RESUMEN
Lactoferrin (LF), a pleiotropic iron-binding glycoprotein, is known to modulate the humoral immune response. However, its exact role in Ig synthesis has yet to be elucidated. In this study, we investigated the effect of LF on Ig production by mouse B cells and its underlying mechanisms. LF, like transforming growth factor (TGF)-ß1, stimulated B cells to produce IgA and IgG2b, while downregulating other isotypes. Using limiting dilution analysis, LF was shown to increase the frequency of IgA-secreting B-cell clones. This was paralleled by an increase in Ig germ-line α (GLα) transcripts, indicating that LF plays a role as an IgA switch factor. Interestingly, LF directly interacted with betaglycan (TGF-ß receptor III, TßRIII) and in turn induced phosphorylation of TßRI and Smad3 through formation of the TßRIII/TßRII/TßRI complex, leading to IgA isotype switching. Peroral administration of LF increased intestinal/serum IgA production as well as number of IgA plasma cells in lamina propria. Finally, we found that LF has an adjuvant activity when nontoxigenic Salmonella typhimurium was inoculated perorally, conferring protection against intragastrical infection of toxigenic S. typhimurium. These results suggest that LF has an important effect on the mucosal/systemic IgA response and can contribute to protection against intestinal pathogens.
Asunto(s)
Inmunoglobulina A/inmunología , Cambio de Clase de Inmunoglobulina , Inmunoglobulina G/inmunología , Lactoferrina/metabolismo , Proteoglicanos/metabolismo , Receptores de Factores de Crecimiento Transformadores beta/metabolismo , Transducción de Señal , Factor de Crecimiento Transformador beta/metabolismo , Adyuvantes Inmunológicos , Animales , Formación de Anticuerpos/efectos de los fármacos , Formación de Anticuerpos/inmunología , Linfocitos B/efectos de los fármacos , Linfocitos B/inmunología , Linfocitos B/metabolismo , Inmunidad Mucosa , Inmunoglobulina A/biosíntesis , Cambio de Clase de Inmunoglobulina/efectos de los fármacos , Cambio de Clase de Inmunoglobulina/inmunología , Inmunoglobulina G/biosíntesis , Lactoferrina/farmacología , Ratones , Unión Proteica , Transducción de Señal/efectos de los fármacos , Proteína smad3/metabolismo , Factor de Crecimiento Transformador beta/farmacologíaRESUMEN
In a 41-year-old man, right-sided infraspinatus muscle weakness was associated with compression of the suprascapular nerve caused by a spinoglenoid ganglion cyst. The lesion was confirmed using electromyography and MRI. In addition, arthroscopy showed an incomplete discoid labrum. The free inner edge of the labrum was removed as in a meniscectomy of a discoid meniscus in the knee joint. Arthroscopic decompression of the cyst was performed through a juxtaglenoid capsulotomy which was left open. Neurological function recovered completely.
Asunto(s)
Ganglión/patología , Síndromes de Compresión Nerviosa/patología , Escápula/anomalías , Articulación del Hombro/patología , Adulto , Artroscopía/métodos , Ganglión/complicaciones , Ganglión/cirugía , Humanos , Masculino , Síndromes de Compresión Nerviosa/complicaciones , Síndromes de Compresión Nerviosa/cirugía , Resultado del TratamientoRESUMEN
The rabbit establishes its primary Ab repertoire by somatically diversifying an initial repertoire that is limited by restricted VH gene segment usage during VDJ gene rearrangement. Somatic diversification occurs in gut-associated lymphoid tissue (GALT), and by about 1-2 mo of age nearly all Ig VDJ genes are somatically diversified. In other species that are known to establish their primary Ab repertoire by somatic diversification, such as chicken, sheep, and cattle, diversification appears to be developmentally regulated: it begins before birth and occurs independent of exogenous factors. Because somatic diversification in rabbit occurs well after birth in GALT, the diversification process may not be developmentally regulated, but may require interaction with exogenous factors derived from the gut. To test this hypothesis, we examined Ab repertoire diversification in rabbits in which the appendix was ligated shortly after birth to prevent microbial colonization and all other organized GALT was surgically removed. We found that by 12 wk of age nearly 90% of the Ig VDJ genes in PBL were undiversified, indicating that intestinal microflora are required for somatically diversifying the Ab repertoire. We also examined repertoire diversification in sterilely derived remote colony rabbits that were hand raised away from contact with conventional rabbits and thereby acquired a different gut microflora. In these remote colony rabbits, GALT was underdeveloped, and 70% of the Ig VDJ genes in PBL were undiversified. We conclude that specific, currently unidentified intestinal microflora are required for Ab repertoire diversification.
