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Annals of Surgery Jan 2023The aim of this review was to review the ethical and multidisciplinary clinical challenges facing trauma surgeons when resuscitating patients presenting with penetrating... (Review)
Review
OBJECTIVE
The aim of this review was to review the ethical and multidisciplinary clinical challenges facing trauma surgeons when resuscitating patients presenting with penetrating brain injury (PBI) and multicavitary trauma.
BACKGROUND
While there is a significant gap in the literature on managing PBI in patients presenting with multisystem trauma, recent data demonstrate that resuscitation and prognostic features for such patients remains poorly described, with trauma guidelines out of date in this field.
METHODS
We reviewed a combination of recent multidisciplinary evidence-informed guidelines for PBI and coupled this with expert opinion from trauma, neurosurgery, neurocritical care, pediatric and transplant surgery, surgical ethics and importantly our community partners.
RESULTS
Traditional prognostic signs utilized in traumatic brain injury may not be applicable to PBI with a multidisciplinary team approach suggested on a case-by-case basis. Even with no role for neurosurgical intervention, neurocritical care, and neurointerventional support may be warranted, in parallel to multicavitary operative intervention. Special considerations should be afforded for pediatric PBI. Ethical considerations center on providing the patient with the best chance of survival. Consideration of organ donation should be considered as part of the continuum of patient, proxy and family-centric support and care. Community input is crucial in guiding decision making or protocol establishment on an institutional level.
CONCLUSIONS
Support of the patient after multicavitary PBI can be complex and is best addressed in a multidisciplinary fashion with extensive community involvement.
Topics: Humans; Child; Head Injuries, Penetrating; Brain Injuries, Traumatic; Resuscitation; Neurosurgical Procedures; Tissue and Organ Procurement
PubMed: 35997268
DOI: 10.1097/SLA.0000000000005608 -
Ugeskrift For Laeger Jun 2020Current Danish guidance stipulates, that the physician responsible for treatment must assess, if resuscitation is medically indicated in patients with life-threatening... (Review)
Review
Current Danish guidance stipulates, that the physician responsible for treatment must assess, if resuscitation is medically indicated in patients with life-threatening illness. Nevertheless, terminally ill patients without medical indication for resuscitation are still asked about preferences for resuscitation rather than informed about the decision not to resuscitate. This review describes clinical dilemmas, which may arise, if these legal rights are misinterpreted. It provides a communication guide designed to assist physicians communicating with patients about the decision to resuscitate or not.
Topics: Communication; Decision Making; Humans; Physician-Patient Relations; Physicians; Resuscitation
PubMed: 32515341
DOI: No ID Found -
European Journal of Trauma and... Aug 2018Circulatory collapse is a leading cause of mortality among traumatic major exsanguination and in ruptured aortic aneurysm patients. Approximately 40% of patients die... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Circulatory collapse is a leading cause of mortality among traumatic major exsanguination and in ruptured aortic aneurysm patients. Approximately 40% of patients die before hemorrhage control is achieved. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an adjunct designed to sustain the circulation until definitive surgical or endovascular repair. A systematic review was conducted for the current clinical use of REBOA in patients with hemodynamic instability and to discuss its potential role in improving prehospital and in-hospital outcome.
METHODS
Systematic review and meta-analysis (1900-2017) using MEDLINE, Cochrane, EMBASE, Web of Science and Central and Emcare using the keywords "aortic balloon occlusion", "aortic balloon tamponade", "REBOA", and "Resuscitative Endovascular Balloon Occlusion" in combination with hemorrhage control, hemorrhage, resuscitation, shock, ruptured abdominal or thoracic aorta, endovascular repair, and open repair. Original published studies on human subjects were considered.
RESULTS
A total of 490 studies were identified; 89 met criteria for inclusion. Of the 1436 patients, overall reported mortality was 49.2% (613/1246) with significant differences (p < 0.001) between clinical indications. Hemodynamic shock was evident in 79.3%, values between clinical indications showed significant difference (p < 0.001). REBOA was favored as treatment in trauma patients in terms of mortality. Pooled analysis demonstrated an increase in mean systolic pressure by almost 50 mmHg following REBOA use.
