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Catastrophic Haemorrhage
Published in Ian Greaves, Keith Porter, Jeff Garner, Trauma Care Manual, 2021
Ian Greaves, Keith Porter, Jeff Garner
Patient and limb positioning is often overlooked. Where possible, the patient should be nursed supine in order to keep the physiological demands on the patient as low as possible. A bleeding limb should be elevated above the level of the heart in order to reduce the systolic pressure within the limb pending more effective haemorrhage control. Elevation may, however, be difficult or contraindicated in long-bone fractures and is certainly contraindicated in leg injuries when there is significant suspicion of an unstable pelvic fracture. There should always be a low threshold for applying splints to injured limbs. Splints will reduce bleeding, allow clot formation and reduce the patient’s analgesic requirements. If an unstable pelvic fracture is suspected, then it must be splinted using a commercial pelvic splint such as the SAM Pelvic Sling®. There is no role for improvised splintage in hospital practice. If a femoral fracture is suspected then some form of traction must be applied to reduce the potential space within the thigh compartment.
Cardiopulmonary Resuscitation
Published in Anthony FT Brown, Michael D Cadogan, Emergency Medicine, 2020
Anthony FT Brown, Michael D Cadogan
Clear the airway by sucking out any secretions, remove loose or broken dentures, and insert an oropharyngeal airway. Give 100% oxygen by tight-fitting mask with reservoir bag. Aim for an oxygen saturation above 94%. Position head-up at 20–30 degree elevation.
Trauma
Published in Christoph Schroth, Peter Phillips, 100 Cases in UK Paramedic Practice, 2018
Christoph Schroth, Peter Phillips
Thermal burns should be cooled with cold or tepid, running water for 20–30 minutes, as soon as possible after the injury (ideally within 20 minutes). This was already started by Robert’s wife, so this should be continued until 20–30 minutes have elapsed. After cooling the burnt areas should be covered in cling film to prevent bacterial colonisation, ensuring that it is layered, rather than wrapped circumferentially to prevent vasoconstriction. Elevation is also recommended, because it can prevent oedema, which may affect healing. Now that these steps have been completed, your focus can shift to dealing with analgesia options other than nitrous oxide. Oral paracetamol, ibuprofen or paracetamol could be considered, but oral analgesics have a prolonged time until onset of action compared with intravenous drugs. However, the nitrous oxide could be the best option at this time, as intravenous access could be challenging, because both arms are injured, thus eliminating them as cannulation sites. Yes, legs could be considered as an alternative, but intravenous access might not be possible there, either. This leaves intraosseous access, but this intervention might not be available to you as Robert is conscious, and not all ambulance trusts have adopted lidocaine for intraosseous infusions in conscious patients. Your options are possibly limited to nitrous oxide administration, oral analgesics and transporting Robert in a position of comfort in a speedy fashion to allow for other drugs to be administered in the ED.
Special maternal care bundle to attenuate post-spinal hypotension in cesarean section: A randomized controlled clinical trial
Published in Egyptian Journal of Anaesthesia, 2023
Abdelrhman Alshawadfy, Shaimaa A. Dahshan, Ahmed A. Ellilly, Ahmed M. Elewa
Concerning the maternal position, using a combined supine V-shaped position with 15° head up and 15° leg up with 15° left tilting as a part of maternal care bundle was effective in reducing hypotension with little adverse effect. Lewis et al. [36] reported that the supine wedge position was associated with a relatively faster block onset, but it produced a spinal block with similar characteristics to that obtained in the left lateral position. The cardiac output and mean arterial pressure also increased when the position was changed from supine to the tilted left lateral position. The two tilt angles (15° and 30°) were comparable to each other [15]. Leg elevation would be useful in the prevention and treatment of profound spinal-induced hypotension, especially when combined with other measures [5]. Head elevation during CS was superior to positioning without head elevation in the lateral to supine position because it resulted in a more gradual onset, an optimal block height and enhanced hemodynamics [6]. A modest (5–10°) head-up position does not influence the occurrence of venous air embolism in patients having CS. An et al. [37] found that the incidence and grade of venous air embolism in the head-up tilt group were statistically lower compared to those in the supine group during abdominal myomectomy.
The experience of using a hospital bed alternative at home among individuals with spinal cord injury: A case series
Published in The Journal of Spinal Cord Medicine, 2023
Rachel Levinson, Lorena Salas, Jeanne M. Zanca
Some of the features that all of the individuals reported using on the alternative adjustable bed system included the head of bed elevation, height elevation, and the bedrails. These features provided the participants with increased independence. For example, head elevation was helpful for performing activities in bed such as watching TV or intermittent catheterization. The height elevation feature was used to facilitate transfers, as well as to improve caregiver ergonomics when providing assistance for activities of daily living. One participant stated “Yeah, they [bedrails] help a lot. I can turn myself with the bedrails, without them I need assistance” [Participant 4]. Two participants also mentioned that they used the foot elevation features for positioning and edema management.
The role of serological biomarkers in the diagnosis and management of autoimmune pancreatitis
Published in Expert Review of Clinical Immunology, 2022
Nicolò de Pretis, Antonio Amodio, Giulia De Marchi, Eugenio Marconato, Rachele Ciccocioppo, Luca Frulloni
Serum IgG4 level is considered by the ICDC to be the single best marker of AIP[1]. Serum IgG4 is considered elevated if it is > 140 mg/dL. However, between 140 and 280 mg/dL, the elevation is considered mild, with associated low specificity. If serum IgG4 is higher (> 280 mg/dL = two times the upper normal limit), the diagnostic specificity is significantly higher and strongly suggestive of AIP. A meta-analysis published in 2016 on nine case–control studies on IgG4-related disease reported a serum IgG4 sensitivity of 87% and a serum IgG4 specificity of 82%, considering a cutoff value ranging from 135 to 144 mg/dL. With a cutoff value ranging from 270 to 280 mg/dL as the upper normal limit, the specificity increased to 94%, but the sensitivity dropped to 63%[26]. A more recent meta-analysis published in 2021 on thirteen studies including 594 patients with AIP reported 71.5% pooled sensitivity and 93.4% pooled specificity for serum IgG4 with an upper normal limit of 130–140 mg/dL. In the same study, the authors evaluated 6 out of 13 studies that assessed serum IgG4 levels over twice the upper limit of normal (260–280 mg/dL). In this subanalysis, the pooled sensitivity dropped to 43.4% with a slight increase in specificity up to 98.3%. The authors confirmed that serum IgG4 is a good serological marker for the diagnosis of AIP and for the differential diagnosis from pancreatic cancer, with the best cutoff at 140 mg/dL, rather than 280 mg/dL[27].