESIGN: Retrospective, observational study. SETTING: Observational analysis of ED sites enrolled in a national clinical quality registry. PARTICIPANTS: One hundred and sixty-four ED sites in 33 states from January 1, 2019 to November 15, 2020. MAIN OUTCOME AND MEASURES: We measured daily ED visit counts for acute myocardial infarction (AMI), stroke, sepsis, fall, and hip fracture, as well as deaths in the ED, by age categories. We estimated Poisson regression models comparing early and post-early pandemic periods (defined by the Centers for Disease Control and Prevention) to the pre-pandemic period. We report incident rate ratios to summarize changes in visit incidence. RESULTS: For AMI, stroke, and sepsis, the older (75-84) and oldest old (85+ years) had the greatest decline in visit counts initially and the smallest recovery in the post-early pandemic periods. For falls, visits declined early and partially recovered uniformly across age categories. In contrast, hip fractures exhibited less change in visit rates across time periods. Deaths in the ED increased during the early pandemic period, but then fell and were persistently lower than baseline, especially for the older (75-84) and oldest old (85+ years). CONCLUSIONS: The decline in ED visits for emergent conditions among older adults has been more pronounced and persistent than for younger patients, with fewer deaths in the ED. This is concerning given the greater prevalence and risk of poor outcomes for emergent conditions in this age group that are amenable to time-sensitive ED diagnosis and treatment, and may in part explain excess mortality during the COVID-19 era among older adults.


Assuntos
Acidentes por Quedas/estatística & dados numéricos , Envelhecimento , COVID-19/epidemiologia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Infarto do Miocárdio , Sepse , Acidente Vascular Cerebral , Idoso , Idoso de 80 Anos ou mais , Envelhecimento/fisiologia , Envelhecimento/psicologia , COVID-19/prevenção & controle , Emergências/epidemiologia , Serviços Médicos de Emergência/métodos , Serviços Médicos de Emergência/estatística & dados numéricos , Humanos , Mortalidade , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/mortalidade , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , SARS-CoV-2 , Sepse/diagnóstico , Sepse/mortalidade , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/mortalidade , Estados Unidos/epidemiologia
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