CONCLUSION
REBOA has been used in trauma patients and ruptured aortic aneurysm patients with improvement of hemodynamic parameters and outcomes for several decades. Formal, prospective study is warranted to clarify the role of this adjunct in all hemodynamic unstable patients.
Topics: Aorta; Balloon Occlusion; Exsanguination; Hemodynamics; Humans; Resuscitation; Shock, Hemorrhagic
PubMed: 29785654
DOI: 10.1007/s00068-018-0959-y -
Oxygen saturation after birth in resuscitated neonates in Uganda: a video-based observational study.BMJ Paediatrics Open Jan 2022Monitoring of peripheral capillary oxygen saturation (SpO) during neonatal resuscitation is standard of care in high-resource settings, but seldom performed in... (Observational Study)
Observational Study
BACKGROUND
Monitoring of peripheral capillary oxygen saturation (SpO) during neonatal resuscitation is standard of care in high-resource settings, but seldom performed in low-resource settings. We aimed to measure SpO and heart rate during the first 10 min of life in neonates receiving positive pressure ventilation (PPV) according to the Helping Babies Breathe (HBB) protocol and compare results with SpO and heart rate targets set by the American Heart Association (AHA).
METHODS
A cross-sectional study was conducted at Mulago National Referral Hospital, Kampala, Uganda, as a substudy of the NeoSupra Trial. SpO and heart rate were measured on apnoeic neonates (≥34 weeks) who received PPV according to HBB (room air). Those who remained distressed after PPV received supplemental oxygen (O). All resuscitations were video recorded and data were extracted by video review at 1 min intervals until 10 min post partum. Data were analysed for all observations and separately for only observations before and during PPV.
RESULTS
49 neonates were analysed. Median SpO at 5 min (n=39) was 67% (49-88) with 59% of the observations below AHA target of 80%. At 10 min median SpO (n=44) was 93% (80-97) and 32% were below AHA target of 85%. When only observations before and during PPV were analysed, median SpO at 5 min (n=18) was 52% (34-66) and 83% were below AHA target. At 10 min (n=15), median SpO was 72% (57-89) and 67% were below AHA target. Median heart rates were above AHA target of 100 beats/min at all time intervals.
CONCLUSIONS
A high proportion of neonates resuscitated with PPV after birth failed to reach the AHA SpO target in this small sample, implying an increased risk of hypoxic-ischaemic encephalopathy. Further studies in low-resource settings are needed to evaluate baseline data and the need for supplemental O and optimal SpO during PPV.
TRIAL REGISTRATION NUMBER
This is a substudy to the trial 'Neonatal Resuscitation with Supraglottic Airway Trial (NeoSupra)'; ClinicalTrials.gov Registry (NCT03133572).
Topics: Cross-Sectional Studies; Humans; Infant, Newborn; Oxygen Saturation; Resuscitation; Uganda; United States
PubMed: 35258476
DOI: 10.1136/bmjpo-2021-001225 -
BMJ Quality & Safety Feb 2011The Neonatal Resuscitation Program (NRP) and similar courses have been used to train clinicians. However, formal teamwork training was not included in these courses, and...
BACKGROUND
The Neonatal Resuscitation Program (NRP) and similar courses have been used to train clinicians. However, formal teamwork training was not included in these courses, and their effectiveness has been questioned. In adult resuscitation, debriefings using video recordings have improved outcomes, but recordings of neonatal resuscitation have been used primarily for research.
AIMS
To test if debriefings that include video recordings of neonatal resuscitations can improve teamwork and clinical practice.