Asunto(s)
Diversidad de Anticuerpos , Mucosa Intestinal/inmunología , Mucosa Intestinal/microbiología , Animales , Animales Recién Nacidos/genética , Animales Recién Nacidos/crecimiento & desarrollo , Animales Recién Nacidos/inmunología , Diversidad de Anticuerpos/genética , Apéndice/inmunología , Apéndice/microbiología , Linfocitos B/citología , Linfocitos B/inmunología , Linfocitos B/metabolismo , Bacterias/crecimiento & desarrollo , Dieta , Genes de Inmunoglobulinas , Vida Libre de Gérmenes , Cadenas Pesadas de Inmunoglobulina/genética , Región Variable de Inmunoglobulina/genética , Inmunoglobulinas/sangre , Mucosa Intestinal/metabolismo , Ligadura , Recuento de Linfocitos , Tejido Linfoide/citología , Tejido Linfoide/inmunología , Tejido Linfoide/metabolismo , Tejido Linfoide/microbiología , Ratones , Datos de Secuencia Molecular , ConejosRESUMEN
Fibrin derived from fibrinogen after thrombin cleavage plays an essential role in forming blood clots. Fibrin as well as fibrinogen is also involved in the induction of platelet aggregation, leukocyte cell adhesion and phagocytosis. An additional biological role of fibrin and fibrinogen is presented in this study. One of the proteolytic peptides of fibrin/fibrinogen, fragment E, and not fragment D, was able to stimulate rat peritoneal macrophages to express interleukin-6 (IL-6). The stimulation of fibrin/fibrinogen fragment E on macrophages appeared to work in a dose- and time-dependent manner. Adherent fibrin fragment E was able to stimulate IL-6 expression as well as IL-6 protein production. The effect of fibrin fragment E was inhibited by the addition of an excess amount of GPRP tetrapeptide, but not by GHRP, which are the amino acids derived from the amino terminus of fibrin alpha and beta chains, respectively. These results suggest that fibrin as well as fibrinogen function as a stimulator to macrophages, and leukocyte integrin p150,95 (CD11c/ CD18), not Mac-I (CD11b/CD18), is involved in mediating fibrin stimulatory activity in macrophages.
Asunto(s)
Productos de Degradación de Fibrina-Fibrinógeno/farmacología , Interleucina-6/biosíntesis , Macrófagos Peritoneales/efectos de los fármacos , Animales , Relación Dosis-Respuesta a Droga , Ratas , Ratas Sprague-Dawley , Factores de TiempoRESUMEN
STUDY OBJECTIVE: To evaluate intramuscular dihydroergotamine in direct comparison with opioid analgesia in the treatment of acute migraine headache. METHODS: This was a prospective, multicenter, double-blind trial performed in the emergency departments of 11 general hospitals in the United States. One hundred seventy-one patients between the ages of 18 and 60 years who presented to the ED with acute migraine headache were enrolled. Patients were randomly assigned to receive either 1 mg dihydroergotamine (DHE) or 1.5 mg/kg meperidine (MEP) by intramuscular injection. The anti-nauseant hydroxyzine (H) was coadministered in both treatment groups. RESULTS: One hundred fifty-six patients were evaluable. Treatment groups were comparable in sample size, demographics, and baseline measurements of headache pain. Reduction of headache pain as measured on a 100-mm visual analog scale was 41+/-33 mm (53.5% reduction) for the DHE group, and 45+/-30 mm (55.7% reduction) for the MEP group at 60 minutes after treatment (difference=2.2%; 95% confidence interval [CI] -10%, 14.5%; P=.81). Reduction in the severity of nausea and improvement in functional ability were similar between treatment groups. Central nervous system adverse events were less common in the DHE group (DHE 23.5% versus MEP 37.6%, difference-14.1%: 95% CI -28%, 0%). In particular, dizziness was reported less commonly with DHE than MEP (2% versus 15%, difference=-13%: 95% CI -21%, -5%). CONCLUSION: In this prospective, double-blind trial of a convenience sample of ED patients randomly assigned to one of two treatment regimens, DHE and MEP were comparable therapies for acute migraine. The use of DHE avoids several problems associated with opioid analgesia, including dizziness.
