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Critical Care
Published in Vincenzo Berghella, Maternal-Fetal Evidence Based Guidelines, 2022
Jaimie Maines, Lauren A. Plante
Transfer in cases of critical illness is more complex than the usual perinatal transfer. The transport process increases risk of morbidity and mortality for the critically ill [73], and therefore cannot be embarked upon lightly. Once the decision to transfer has been made and the patient (or her designated decision-maker) has consented, she should be transferred as expeditiously as possible to the receiving facility that has agreed to accept her. If the patient is unstable, she should be stabilized and/or resuscitated to the best possible condition prior to transport, albeit with the understanding that complete stabilization may not be possible outside of the receiving facility. Transport may be by ground or air, based on the urgency of the patient's condition, the distance between facilities, weather conditions, potential interventions during transport, and equipment or personnel available. The minimum monitoring of a critically ill patient during transport includes continuous pulse oximetry and ECG as well as regular assessment of vital signs [73]. Patients who already have arterial or central lines should have those monitored as well. Women who are mechanically ventilated must have the endotracheal tube position confirmed and secured before transport and must be assessed for adequacy of oxygenation and ventilation. All critically ill patients must have secure venous access before transport.
Trauma Systems, Centres and Teams
Published in Ian Greaves, Keith Porter, Jeff Garner, Trauma Care Manual, 2021
Ian Greaves, Keith Porter, Jeff Garner
If a patient is deemed to be at high risk of having suffered major trauma, or major injuries are evident on initial assessment, they should be transferred directly to an MTC, bypassing other potentially closer units, as long as the MTC is within 60 minutes travel time. If the patient is critically unstable, they can be transferred to a closer hospital for stabilization or optimization; this decision must be made on a case-by-case basis. Any imaging taken outside the MTC should be transferred immediately to the MTC, usually electronically. The MTC duty consultant should be made aware of the patient, to enable them to assist the ambulance control paramedic with the coordination of the patient’s care.
Extremity Trauma
Published in Kenneth D Boffard, Manual of Definitive Surgical Trauma Care: Incorporating Definitive Anaesthetic Trauma Care, 2019
The acute stabilization by early external fixation as part of damage control orthopaedics may obviate some of the risks. In cases where damage control surgery is indicated, a phased approach by temporary fixation in the acute phase, followed by definitive reconstruction as a secondary procedure. Long bone fractures like femur, tibia, and humerus can be stabilized with a simple unilateral frame. Periarticular fracture can be treated initially with a bridging external fixation. Localization of pin placement is dictated by anatomy of relevant structures such as the radial nerve in case of a humeral shaft external fixation. The definitive care by internal fixation should be considered as well, pin placement should be as far as possible from the definitive approach.
Prehospital Ultrasound Diagnosis of Massive Pulmonary Embolism by Non-Physicians: A Case Series
Published in Prehospital Emergency Care, 2023
Aaron E. Robinson, Nicholas S. Simpson, John L. Hick, Johanna C. Moore, Gregg A. Jones, Michael D. Fischer, Seth Z. Bravinder, Kolby L. Kolbet, Robert F. Reardon
The prehospital treatment of critical trauma patients is significantly different from that of critical medical patients in regards to scene time. Evidence has demonstrated that scene time in trauma has an effect on outcome; that is, the longer the scene time, the higher the mortality (12). Medical patients tend to benefit from initial stabilization on scene (13). Medical patients also tend to be more complex, with more complicating factors. There is extensive literature showing that POCUS has significant benefit in the evaluation of an undifferentiated medical patient in the emergency department setting (7, 14–17). Additionally, ultrasound can be used to facilitate procedures with a higher success rate than their non-ultrasound guided (i.e. “blind) counterparts (18–21). It has been demonstrated in physician-led EMS services, where physicians are the first point of contact, that POCUS can be beneficial (22, 23). In paramedic-performed POCUS, there is minimal literature (3, 4, 8).
Pituitary apoplexy of a giant prolactinoma during pregnancy
Published in Gynecological Endocrinology, 2021
Safa Khaldi, Ghada Saad, Hamza Elfekih, Asma Ben Abdelkrim, Taieb Ach, Maha Kacem, Molka Chaieb, Amel Maaroufi, Yosra Hasni, Koussay Ach
Pregnancy is a well-known risk factor for pituitary tumor apoplexy (PA). The hormonal stimulation of the gland and the increased blood flow increases pituitary gland size and the pituitary tumor [20]. In our case, the adenoma’s size, pregnancy and cessation of cabergoline therapy might have led to PA. Initial approach to a patient with PA is prompt corticosteroid replacement [21]. After stabilization, there are two options: surgery or medical treatment. By lack of clear guidelines on the management of pituitary apoplexy in pregnancy, each patient should be evaluated and managed on a case by case basis. In the setting of a prolactinoma, the majority of teams recommend re-initiation of a dopamine agonist as first-line therapy as it’s less risky to the mother and fetus than surgical intervention and preserves endocrine functions [21]. In our case, the re-initiation of dopamine agonist allowed a rapid resolution of the symptoms but it can be implicated in premature labor [22,23]. The rates of spontaneous abortions and preterm deliveries are increased by the use of dopamine agonists [22]. These risks are about sevenfold greater for bromocriptine [23]. Twin pregnancy is also a confounding factor as it is a risk factor for premature birth [24].
Erlotinib complexation with randomly methylated β-cyclodextrin improves drug solubility, intestinal permeability, and therapeutic efficacy in non-small cell lung cancer
Published in Pharmaceutical Development and Technology, 2021
Nazlı Erdoğar, Safiye Akkın, Gamze Varan, Erem Bilensoy
Among these formulation approaches, inclusion complexes are promising in the sense that they improve and alter the chemical, biological and pharmacological properties of the included guest molecule, drug. As a result of the stabilization of the drug inside the CD cavity, solubility, and bioavailability increase. This stabilization also leads to the successful delivery of the drug to the active site (Carneiro et al. 2019). Cyclodextrins (CDs) are cyclic oligosaccharides that are enzymatic degradation products of starch and β-CD is one of the most commonly used natural CDs contains seven of these glucopyranose units. Among the chemically modified derivatives of β-CD, randomly methylated-β-CD (RAMEB CD) is known for high solubility in water (80% w/w at 25 °C). Other derivatives, such as methylated-β-CD (M-β-CD, CRYSMEB) are low methylated and have aqueous solubility (20% w/w at 20 °C) lower than RAMEB CD.