Airway and ventilation management strategies for haemorrhagic shock. To tube, or not to tube, that is the question!

Many standard trauma management guidelines advocate the early use of endotracheal intubation and positive pressure ventilation as key treatment interventions in haemorrhagic shock. The evidence for using these airway and ventilation strategies to manage a circulation problem is unclear. The potentially harmful effects of drug assisted intubation and positive pressure ventilation include reduced cardiac output, apnoea, hypoxia, hypocapnoea (due to inadvertent hyperventilation) and unnecessarily prolonged on-scene times. Conversely the beneficial effects of spontaneous, negative pressure ventilation upon cardiac output are well described. Few studies, however, have attempted to explore the potential advantages of a strategy of delayed intubation and ventilation (together with a policy of aggressive volume replacement) in shocked trauma patients. Given the lack of evidence, the decision making around how, when and where to subject shocked trauma patients to intubation and positive pressure ventilation remains complex. If providers choose to delay intubation they must have the appropriate skills to safely manage the airway and recognise the need for subsequent intervention. If they decide to perform intubation and positive pressure ventilation they must understand the potential risks and how best to minimise them. We suggest that for patients with haemorrhagic shock who do not have a compromised airway and who are able to maintain adequate oxygen saturation (or mentation if monitoring is unreliable) then a strategy of delayed intubation should be strongly encouraged

Asset Bubbles in Shipping? An Analysis of Recent History in the Drybulk Market

The purpose of this paper is to investigate the hypothesis that the freight market boom in the drybulk freight market between 2003 and 2005 caused asset values in the second-hand market to deviate from underlying fundamentals. We test the instantaneous equilibrium relationship between the markets for second-hand ships, newbuildings and freight in a Vector Error Correction Model (VECM) framework. We also estimate and account for the time-varying delivery lag in the newbuilding market. Our empirical results suggest that the second-hand market was closely cointegrated with the fundamental freight and newbuilding market with no evidence of a short-term asset ‘bubble’. Maritime Economics & Logistics (2006) 8, 223–233. doi:10.1057/palgrave.mel.9100162