Asunto(s)
Analgésicos no Narcóticos/uso terapéutico , Analgésicos Opioides/uso terapéutico , Antieméticos/uso terapéutico , Dihidroergotamina/uso terapéutico , Hidroxizina/uso terapéutico , Meperidina/uso terapéutico , Trastornos Migrañosos/tratamiento farmacológico , Enfermedad Aguda , Adolescente , Adulto , Analgésicos no Narcóticos/administración & dosificación , Analgésicos no Narcóticos/efectos adversos , Analgésicos Opioides/administración & dosificación , Analgésicos Opioides/efectos adversos , Antieméticos/administración & dosificación , Antieméticos/efectos adversos , Dihidroergotamina/administración & dosificación , Dihidroergotamina/efectos adversos , Método Doble Ciego , Combinación de Medicamentos , Servicio de Urgencia en Hospital , Femenino , Estudios de Seguimiento , Humanos , Hidroxizina/administración & dosificación , Hidroxizina/efectos adversos , Inyecciones Intramusculares , Masculino , Meperidina/administración & dosificación , Meperidina/efectos adversos , Persona de Mediana Edad , Náusea/tratamiento farmacológico , Dimensión del Dolor , Estudios Prospectivos , Factores de TiempoRESUMEN
OBJECTIVE: To compare the efficacy of percutaneous transtracheal ventilation (PTV) in the unparalyzed state with that in the paralyzed state using a sedated nonobstructed canine model. METHODS: Eight mongrel dogs (16.8-32 kg) were anesthetized, instrumented, and placed in a volume plethysmograph. Anesthesia was achieved with pentobarbital sodium (up to 30 mg/kg). The spontaneous respiratory drive was kept intact. PTV was performed using a 13-ga transtracheal catheter and compressed air at 45 psi at an I:E ratio of 1:3 (15 breaths/min). Each dog was sequentially ventilated in both the paralyzed and unparalyzed states. The paralyzed/unparalyzed sequence was alternated among the animals to avoid sequence bias. Paralysis was achieved with succinylcholine (0.1 mg/kg bolus and 0.01 mg/kg/min drip). Reversal of paralysis was achieved by discontinuing the succinylcholine infusion. Key variables, including arterial blood gas, tidal volume, and pulmonary mechanics, were measured and compared for the paralyzed and unparalyzed states. RESULTS: Gas exchanges and lung mechanics were similar between the unparalyzed and paralyzed states. There was no significant difference in mean pH, pCO2, pO2, tidal volume, or peak inspiratory transpulmonary pressure. There was also no significant difference in pulmonary resistance or pulmonary compliance. CONCLUSION: In a sedated nonobstructed canine model, PTV is as efficacious in the unparalyzed state as it is in the paralyzed state. The lung mechanics are also similar in the 2 states. These data suggest that it may be unnecessary to induce paralysis when using PTV for emergency ventilation in the heavily sedated state.
