Assessment of safe endotracheal tube cuff pressures in emergency care – time for change?

Endotracheal intubation is performed in the prehospital and emergency department (ED) environments by advanced life support (ALS) paramedics and emergency doctors. Cuffed endotracheal tubes (ETTs) are used in adults² and more recently in children to ensure that the airway is protected, and to prevent air leakage between the wall of the trachea and the ETT during positive pressure ventilation. Cuffs are typically high volume, low pressure in their design and have a safe working pressure of <30 cm H₂O in adults and <20 cm H₂O in children.¹ Over-inflation of ETT cuffs to pressures exceeding 30 cm HO₂ may result in serious complications including tracheal stenosis, tracheal rupture and tracheo-oesophageal fistula. ³ Tracheal injury may occur after as little as 15 minutes with ETT cuff pressures exceeding 27 cm H₂O. ² To avoid tracheal injury due to emergency intubation, it is important that ETT cuff over-inflation is avoided in the pre-hospital and ED phases of emergency care. Although ETT cuff pressure manometry is optimal in determining safe ETT cuff pressure, it is standard practice in the ED and in the pre-hospital emergency care environment to assess ETT cuff pressure using palpation of the cuff ’s pilot balloon – a qualitative technique prone to subjective interpretation

Glass injuries seen in the emergency department of a South African district hospital

BACKGROUND : The emergency department of Embhuleni Hospital frequently manages patients with glass-related injuries. This study assessed these injuries and the glass that caused them in more detail. AIM : The objectives of our study included determining the type of glass causing these injuries and describing the circumstances associated with different types of glass injuries. SETTING : The emergency department of Embhuleni Hospital in Elukwatini, Mpumalanga province, South Africa. METHODS : This was a cross-sectional study with a sample size of 104 patients. Descriptive statistics were used to assess the characteristics of the glass injuries. RESULTS : Five different types of glass were reported to have caused the injuries, namely car glass (7.69%), glass ampoules (3.85%), glass bottles (82.69%), glass windows (3.85%) and street glass shards (1.92%). Glass bottle injuries were mainly caused by assaults (90.47%) and most victims were mostly young males (80.23%). The assaults occurred at alcohol-licensed premises in 65.11% of cases. These injuries occurred mostly over weekends (83.72%), between 18:00 and 04:00. The face (34.23%) and the scalp (26.84%) were the sites that were injured most often. CONCLUSION : Assault is the most common cause of glass injuries, usually involving young men at alcohol-licensed premises. Glass injuries generally resulted in minor lacerations, with few complications (2.68%).CONTEXTE : Le service des urgences de l’hôpital Embhuleni traite souvent des patients blessés par des éclats de verre. Cette étude a examiné en détail ces blessures et le verre qui les a causées. OBJECTIF : Notre étude avait pour but de déterminer le type de verre qui avait causé ces blessures et de décrire les circonstances des différents types de blessures causées par du verre. LIEU : Le service des urgences à l’hôpital Embhuleni à Elukwatini, dans la province du Mpumalanga, en Afrique du Sud. METHODES : C’est une étude transversale avec un échantillonnage de 104 patients. On a utilisé des statistiques descriptives pour évaluer les caractéristiques des blessures causées par le verre. RESULTATS : Les blessures ont été causées par différents types de verre, à savoir du verre automobile (7.69%), du verre d’ampoules (3.85%), du verre de bouteille (82.69%), du verre de vitre (3.85%) et des éclats de verre dans la rue (1.92%). Les blessures causées par du verre de bouteille provenaient surtout d’agressions (90.47%) et la plupart des victimes étaient des jeunes hommes (80.23%). Les agressions avaient eu lieu dans des locaux autorisés à servir de l’alcool dans 65.11% des cas. Ces blessures ont eu lieu surtout pendant le weekend (83.72%), entre 18h00 et 04h00. Les blessures étaient le plus souvent au visage (34.23%) et au cuir chevelu (26.84%). CONCLUSION : Les agressions sont la cause la plus fréquente des blessures causées par du verre et impliquent en général des jeunes hommes dans des locaux autorisés à servir de l’alcool. Les blessures causées par du verre étaient en général des lacérations mineures avec peu de complications (2.68%).Department of Family Medicine at Sefako Makgatho Health Sciences Universityhttp://www.phcfm.orgam2016Family Medicin

Sudden cardiac arrest on the football field of play - highlights for sports medicine from the European Resuscitation Council 2015 Consensus Guidelines

The European Resuscitation Council (ERC) 2015 Guidelines for Resuscitation were published recently. For the first time, these guidelines included a subsection on ‘cardiac arrest during sports activities’ in the section dealing with cardiac arrest in special circumstances, endorsing both the importance and unique nature of this form of cardiac arrest. This paper reviews four critical areas in the management of sudden cardiac arrest in a football player: recognition, response, resuscitation and removal from the field of play. Expeditious response with initiation of immediate resuscitation at the side of a collapsed player remains crucial for survival, and chest compressions should be continued until the automated external defibrillator (AED) has been fully activated, so that the sideline medical team response to the side of a non-contact collapsed player on the field of play, with AED and defibrillation, occurs within a maximum of2 min from collapse.http://bjsm.bmj.comhb201

