Altitude-Related Change in Endotracheal Tube Cuff Pressures in Helicopter EMS

INTRODUCTION: Over-inflation of endotracheal tube (ETT) cuffs has the potential to lead to scarring and stenosis of the trachea.1, 2,3, 4 The air inside an ETT cuff is subject to expansion as atmospheric pressure decreases, as happens with an increase in altitude. Emergency medical services helicopters are not pressurized, thereby providing a good environment for studying the effects of altitude changes ETT cuff pressures. This study aims to explore the relationship between altitude and ETT cuff pressures in a helicopter air-medical transport program. METHODS: ETT cuffs were initially inflated in a nonstandardized manner and then adjusted to a pressure of 25 cmH2O. The pressure was again measured when the helicopter reached maximum altitude. A final pressure was recorded when the helicopter landed at the receiving facility. RESULTS: We enrolled 60 subjects in the study. The mean for initial tube cuff pressures was 70 cmH2O. Maximum altitude for the program ranged from 1,000-3,000 feet above sea level, with a change in altitude from 800-2,480 feet. Mean cuff pressure at altitude was 36.52 +/- 8.56 cmH2O. Despite the significant change in cuff pressure at maximum altitude, there was no relationship found between the maximum altitude and the cuff pressures measured. CONCLUSION: Our study failed to demonstrate the expected linear relationship between ETT cuff pressures and the maximum altitude achieved during typical air-medical transportation in our system. At altitudes less than 3,000 feet above sea level, the effect of altitude change on ETT pressure is minimal and does not require a change in practice to saline-filled cuffs

Retrospective Analysis of Emergency Medical Services (EMS) Physician Medical Control Calls

INTRODUCTION: Although emergency medical services (EMS) standing-order protocols provide more efficient and accurate on-scene management by paramedics, online medical direction (OLMD) has not been eliminated from practice. In this modern era of OLMD, no studies exist to describe the prevalence of reasons for contacting OLMD. OBJECTIVES: The primary goal of this study was to describe the quantity of and reasons for calls for medical direction. We also sought to determine time diverted from emergency physicians due to OLMD. Finally, we hoped to identify any areas for potential improvement or additional training opportunities for EMS providers. METHODS: This was a descriptive study with retrospective data analysis of recorded OLMD calls from January 1, 2016, to December 31, 2016. Data were extracted by research personnel listening to audio recordings and were entered into a database for descriptive analysis. We abstracted the date and length of call, patient demographic information (age and gender), category of call (trauma, medical, cardiac, or obstetrics), reason for call, and origin of call (prehospital, interhospital, nursing home, or discharge). RESULTS: The total number of recordings analyzed was 519. Calls were divided into four categories pertaining to their nature: 353 (68.5%) medical; 70 (13.6%) trauma; 83 (16.1%) cardiac; and 9 (8%) were obstetrics related. Repeat calls regarding the same patient encounter comprised 48 (9.4%) of the calls. Patient refusal of transport was the most common reason for a call medical direction (32.3% of calls). The total time for medical direction calls for the year was 26.6 hours. The maximum number of calls in a single day was seven, with a mean of 2.04 calls per day (standard deviation [SD] +/- 1.18). The mean call length was 3.06 minutes (SD +/- 2.51). CONCLUSION: Our analysis shows that the use of OLMD frequently involves complex decision-making such as determination of the medical decision-making capacity of patients to refuse treatment and transport, and evaluation of the appropriate level of care for interfacility transfers. Further investigation into the effect of EMS physician-driven medical direction on both the quality and time required for OLMD could allow for better identification of areas of potential improvement and training

Prehospital Intubations Are Associated With Elevated Cuff Pressures: A Cross-Sectional Study Characterizing ETT Cuff Pressures at the UMMMC University Emergency Department

Abstract will be available upon expiration of embargo

The Victorian Newsletter (Spring 1973)

The Victorian Newsletter is sponsored for the English X Group of the Modern Language Association by New York University and Queens College, City University of New York.The State of Victorian Studies: 1962-1972 - Introductory Remarks / Robert A. Colby -- Victorian Nonfiction Prose / G. B. Tennyson -- Victorian Poetry / R. C. Tobias -- Victorian Fiction / Lionel Stevenson -- Emily Brontë and the Responsible Imagination / Victor A. Neufeldt -- Wave and Fire Imagery in Tennyson's Idylls / Henry Kozicki -- Tennyson and the Spasmodics / Joseph J. Collins -- Recent Publications: A Selected List / Arthur F. Minerof -- English X New