METHODS
Over 9 months, clinicians voluntarily attended weekly debriefings in which recently performed resuscitations were presented, evaluated and then discussed. Discussions were focused on teamwork and were facilitated by an education nurse and a human factors expert with a training background. Subsequently, three experts, a neonatologist, a neonatal nurse educator and a midwifery educator from different organisations viewed and scored 19 recordings from the first 4.5 months and 19 recordings from the second 4.5 months. Experts were blinded to the recording period. The two sets of recordings were balanced for babies' gestation and birth weight. Scoring included 'teamwork' items, 'following guidelines' items and 'temporal control of the resuscitation procedure' items.
RESULTS
All 'teamwork' items improved between the two periods and one item improved significantly (p<0.05). Scores for 'Following guidelines' showed little change except 'Intubation' which deteriorated (p<0.05). There was no significant interaction between periods and raters. Cronbach's alpha indicated inter-expert rating consistency ranging from 0.54 to 0.86.
CONCLUSIONS
Voluntary debriefings had some positive effect on neonatal resuscitation teamwork. Future studies are warranted to determine the best methods for debriefing combined with other training methods.
Topics: Humans; Infant, Newborn; Patient Care Team; Queensland; Resuscitation; Teaching; Video Recording
PubMed: 21216792
DOI: 10.1136/bmjqs.2010.043547 -
The Western Journal of Emergency... Jul 2018
Topics: Clinical Competence; Competency-Based Education; Education, Medical, Graduate; Emergency Medicine; Humans; Internship and Residency; Resuscitation
PubMed: 30013713
DOI: 10.5811/westjem.2018.5.38176 -
The Journal of Emergency Medicine Jun 2019Extracorporeal membrane oxygenation (ECMO) has several applications as a resuscitative intervention, including extracorporeal cardiopulmonary resuscitation (ECPR). ECPR...
BACKGROUND
Extracorporeal membrane oxygenation (ECMO) has several applications as a resuscitative intervention, including extracorporeal cardiopulmonary resuscitation (ECPR). ECPR is rarely initiated in the emergency department (ED) by emergency physicians outside regional academic institutions.
OBJECTIVES
To evaluate whether ECPR improves clinical outcomes after cardiac arrest when initiated by emergency physicians (EPs) in a nonacademic hospital.
METHODS AND MATERIALS
We performed a retrospective analysis of prospectively identified consecutive EP-initiated ECMO subjects from a single community hospital over a 7-year period. Logistic regression and propensity models tested the association between ECPR and survival to hospital discharge compared with concurrent ECPR-eligible control subjects.
RESULTS
Over 7 years (2010-2017), EPs initiated ECMO on 58 subjects; 44 (76%) were venoarterial cases (43 ECPR) initiated in the ED. Of those, 11 (25%) survived to discharge (n = 9 with cerebral performance category score 1) and most were still alive after 5 years (66%). Adjusting for known covariates, ECPR subjects were more likely than concurrent controls to survive to discharge (odds ratio 8.4; 95% confidence interval 1.2-60.4). Propensity analysis revealed a favorable trend toward survival to discharge after ECPR (odds ratio 2.0; 95% confidence interval 0.51-7.8).
CONCLUSIONS
Emergency physicians initiated ECMO with promising clinical outcomes. Prospective trials are needed to define the efficacy, safety, and cost-effectiveness of EP-initiated ECMO.
Topics: Emergency Medicine; Emergency Service, Hospital; Extracorporeal Membrane Oxygenation; Humans; Logistic Models; Practice Patterns, Physicians'; Propensity Score; Prospective Studies; Resuscitation; Retrospective Studies; Survivors; Time Factors; Treatment Outcome
PubMed: 31031069
DOI: 10.1016/j.jemermed.2019.02.004 -
AMA Journal of Ethics May 2018This essay explores how some of the arguments advanced for and against family presence during cardiopulmonary resuscitation might apply to the question of whether family...