Asunto(s)
Pulmón/fisiología , Parálisis/fisiopatología , Respiración Artificial , Mecánica Respiratoria , Animales , Estudios Cruzados , Perros , Intercambio Gaseoso Pulmonar , Pruebas de Función Respiratoria , TráqueaRESUMEN
OBJECTIVE: To compare the efficacy of dopamine (DA) with that of norepinephrine (NE) in the treatment of refractory hypotension caused by tricyclic antidepressants (TCAs). METHODS: A retrospective analysis was used to compare blood pressure responses in concurrent case series of patients treated with vasopressors for TCA-associated hypotension. The patients were adults (aged > or = 16 years) treated at 2 urban teaching hospitals from 1983 to 1994. All patients were diagnosed as having TCA ingestion (positive serum toxicologic assay), were hypotensive [systolic blood pressures (SBPs) < or = 90 mm Hg], and required vasopressor therapy. The patients were grouped by initial vasopressor treatment (i.e., NE vs DA). RESULTS: There were 26 hypotensive adult patients who met study criteria. All 26 patients remained hypotensive after initial treatment of their TCA-associated hypotension with crystalloid infusion and alkalinization. The NE and DA groups were similar in age, sex, and proportion of patients with single and co-drug ingestion. The NE group, however, had a significantly lower average SBP at study entry (56 vs 74 mm Hg, p = 0.04). Nine of 15 (60%) patients responded to DA (5-10 micrograms/kg/min) and 11/11 (100%) patients responded to NE (5-53 micrograms/min). The difference in response rates was statistically significant (p = 0.02). Six patients in whom DA (max rate 10-50 micrograms/min/kg) failed to raise the SBP subsequently responded to NE (max rate 5-74 micrograms/ min) when this drug was later used. One patient receiving NE (12 micrograms/min) developed ventricular ectopy, successfully treated with lidocaine. There were no ischemic complications from either NE or DA. Patients who failed DA therapy tended to be older (39 vs 30 years, p = 0.08), to be more hypotensive at study entry (64 vs 81 mm Hg, p = 0.008), and to remain hypotensive even at higher doses of DA (24 vs 7 micrograms/min/kg, p = 0.002). CONCLUSION: While this was not a prospective randomized study, NE appears advantageous over DA as the first-line vasopressor agent for those patients who require vasopressor support in the setting of TCA-induced hypotension that is refractory to IV fluid and serum alkalinization.
Asunto(s)
Antidepresivos Tricíclicos/efectos adversos , Dopamina/uso terapéutico , Hipotensión/inducido químicamente , Hipotensión/tratamiento farmacológico , Norepinefrina/uso terapéutico , Vasoconstrictores/uso terapéutico , Adolescente , Adulto , Determinación de la Presión Sanguínea , Femenino , Humanos , Masculino , Persona de Mediana Edad , Probabilidad , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
STUDY OBJECTIVES: To determine (1) reliability and validity estimates of three modalities used to assess open thoracotomy procedural competency and (2) the effect of computer practice on procedural performance as measured by the three assessment modalities. METHODS: An experimental, sequential assessment design with volunteer examinees completing all three assessment modalities (paper, computer, pig model) was implemented at the animal support facilities of a university medical school with an affiliated emergency medicine residency program. Level of physician training (student, resident, faculty) and type of computer practice (thoracotomy, cricothyrotomy) were independent variables. Procedural competency scores were determined for each modality; scores were defined in terms of performance time and performance accuracy for three thoracotomy procedures (opening the chest, pericardiotomy, and aortic cross-clamping). RESULTS: Thoracotomy performance on the pig reliably discriminated among examinees known to differ in level of training. However, computer simulation performance did not significantly differ among examinees with different levels of training. Computer simulation practice significantly improved later performance on the computer assessment (P < .05) but not on the pig assessment. The greatest predictor of procedural competency (time and accuracy) on the pig assessment was the ability to sequentially order procedural steps. CONCLUSION: This study establishes the pig model as superior to the paper and computer models as the criterion standard for open thoracotomy assessment. Psychometric properties support the pig model as the most reliable and valid model yet described for assessing thoracotomy procedural competency. Computer simulation practice using visual images (complex anatomy) and the sequential ordering of procedural steps through paper modeling show promise for teaching and assessment of prerequisite skills required to develop psychomotor procedural competency.
Asunto(s)
Competencia Clínica , Educación de Postgrado en Medicina , Medicina de Emergencia/educación , Toracotomía , Animales , Simulación por Computador , Modelos Animales de Enfermedad , Docentes Médicos , Humanos , Internado y Residencia , Estudiantes de Medicina , Porcinos , Enseñanza/métodosRESUMEN
A telephone questionnaire examining perceived quality of and satisfaction with Emergency Department (ED) care was administered to randomly selected patients within 60 days of their visit to a university hospital ED over a 13-month period. Patients, or the persons who accompanied them to the ED, rated overall service, nursing technical performance, physician technical performance, nursing bedside manner, physician bedside manner, and registration clerk service on a 5-point rating scale (5 = excellent, 4 = very good, 3 = good, 2 = fair, 1 = poor). Patients were also asked if they felt the care was delivered in a timely manner. A total of 618 interviews were conducted (1333 attempts to contact, 12 people declined to be interviewed). The results suggest that patient perceptions of the technical quality of care are more important than perceived timeliness of care or bedside manner in determining patient satisfaction with ED care.