Recommendations for initial examination, differential diagnosis, and management of concussion and other head injuries in high-level football

Head injuries can result in substantially different outcomes, ranging from no detectable effect to transient functional impairments to life-threatening structural lesions. In high-level international football (soccer) tournaments, on average, one head injury occurs in every third match. Making the diagnosis and determining the severity of a head injury immediately on-pitch or off-field is a major challenge for team physicians, especially because clinical signs of a brain injury can develop over several minutes, hours, or even days after the injury. A standardized approach is useful to support team physicians in their decision whether the player should be allowed to continue to play or should be removed from play after head injury. A systematic, football-specific procedure for examination and management during the first 72 hours after head injuries and a graduated Return-to-Football program for high-level players have been developed by an international group of experts based on current national and international guidelines for the management of acute head injuries. The procedure includes seven stages from the initial on-pitch examination to the graduated Return-to-Football program. Details of the assessments and the consequences of different outcomes are described for each stage. Criteria for emergency management (red flags), removal from play (orange flags), and referral to specialists for further diagnosis and treatment (persistent orange flags) are provided. The guidelines for return to sport after concussion-type head injury are specified for football. Thus, the present paper presents a comprehensive procedure for team physicians after a head injury in high-level football

Haiti : the South African perspective

The original publication is available at http://www.samj.org.zaBackground and problem statement. The South African response to the Haitian earthquake consisted of two independent nongovernment organisations (NGOs) working separately with minimal contact. Both teams experienced problems during the deployment, mainly owing to not following the International Search and Rescue Advisory Group (INSARAG) guidelines. Critical areas identified. To improve future South African disaster responses, three functional deployment categories were identified: urban search and rescue, triage and initial stabilisation, and definitive care. To best achieve this, four critical components need to be taken into account: rapid deployment, intelligence from the site, government facilitation, and working under the auspices of recognized organisations such as the United Nations and the World Health Organization. Conclusion. The proposed way forward for South African medical teams responding to disasters is to be unified under a leading academic body, to have an up-to-date volunteer database, and for volunteers to be current with the international search and rescue course currently being developed by the Medical Working Group of INSARAG. An additional consideration is that South African rescue and relief personnel have a primary responsibility to the citizens of South Africa, then the Southern African Development Community region, then the rest of the African continent and finally further afield. The commitment of government, private and military health services as well as NGOs is paramount for a unified response.Publishers' versio

Position statement: Pre-hospital rapid sequence intubation

The Professional Board for Emergency Care at the Health Professions Council of South Africa (HPCSA) has approved pre-hospital rapid sequence intubation (RSI) as part of the scope of practice for registered emergency care practitioners (ECPs). RSI is an advanced airway management process that facilitates endotracheal intubation in adults and children. Features of this technique include pre-oxygenation, rapid pharmacological induction of unconsciousness, and neuromuscular blockade to enable the placement of an endotracheal tube. RSI has become widespread as the procedure of choice for definitive airway management by pre- and in-hospital emergency care personnel worldwide. In the emergency department setting, RSI is superior to intubation with deep sedation, a technique not incorporating pharmacological paralysis as part of the intubation sequence. For this reason, the implementation of RSI in the pre-hospital environment is supported, provided that it is practised within an appropriate framework of clinical governance

The FIFA medical emergency bag and FIFA 11 steps to prevent sudden cardiac death : setting a global standard and promoting consistent football field emergency care

Life-threatening medical emergencies are an infrequent but regular occurrence on the football field. Proper prevention strategies, emergency medical planning and timely access to emergency equipment are required to prevent catastrophic outcomes. In a continuing commitment to player safety during football, this paper presents the FIFA Medical Emergency Bag and FIFA 11 Steps to prevent sudden cardiac death.These recommendations are intended to create a global standard for emergency preparedness and the medical response to serious or catastrophic on-field injuries in football.http://bjsm.bmj.com

Membrane lipid interactions in intestinal ischemia/reperfusion-induced Injury

Ischemia, lack of blood flow, and reperfusion, return of blood flow, is a common phenomenon affecting millions of Americans each year. Roughly 30,000 Americans per year experience intestinal ischemia-reperfusion (IR), which is associated with a high mortality rate. Previous studies of the intestine established a role for neutrophils, eicosanoids, the complement system and naturally occurring antibodies in IR-induced pathology. Furthermore, data indicate involvement of a lipid or lipid-like moiety in mediating IR-induced damage. It has been proposed that exposure of neo-antigens are recognized by antibodies, triggering action of the complement cascade. While it is evident that the pathophysiology of IR-induced injury is complex and multi-factorial, we focus this review on the involvement of eicosanoids, phospholipids and neo-antigens in the early pathogenesis. Lipid changes occurring in response to IR, neo-antigens exposed and the role of a phospholipid transporter, phospholipid scramblase 1 will be discussed