This essay explores how some of the arguments advanced for and against family presence during cardiopulmonary resuscitation might apply to the question of whether family should be permitted in the trauma bay. While the first section suggests that many of the proposed benefits might apply to family presence during trauma resuscitations, the second section contends that family presence in the trauma bay could detract from the quality of patient care, violate patient privacy, and be psychologically damaging for the witnessing family. The essay concludes by proposing a chaperoning system that could mitigate some of the proposed concerns with a family presence policy and by analyzing some of the ethical commitments that underlie the discussion of family in the trauma bay.
Topics: Attitude of Health Personnel; Cardiopulmonary Resuscitation; Emergency Service, Hospital; Family; Humans; Organizational Policy; Patient Care Team; Visitors to Patients
PubMed: 29763392
DOI: 10.1001/journalofethics.2018.20.5.ecas5-1805 -
Scandinavian Journal of Trauma,... Jul 2021Self-Inflating Resuscitation Bags (SIRB) are common and essential tools in airway management and ventilation. They are often used in resuscitation and emergency...
BACKGROUND
Self-Inflating Resuscitation Bags (SIRB) are common and essential tools in airway management and ventilation. They are often used in resuscitation and emergency anaesthesia outside the operating theatre. There is a common notion that all SIRBs applied with a tight sealed mask will deliver close to 100 % oxygen during spontaneous breathing. The aim of the study was to measure the oxygen delivery of six commonly used SIRBs in a mechanical spontaneous breathing adult in vitro model.
METHODS
Three SIRBs of each of the six models were evaluated for oxygen delivery during simulated breathing with an adult mechanical lung. The test was repeated three times per device (54 tests in total). The breathing profile was fixed to a minute volume of 10 L/min, a tidal volume of 500 mL and the SIRBs supplied with an oxygen fresh gas flow of 15 L/min. The fraction of delivered oxygen (FDO) was measured over a three-minute period. Average FDO was calculated and compared at 30, 60 and 90 s.
RESULTS
At 90 s all models had reached a stable FDO. Average FDO at 90 s; Ambu Oval Plus 99,5 %; Ambu Spur II 99,8 %; Intersurgical BVM Resuscitator 76,7 %; Laerdal Silicone 97,3 %; Laerdal The Bag II 94,5 % and the O-Two Smart Bag 39,0 %. All differences in FDO were significant apart from the two Ambu models.
CONCLUSIONS
In simulated spontaneous breathing, four out of six (by Ambu and Laerdal) Self-Inflating Resuscitation Bags delivered a high fraction of oxygen while two (Intersurgical and O-two) underperformed in oxygen delivery. These large variations confirm results reported in other studies. It is our opinion that underperforming Self-Inflating Resuscitation Bags might pose a serious threat to patients' health if used in resuscitation and anaesthesia. Manufacturers of Self-Inflating Resuscitation Bags rarely provide information on performance for spontaneous breathing. This poses a challenge to all organizations that need their devices to deliver adequate oxygen during spontaneous breathing.
Topics: Computer Simulation; Equipment Design; Humans; Oxygen; Resuscitation; Tidal Volume
PubMed: 34281616
DOI: 10.1186/s13049-021-00885-3 -
The complications associated with Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA).World Journal of Emergency Surgery :... 2018Non-compressible torso hemorrhage (NCTH) remains a significant cause of morbidity and mortality in the field of trauma and emergency medicine. In recent times, there has... (Review)
Review
Non-compressible torso hemorrhage (NCTH) remains a significant cause of morbidity and mortality in the field of trauma and emergency medicine. In recent times, there has been a resurgence in the adoption of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) for patients who present with NCTH. Like all medical procedures, there are benefits and risks associated with the REBOA technique. However, in the case of REBOA, these complications are not unanimously agreed upon with varying viewpoints and studies. This article aims to review the current knowledge surrounding the complications of the REBOA technique at each step of its application.
Topics: Aorta; Balloon Occlusion; Hemorrhage; Humans; Injury Severity Score; Myocardial Reperfusion Injury; Resuscitation
PubMed: 29774048
DOI: 10.1186/s13017-018-0181-6