Altitude-Related Change in Endotracheal Tube Cuff Pressures in Helicopter EMS

Introduction: Over-inflation of endotracheal tube (ETT) cuffs has the potential to lead to scarring and stenosis of the trachea. 1, 2, 3, 4 The air inside an ETT cuff is subject to expansion as atmospheric pressure decreases, as happens with an increase in altitude. Emergency medical services helicopters are not pressurized, thereby providing a good environment for studying the effects of altitude changes ETT cuff pressures. This study aims to explore the relationship between altitude and ETT cuff pressures in a helicopter air-medical transport program. Methods: ETT cuffs were initially inflated in a nonstandardized manner and then adjusted to a pressure of 25 cmH 2O. The pressure was again measured when the helicopter reached maximum altitude. A final pressure was recorded when the helicopter landed at the receiving facility. Results: We enrolled 60 subjects in the study. The mean for initial tube cuff pressures was 70 cmH 2O. Maximum altitude for the program ranged from 1,000–3,000 feet above sea level, with a change in altitude from 800–2,480 feet. Mean cuff pressure at altitude was 36.52 ± 8.56 cmH 2O. Despite the significant change in cuff pressure at maximum altitude, there was no relationship found between the maximum altitude and the cuff pressures measured. Conclusion: Our study failed to demonstrate the expected linear relationship between ETT cuff pressures and the maximum altitude achieved during typical air-medical transportation in our system. At altitudes less than 3,000 feet above sea level, the effect of altitude change on ETT pressure is minimal and does not require a change in practice to saline-filled cuffs

Altitude-Related Change in Endotracheal Tube Cuff Pressures in Helicopter EMS

Introduction: Over-inflation of endotracheal tube (ETT) cuffs has the potential to lead to scarring and stenosis of the trachea. 1, 2, 3, 4 The air inside an ETT cuff is subject to expansion as atmospheric pressure decreases, as happens with an increase in altitude. Emergency medical services helicopters are not pressurized, thereby providing a good environment for studying the effects of altitude changes ETT cuff pressures. This study aims to explore the relationship between altitude and ETT cuff pressures in a helicopter air-medical transport program. Methods: ETT cuffs were initially inflated in a nonstandardized manner and then adjusted to a pressure of 25 cmH 2O. The pressure was again measured when the helicopter reached maximum altitude. A final pressure was recorded when the helicopter landed at the receiving facility. Results: We enrolled 60 subjects in the study. The mean for initial tube cuff pressures was 70 cmH 2O. Maximum altitude for the program ranged from 1,000–3,000 feet above sea level, with a change in altitude from 800–2,480 feet. Mean cuff pressure at altitude was 36.52 ± 8.56 cmH 2O. Despite the significant change in cuff pressure at maximum altitude, there was no relationship found between the maximum altitude and the cuff pressures measured. Conclusion: Our study failed to demonstrate the expected linear relationship between ETT cuff pressures and the maximum altitude achieved during typical air-medical transportation in our system. At altitudes less than 3,000 feet above sea level, the effect of altitude change on ETT pressure is minimal and does not require a change in practice to saline-filled cuffs

Delayed Recognition of Acute Stroke by Emergency Department Staff Following Failure to Activate Stroke by Emergency Medical Services

Introduction: Early recognition and pre-notification by emergency medical services (EMS) improves the timeliness of emergency department (ED) stroke care; however, little is known regarding the effects on care should EMS providers fail to pre-notify. We sought to determine if potential stroke patients transported by EMS, but for whom EMS did not provide pre-notification, suffer delays in ED door-to-stroke-team activation (DTA) as compared to the other available cohort of patients for whom the ED is not pre-notified–those arriving by private vehicle.Methods: We queried our prospective stroke registry to identify consecutive stroke team activation patients over 12 months and retrospectively reviewed the electronic health record for each patient to validate registry data and abstract other clinical and operational data. We compared patients arriving by private vehicle to those arriving by EMS without pre-notification, and we employed a multivariable, penalized regression model to assess the probability of meeting the national DTA goal of ≤15 minutes, controlling for a variety of clinical factors.Results: Our inclusion criteria were met by 200 patients. Overall performance of the regression model was excellent (area under the curve 0.929). Arrival via EMS without pre-notification, compared to arrival by private vehicle, was associated with an adjusted risk ratio of 0.55 (95% confidence interval, 0.27-0.96) for achieving DTA ≤ 15 minutes. Conclusion: Our single-center data demonstrate that potential stroke patients arriving via EMS without pre-notification are less likely to meet the national DTA goal than patients arriving via other means. These data suggest a negative, unintended consequence of otherwise highly successful EMS efforts to improve stroke care, the root of which may be ED staff over-reliance on EMS for stroke recognition.

