Management of acute respiratory distress syndrome using pumpless extracorporeal lung assist

Purpose: To describe the use of a pumpless extracorporeal lung assist device in the treatment of severe acute respiratory distress syndrome (ARDS). Clinical features: A 15-yr-old girl developed severe post-traumatic ARDS. After all conventional treatment strategies failed, we inserted a pumpless extracorporeal lung assist device. This device consists of an arterial cannula inserted into the femoral artery, and a membrane oxygenator with a venous cannula that returns the oxygenated blood back to the patient's femoral vein. Since the driving force is the patient's blood pressure, a roller pump with its negative side effects is not needed. The device allowed removal of excessive PaCO2 and, by applying minimal ventilation, minimization of further ventilator-induced lung injury. The pumpless extracorporeal lung assist device remainedin situ for ten days without any adverse side effect. During this time, the lung recovered such that mechanical ventilation could be reinstalled cautiously. The device was then removed and, after a prolonged period of intensive care, the patient recovered without any sequelae. Conclusion: In this case of a severely damaged lung, an arteriovenous pumpless extracorporeal lung assist was a helpful device to remove elevated CO2 and reduce mechanical stress by applying minimal ventilation. This device is simple to operate and has the potential of being used routinely in the treatment of severe ARD

X-Ray of One-Sided “White Lung” after Central Venous Catheterization

Complications during insertion of a subclavian central venous line are rare but potentially serious. This case report describes the radiological abnormality of a one-sided pleural effusion during a routine control directly after a difficult central venous catheterization. We illustrate the findings, the initial emergency management, and our procedure to rule out an iatrogenic hemothorax. Possible differential diagnoses and strategies for management of a suspected complication are discussed

The use of Glasgow Coma Scale in injury assessment : a critical review

PRIMARY OBJECTIVE: Patients with brain injuries are assessed using the Glasgow Coma Scale (GCS). This review evaluates the use of GCS scoring in medical literature and identifies the reasons for inaccuracy. LITERATURE SELECTION AND CRITICAL APPRAISAL: Pubmed and ISI Web of Knowledge SM were searched using specific keywords. The authors critically appraised the current state of GCS scoring, GCS definitions, the time and frequency of assessment, confounders, GCS reporting and GCS assessment schemes. MAIN OUTCOME AND RESULTS: More than 90% of the publications using GCS scoring cite the 14-item GCS rather than the 15-item GCS. The timing of the initial GCS assessment is inconstant. GCS components are seldom utilized, contributing to the loss of information. Confounders are often not reported and, if they are, not in a standardized manner. The order of the GCS components is not consistent. CONCLUSIONS: The current inconsistent and inappropriate use of GCS diminishes its reliability in both a clinical and a scientific context. A consensus statement is needed to correct this situation. Citing the correct references, early and repeated GCS assessments at defined intervals, standardized reporting of confounders and GCS component plus sum scores, and the utilization of a uniform assessment scheme are recommended

Rocuronium versus succinylcholine for rapid sequence induction of anesthesia and endotracheal intubation: a prospective, randomized trial in emergent cases

When anesthesia is induced with propofol in elective cases, endotracheal intubation conditions are not different between succinylcholine and rocuronium approximately 60 s after the injection of the neuromuscular relaxant. In the present study, we investigated whether, in emergent cases, endotracheal intubation conditions obtained at the actual moment of intubation under succinylcholine differ from those obtained 60 s after the injection of rocuronium. One-hundred-eighty adult patients requiring rapid sequence induction of anesthesia for emergent surgery received propofol (1.5 mg/kg) and either rocuronium (0.6 mg/kg; endotracheal intubation 60 s after injection) or succinylcholine (1 mg/kg; endotracheal intubation as soon as possible). The time from beginning of the induction until completion of the intubation was shorter after the administration of succinylcholine than after rocuronium (median time 95 s versus 130 s; P > 0.0001). Endotracheal intubation conditions, rated with a 9-point scale, were better after succinylcholine administration than after rocuronium (8.6 +/- 1.1 versus 8.0 +/- 1.5; P > 0.001). There was no significant difference in patients with poor intubation conditions (7 versus 12) or in patients with failed first intubation attempt (4 versus 5) between the groups. We conclude that during rapid sequence induction of anesthesia in emergent cases, succinylcholine allows for a more rapid endotracheal intubation sequence and creates superior intubation conditions compared with rocuronium

Endotracheal tube intracuff pressure during helicopter transport

We evaluate changes in endotracheal tube intracuff pressures among intubated patients during aeromedical transport. We determine whether intracuff pressures exceed 30 cm H(2)O during aeromedical transport

Assessing the quality of patient handoffs at care transitions

Effective handoff practices (ie, mechanisms for transferring information, responsibility and authority) are critical to ensure continuity of care and patient safety

Epinephrine improves 24-hour survival in a swine model of prolonged ventricular fibrillation demonstrating that early intraosseous is superior to delayed intravenous administration

Vasopressors administered IV late during resuscitation efforts fail to improve survival. Intraosseous (IO) access can provide a route for earlier administration. We hypothesized that IO epinephrine after 1 minute of cardiopulmonary resuscitation (CPR) (an "optimal" IO scenario) after 10 minutes of untreated ventricular fibrillation (VF) cardiac arrest would improve outcome in comparison with either IV epinephrine after 8 minutes of CPR (a "realistic" IV scenario) or placebo controls with no epinephrine