Asunto(s)
Servicio de Urgencia en Hospital/normas , Satisfacción del Paciente , Percepción Social , Adulto , Servicios Médicos de Urgencia/normas , Enfermería de Urgencia/normas , Humanos , Calidad de la Atención de Salud , Encuestas y CuestionariosRESUMEN
STUDY OBJECTIVE: To compare the overall satisfaction with emergency department care of patients seen by a nurse practitioner (NP) with that of patients seen in the usual fashion. DESIGN: A case-control study comparing responses by means of a five-point scale from a prospectively designed telephone survey. SETTING: Midwestern urban university hospital ED in which most patients are seen mainly by fourth-year medical students or house staff and all patients are seen and evaluated by the attending staff. PARTICIPANTS: Patients or, for children and incompetent adults, the person who accompanied the patient to the ED. RESULTS: Overall satisfaction was good for both groups of patients and was not significantly different: 3.9 (SD, 1.1) for the NP group versus 4.0 (SD, 1.3) for the control group (P = .66 [NS]). CONCLUSIONS: This study supports data from earlier studies suggesting that patients are satisfied with ambulatory care delivered by NPs.
Asunto(s)
Servicios Médicos de Urgencia , Enfermeras Practicantes , Satisfacción del Paciente , Estudios de Casos y Controles , Servicio de Urgencia en Hospital , Femenino , Hospitales Universitarios , Humanos , Masculino , Nebraska , Aceptación de la Atención de Salud , Estudios ProspectivosRESUMEN
The purpose of this study was to compare the performance of a nurse resident crew (N/R) to that of the usual nurse/nurse (N/N) crew in a helicopter transport service using scene time as a measure of overall teamwork. It was designed as a retrospective case control study carried out by a university-based helicopter emergency transport service. Emergency Medicine second-year residents who volunteered to be assigned to the helicopter transport service for 1 month rotations flew with an experienced flight nurse. This nurse/resident (N/R) team was compared to the usual nurse/nurse (N/N) team in scene trauma flights. The average ground time for the N/N crew (10.5 minutes, n = 43) was not significantly different from that of the N/R crew (10.3 minutes, n = 43). This study suggests that an emergency medicine resident can be incorporated into a flight crew without adversely affecting scene time.
Asunto(s)
Servicios Médicos de Urgencia , Enfermería de Urgencia , Internado y Residencia , Transporte de Pacientes , Adolescente , Adulto , Aeronaves , Estudios de Casos y Controles , Humanos , Estudios Retrospectivos , Factores de TiempoRESUMEN
STUDY OBJECTIVE: To quantify the delivered tidal volume and other selected measurements of pulmonary mechanics in an animal model during transtracheal jet ventilation (TTJV), with comparison to positive-pressure mechanical ventilation (PPMV) and spontaneous breathing. DESIGN: Prospective, nonblinded laboratory animal study. INTERVENTIONS: Seven mongrel dogs weighing 24.5 +/- 3.7 kg were anesthetized, paralyzed, and placed within a specially designed volume plethysmograph with the head and neck externalized. Ventilation was performed using TTJV under variable inspiratory time:expiratory time ratios (TI:TE) (1:1, 1:2, 1:3, 1:4, 1.5:2.5, 2:1, 2:2, 3:1, and 4:1) and variable driving air pressures (40, 45, and 50 psi). The dogs then were ventilated with PPMV. Tidal volume, tracheal pressure, transpulmonary pressure, air flow, arterial pressure, central venous pressure, and arterial blood gases were measured during spontaneous ventilation, TTJV, and PPMV. Quasistatic compliance of the lungs was measured after all methods of ventilation. Statistical significance was accepted at P < .05. RESULTS: There was no significant difference between delivered tidal volume during TTJV (446 +/- 69 mL at a TI:TE of 1:3 and 45 psi) and spontaneous breathing (506 +/- 72 mL). TTJV delivered a tidal volume significantly higher than the standard 15 mL/kg volume used for mechanical ventilation in dogs. Tracheal pressure and transpulmonary pressure were not significantly different between TTJV and PPMV. Variations in TI:TE had no significant effect on most of the measured variables, specifically tidal volume or transpulmonary pressure. Minute ventilation increased significantly and PCO2 decreased significantly as frequency increased during TI:TE settings of 1:1, 1:2, and 2:1. Increases in the driving air pressure during TTJV significantly increased the tidal volume as it was raised from 40 psi to 50 psi. There was no change in quasistatic lung compliance during any method of ventilation. CONCLUSION: TTJV delivers an effective tidal volume comparable to both spontaneous breathing and PPMV in a dog model. In the absence of upper-airway obstruction, there was no significant difference in the pulmonary pressures, resistance, and compliance during TTJV, as compared to mechanical ventilation. Variation in TI:TE during TTJV had no major effect on pulmonary mechanics, except to increase minute ventilation and decrease PCO2 as the frequency was increased significantly. Increasing the driving air pressure to the TTJV apparatus significantly augmented delivered tidal volume due to increased air flow.
