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Case 31
Published in Andrew Solomon, Julia Anstey, Liora Wittner, Priti Dutta, Clinical Cases, 2021
Andrew Solomon, Julia Anstey, Liora Wittner, Priti Dutta
Historically, innumerable numbers of acutely admitted adult medical patients, including those with a variety of cardio-respiratory disorders, arrived in emergency departments with a non-rebreather mask attached to high-flow oxygen. It is increasingly clear that oxygen is a drug that needs coordinated prescription and careful titration. Recent evidence, whilst not diminishing the need for oxygen in those for whom it is required, such as those with severe hypoxia, suggest the need for an alteration in approach.
Introduction to the clinical stations
Published in Sukhpreet Singh Dubb, Core Surgical Training Interviews, 2020
I would resuscitate the patient and assess their level of health using the ALS protocol A, B, C and also ask for senior and nursing assistance. Starting with the airway, I would speak with the patient and ensure there was a patent airway and no escalation was needed. I would initiate high-flow oxygen through a non-rebreather mask, adjusting this decision if needed later. I would briefly examine the chest for gross pathologies. At circulation, I would ensure there were two large bore grey cannulae placed at both antecubital fossae, oxygen saturation, ECG monitoring and blood pressure monitoring. I would request a full set of bloods for any pathology including FBC, U&E, LFTs, clotting and crossmatch for 4 units of blood. I would also order an ABG to review acid-base status, oxygenation and lactate levels. I would examine the patient's cardiovascular system and assess their haemodynamic status based on capillary refill, presence of pallor, pulse rate, rhythm and nature and praecordium examination findings. I would react to any abnormal clinical findings and initiate therapy, after which I would reassess the patient.
Hypoxemia
Published in Lauren A. Plante, Expecting Trouble, 2018
When hypoxemia is confirmed, the initial therapeutic approach is to administer supplemental oxygen. Because the A–a gradient is widened when a pregnant woman is in a supine position, she should be moved to a sitting or semirecumbent position. Oxygen can be administered via a nasal cannula or via a face mask. At a flow rate of 10 L/min, a nasal cannula delivers about 3 percentage points (above room air FIO2 of 21% or 0.21) per liter per minute flow rate. For example, a flow rate of 1 L/min would produce an FIO2 of approximately 0.24, and a flow rate of 5 L/min, about 0.36. (This varies some depending on the size of the patient’s nasal cavity, since there is no other reservoir, and upon the respiratory demand, since higher demand entrains more room air.) A promising new development is the use of high-flow oxygen through a specialized system of nasal prongs (Optiflow™, Fisher & Paykel Healthcare), although as yet, there are no reports in pregnancy. Face masks can be fitted with a Venturi adapter, which can deliver different FIO2 between about 0.24 and 0.60, depending on the oxygen flow rate and the size of the entrainment port. Finally, a nonrebreather mask can deliver FIO2 between 0.60 and 0.90, depending on flow rates; these have both a reservoir bag inflated with oxygen and a series of one-way valves that prevent the entrainment of room air into the mask.
Life-Threatening Cyanide Intoxication after Ingestion of Amygdalin in Prehospital Care
Published in Prehospital Emergency Care, 2022
Patrik Cmorej, Petr Bruthans, Jaroslav Halamka, Irena Voriskova, David Peran
EMS crews (paramedic and physician in the rendezvous system) responded and upon the arrival, the patient was found unconscious, spontaneously ventilating with limb convulsions. The physician assessed the patient using the ABCDE algorithm. The airways were clear, with the smell of bitter almonds present. Insufficient spontaneous ventilation was noted with an oxygen saturation of 85%. The patient was given oxygen via a non-rebreather mask at a high flow (15 l per minute). Good air movement and symmetrical chest rise and fall was present. Initial blood pressure was 73/44 mmHg with a regular heart rate of 69 beats per minute. Intravenous access was obtained, and 500 ml infusion bolus of Hartmann’s solution was begun. When the patient’s blood pressure did not respond to fluid bolus, norepinephrine 2 mg in 20 ml of 5% glucose was initiated (100 mcg/ml with initial speed of 20 ml/hour) resulting in blood pressure increase to 80/50 mmHg. A sinus rhythm at 59 beats/min with a single ventricular extrasystole was present on the 12 -leads ECG. In addition, bifascicular block and ST segment depression up to 1 mm on the lateral wall were present. Unconsciousness persisted with a GCS of 1 − 1 − 1.
Prehospital Drug Assisted Airway Management: An NAEMSP Position Statement and Resource Document
Published in Prehospital Emergency Care, 2022
Jeffrey L. Jarvis, John W. Lyng, Brian L. Miller, Michael C. Perlmutter, Heidi Abraham, Ritu Sahni
Efforts to achieve preoxygenation and denitrogenation (henceforth referred to simply as preoxygenation) are vital to reducing the risk of peri-intubation hypoxia (41). Adequate preoxygenation increases safe apnea time and reduces the risk of peri-intubation hypoxia. A common approach to preoxygenation in the emergency setting is to provide 100% oxygen by non-rebreather mask for at least 3 minutes. In the apneic or hypoventilating patient, delivery of preoxygenation by bag-valve-mask may be necessary. While non-rebreather mask and bag-valve-mask are the most commonly used modalities for providing preoxygenation, noninvasive positive pressure ventilation (NIPPV) may be more effective (42–44). In 30 healthy volunteers undergoing a 3-minute trial of preoxygenation, Groombridge et al. observed mean fraction of expired oxygen levels of 0.64 with non-rebreather masks compared with 95% with NIPPV (44). Baillard found similar results in intensive care unit patients undergoing intubation (42).
Ventilator-induced barotrauma in critically ill patients with COVID-19: a retrospective observational study
Published in Journal of Community Hospital Internal Medicine Perspectives, 2021
Anuraag Sah, Emilio J. Fabian, Carlos Remolina
This retrospective study done in a Community Hospital ICU in New Jersey early in the pandemic beginning in April through June of 2020 included all patients positive for SARS-CoV-2 infection who were ventilator-dependent for respiratory failure and severe acute respiratory syndrome. IRB approval was obtained by the Chair of Institutional Review Board at the Hospital with study number TRMC2020-12. Informed Consent was not required as this was a retrospective observational analysis with no patient identifiers published. All participants’ age, sex and BMI were all recorded at admission. Patients who were on non-invasive mechanical ventilation including CPAP or BiPAP at any time during their hospital stay were excluded. However, patients who received other forms of supplemental oxygen such as via Nasal Cannula, Non-Rebreather Mask and High-Flow therapy were included. The incidence of barotrauma was defined by the presence of subcutaneous emphysema, pneumothorax or pneumomediastinum in all intubated patients. Incidence of barotrauma was identified based on radiographic findings alone, either chest X-rays or CT scans. Total time in days on the ventilator was also documented, and end time was defined by either the day of tracheostomy tube placement, extubation or death.