The Commonwealth at Sixty — the Place of the English-Speaking Caribbean : Continuity, Division and Tension

For the last three decades, the Commonwealth has worked at identifying and overcoming the vulnerability of small states. As more small independent states became members, the Commonwealth, especially under Secretary-General Shridath Ramphal, grew more aware of the specific response their particular position called for, therefore emerging as the first international organization to recognize their specificity. Commonwealth action for small states has thus aimed at protecting them against a hostile geographical as well as political environment which they had little resource to resist. In this respect the Commonwealth has fostered regional solidarities as well as individual national resilience. In this context, the Grenada invasion by the United States in 1983 provides a relevant case study of the vulnerability of small Caribbean states on the international scene : confronted to the direct violation of one of their fellows’ sovereignty, many of them took sides with a more powerful foreign state instead of condemning the invasion, therefore breaking regional solidarity ties. As well as enquiring into the tensions generated within the Commonwealth and among English-speaking Caribbean states by the Grenada issue, this paper also delivers an assessment of the work the Commonwealth has accomplished in the Caribbean to promote democracy and developmentDepuis trois décennies, le Commonwealth s’est attaché à identifier et vaincre la vulnérabilité des petits Etats. De plus en plus de petits Etats rejoignant l’organisation, le Commonwealth, surtout sous les mandats du Secrétaire général Shridath Ramphal, a pris conscience des programmes spécifiques que leur position particulière exigeait, devenant ainsi la première organisation internationale à reconnaître leur spécificité. Le Commonwealth a orienté son action en faveur des petits Etats de façon à les protéger d’un environnement géographique et politique hostile auquel leur manque de ressources leur permettait mal de faire face. Le Commonwealth a ainsi favorisé les solidarités régionales ainsi que la résilience nationale de ces Etats. Dans ce contexte, l’invasion de la Grenade par les Etats-Unis en 1983 fournit un exemple marquant de la vulnérabilité des petits Etats de la Caraïbe sur la scène internationale. Confrontés à la violation directe de la souveraineté de l’un de leurs, plusieurs Etats se sont rangés du côté de la grande puissance étrangère, au lieu de condamner l’invasion, rompant ainsi les solidarités régionales. Tout en analysant les tensions que la question de la Grenade a générées au sein du Commonwealth et des Etats de la Caraïbe anglophone, cet article évalue également le rôle de l’organisation pour la promotion de la démocratie et du développement dans la région.Barrow-Giles Cynthia, Grenade Wendy C., Joseph Tennyson S. D. The Commonwealth at Sixty — the Place of the English-Speaking Caribbean : Continuity, Division and Tension. In: Cahiers Charles V, n°49,2010. Le Commonwealth des nations en mutation: décolonisations, globalisation et gouvernance. pp. 125-159

Prehospital Intubations Are Associated with Elevated Endotracheal Tube Cuff Pressures: A Cross-Sectional Study Characterizing ETT Cuff Pressures at a Tertiary Care Emergency Department

INTRODUCTION: Emergency Medical Services (EMS) providers are trained to place endotracheal tubes (ETTs) in the prehospital setting when indicated. Endotracheal tube cuffs are traditionally inflated with 10cc of air to provide adequate seal against the tracheal lumen. There is literature suggesting that many ETTs are inflated well beyond the accepted safe pressures of 20-30cmH2O, leading to potential complications including ischemia, necrosis, scarring, and stenosis of the tracheal wall. Currently, EMS providers do not routinely check ETT cuff pressures. It was hypothesized that the average ETT cuff pressure of patients arriving at the study site who were intubated by EMS exceeds the safe pressure range of 20-30cmH2O. OBJECTIVES: While ETT cuff inflation is necessary to close the respiratory system, thus preventing air leaks and aspiration, there is evidence to suggest that over-inflated ETT cuffs can cause long-term complications. The purpose of this study is to characterize the cuff pressures of ETTs placed by EMS providers. METHODS: This project was a single center, prospective observational study. Endotracheal tube cuff pressures were measured and recorded for adult patients intubated by EMS providers prior to arrival at a large, urban, tertiary care center over a nine-month period. All data were collected by respiratory therapists utilizing a cuff pressure measurement device which had a detectable range of 0-100cmH2O and was designed as a syringe. Results including basic patient demographics, cuff pressure, tube size, and EMS service were recorded. RESULTS: In total, 45 measurements from six EMS services were included with ETT sizes ranging from 6.5-8.0mm. Mean patient age was 52.2 years (67.7% male). Mean cuff pressure was 81.8cmH2O with a range of 15 to 100 and a median of 100. The mode was 100cmH2O; 40 out of 45 (88.9%) cuff pressures were above 30cmH2O. Linear regression showed no correlation between age and ETT cuff pressure or between ETT size and cuff pressure. Two-tailed T tests did not show a significant difference in the mean cuff pressure between female versus male patients. CONCLUSION: An overwhelming majority of prehospital intubations are associated with elevated cuff pressures, and cuff pressure monitoring education is indicated to address this phenomenon