Asunto(s)
Ventilación con Chorro de Alta Frecuencia , Mecánica Respiratoria/fisiología , Animales , Presión Sanguínea/fisiología , Perros , Electrocardiografía , Monitoreo Fisiológico , Pletismografía , Respiración con Presión Positiva , Estudios Prospectivos , Valores de Referencia , Pruebas de Función Respiratoria , Volumen de Ventilación Pulmonar/fisiologíaRESUMEN
STUDY OBJECTIVE: To quantify the effects of graded upper-airway obstruction on the delivered tidal volume and selected parameters of pulmonary mechanics during transtracheal jet ventilation (TTJV) in a dog model. DESIGN: Laboratory study in which seven dogs were anesthetized, paralyzed, and placed within a volume plethysmograph with the head and neck externalized. INTERVENTIONS: Ventilation was performed using TTJV at 45 psi and a frequency of 15 beats per minute. The upper trachea was occluded progressively using a Foley catheter balloon to induce tracheal pressure levels of approximately 150%, 200%, 250%, and 300% of the tracheal pressure obtained during TTJV-c. Tidal volume, tracheal pressure, transpulmonary pressure, airflow, arterial blood pressure, central venous pressure, and arterial blood gases were measured during all conditions of ventilation. Quasistatic compliance curves of the lungs were measured at the conclusion of spontaneous breathing, TTJV-c, and TTJV (at all levels of obstruction). Minute ventilation and pulmonary flow resistance were calculated for each condition of ventilation. RESULTS: Application of graded upper-airway obstruction during TTJV yielded mean tracheal pressures of 130% (level 1), 190% (level 2), 220% (level 3), and 230% (level 4) of that obtained during TTJV-c (10.9 +/- 2.0 cm H2O). Tidal volume significantly increased with each level of obstruction except between levels 3 and 4 (spontaneous breathing, 506 +/- 72 mL; TTJV-c, 446 +/- 69 mL; level 1, 663 +/- 139 mL; level 2, 780 +/- 140 mL; level 3, 931 +/- 181 mL; and level 4, 944 +/- 135 mL). During TTJV at obstruction level 1, transpulmonary pressure was not significantly higher than either spontaneous breathing or TTJV-c, but did significantly increase during higher levels of obstruction. The mean arterial PCO2 significantly decreased at all levels of obstruction due to significantly increased minute ventilation, with a concomitant increase in arterial pH. There was no significant difference seen in the quasistatic compliance of the lungs among spontaneous breathing, TTJV-c, or TTJV at any level of upper airway obstruction. CONCLUSION: Partial upper-airway obstruction increases the delivered tidal volume, minute ventilation, and transpulmonary pressure of the lungs during TTJV, with consequent decreases in the arterial PCO2 as the amount of obstruction increases. No significant changes were seen in the quasistatic compliance of the lungs, pulmonary flow resistance, or alveolar:arterial gradient, lending support to the position that TTJV is a safe technique under conditions of partial upper-airway obstruction. However, due to significant increases in tidal volume and functional residual capacity and decreases in mean arterial blood pressure, concerns still exist during near-total or total upper-airway obstruction.
Asunto(s)
Obstrucción de las Vías Aéreas/fisiopatología , Ventilación con Chorro de Alta Frecuencia , Mecánica Respiratoria/fisiología , Resistencia de las Vías Respiratorias/fisiología , Animales , Perros , Pletismografía , Presión , Volumen de Ventilación Pulmonar/fisiología , Tráquea/fisiopatologíaRESUMEN
STUDY OBJECTIVE: To compare nasotracheal intubation (NTI) to neuromuscular blockade-assisted oral intubation (NMB-assisted oral intubation) in the prehospital care of injured patients. DESIGN: Prospective, randomized study conducted over 21 months. SETTING: A university hospital-sponsored helicopter service. PARTICIPANTS: Consecutive adult (more than 12 years old) injured patients at the accident scene with an initial Glasgow Coma Scale of 8 or less in whom the airway was not managed immediately by unrelaxed oral intubation or cricothyrotomy. Subjects were randomized by 24-hour time blocks into NTI or NMB-assisted oral intubation treatment groups. Forty-four were entered into the NTI group (39 randomized, two crossed over to NMB-assisted oral intubation), and 33 were entered into the NMB-assisted oral intubation group (38 randomized, seven crossed over to NTI). INTERVENTIONS: NMB-assisted oral intubation (succinylcholine 1.5 mg/kg IV) or NTI was carried out according to standard protocols. RESULTS: The success rate for NTI was 79.5% (35 of 44) and was similar to that of NMB-assisted oral intubation, 75.8% (25 of 33; chi 2 = .16; P = .69). There were no significant differences between the NTI and the NMB-assisted oral intubation groups with regard to sex, age, outcome, and Glasgow Coma Scale. For those patients in whom the initial technique was successful, NTI was significantly quicker than NMB-assisted oral intubation (mean time of NTI, 2.9 minutes; mean time of NMB-assisted oral intubation, 5.9 minutes; Mann-Whitney U, 168.0; P < .01). CONCLUSION: In the prehospital management of severely injured patients, there is no significant difference between NMB-assisted oral intubation and NTI in the rate at which endotracheal intubation is achieved. However, practitioners may prefer NTI because it requires significantly less time to perform than NMB-assisted oral intubation.
Asunto(s)
Intubación Intratraqueal/métodos , Adulto , Servicios Médicos de Urgencia , Femenino , Humanos , Masculino , Boca , Nariz , Estudios Prospectivos , Succinilcolina/uso terapéutico , Resultado del TratamientoRESUMEN
INTRODUCTION: Air medical services are being pressured to demonstrate their value. Airway management is the first priority of care when treating injured patients in the prehospital setting. Injured patients with decreased Glasgow Coma Scale (GCS) are candidates for advanced airway procedures and air medical transport. RESEARCH QUESTION: The purpose of this study was to determine the extent of air medical crews' contributions to the airway management of the injured patient in the prehospital setting. METHOD: A study of adult (age > 12 years) injured patients encountered in a field setting, whose GCS on the arrival of the air medical crew was < or = 8, was conducted for 21 months (Feb. 1, 1991-Oct. 31, 1992). RESULTS: During the study period, 174 patients who met the criteria were transported by the air medical crew. All but one received advanced airways including oral tracheal intubation, nasal tracheal intubation or cricothyrotomy. Of those, 68 (39%) of these procedures were completed by ground personnel (ground group), and 105 (61%) were completed by the air medical personnel (air group). The mean GCS for the ground group was 3.69 and for the air group was 4.69. The distributions were significantly different (Wilcoxon Rank Test p = 0.0002). Nineteen percent (13/68) of the patients whose airways were successfully managed by the ground personnel had a GCS of 5 to 8, as did 44% (46/105) of the air group's patients. The groups' patients were not significantly different in age or sex distribution. CONCLUSION: Properly trained air medical personnel positively contribute to the prehospital care of injured patients by establishing definitive airways in patients with higher GCSs.
Asunto(s)
Ambulancias Aéreas/normas , Auxiliares de Urgencia/normas , Terapia Respiratoria/estadística & datos numéricos , Adolescente , Adulto , California , Distribución de Chi-Cuadrado , Análisis Costo-Beneficio , Recolección de Datos , Auxiliares de Urgencia/estadística & datos numéricos , Servicio de Urgencia en Hospital/clasificación , Servicio de Urgencia en Hospital/normas , Servicio de Urgencia en Hospital/estadística & datos numéricos , Estudios de Evaluación como Asunto , Escala de Coma de Glasgow , Humanos , Terapia Respiratoria/clasificaciónRESUMEN
STUDY OBJECTIVES: To determine if the complications associated with skull base fractures are increased when nasotracheal intubation is performed in the field. DESIGN: Retrospective, case-control study over a five-year period. SETTING: A helicopter service returning to a Level I trauma center. TYPE OF PARTICIPANTS: All injured patients treated in the field who had either radiographic or clinical evidence of skull base fractures in whom nasotracheal intubation was attempted (38) compared with all patients with skull base fractures in whom nasotracheal intubation was not attempted (48) and a convenience sample of patients without skull base fractures in whom nasotracheal intubation was attempted (45). Patients with obvious midface motion on initial examination were excluded. Complications of skull base fractures were categorized as cerebral spinal fluid leak of longer than 24 hours and/or meningitis, cranial nerve injury, diabetes insipidus, and intracranial placement of the endotracheal tube. INTERVENTIONS: Blind nasotracheal intubation was performed by experienced flight nurses. RESULTS: There were no patients in whom an endotracheal tube was placed intracranially. There was no significant difference in complication rate between the two groups with skull base fractures (with nasotracheal intubation, 24%; 95% confidence interval, 11% to 40%; without nasotracheal intubation, 25%; 95% confidence interval, 14% to 40%). The group without skull base fracture had none of the complications usually associated with skull base fractures. CONCLUSION: Patients with skull base fracture have a significant complication rate (25%). The complications associated with skull base fractures are not markedly increased by attempts at nasotracheal intubation in the field.
Asunto(s)
Intubación Intratraqueal , Fracturas Craneales/complicaciones , Adulto , Estudios de Casos y Controles , Contraindicaciones , Urgencias Médicas , Femenino , Humanos , Intubación Intratraqueal/efectos adversos , Masculino , Nariz , Estudios RetrospectivosRESUMEN
STUDY OBJECTIVE: To determine the incidence of battery against emergency department medical staff by patients or visitors. DESIGN: Prospective descriptive study over a nine-month period. SETTING: A university-affiliated ED Level I trauma center with an annual census of approximately 64,000 located in a major metropolitan area. PARTICIPANTS: All staff members who had been punched, kicked, grabbed, pushed, or spat on by a patient or visitor while on duty in the ED. INTERVENTIONS: Questionnaire that was completed after the incident. RESULTS: During the study period, there were 19 instances of violence against staff by patients. Staff members were punched six times, kicked seven times, grabbed three times, pushed once, and spat on twice. Blows usually were sustained on the face or head (seven) or on the extremities (seven). In only four cases were hospital incident reports filled out, and in no case was there an injury serious enough to require ED treatment or disability leave. The assailant was usually male (15 of 19, 79%) and usually on a psychiatric or substance abuse detainment (15 of 19, 79%). CONCLUSION: This study suggests that instances of battery in an urban university hospital ED usually are not serious and are committed by patients on a psychiatric or substance abuse detainment.
Asunto(s)
Servicio de Urgencia en Hospital , Violencia , California , Conducta Peligrosa , Enfermería de Urgencia , Femenino , Hospitales Universitarios , Humanos , Masculino , Trastornos Mentales/psicología , Estudios Prospectivos , Restricción Física , Trastornos Relacionados con Sustancias/psicología , Recursos HumanosRESUMEN
We reviewed 16 children with 16 displaced fractures of the femoral neck associated with complications. One was a transepiphyseal fracture, 12 were transcervical fractures, and three were basocervical fractures. The mean age at time of fracture was 11 years 7 months (range, 4 years 6 months to 16 years), and the mean length of follow-up after fracture was 6 years 11 months (range, 2-24 years). Complications in this series were avascular necrosis (AVN) (14 patients), nonunion (seven patients), premature physeal closure (15 patients), chondrolysis (seven patients), and coxa vara (two patients). Avascular necrosis, nonunion, and chondrolysis were associated with a poor outcome. Coxa vara or premature physeal closure alone was not responsible for a poor result.