Pressure Points Technique for Traumatic Proximal Axillary Artery Hemorrhage: A Case Report

INTRODUCTION

While the pressure points technique for proximal hemorrhage control is long known, it is not recommended in standard prehospital guidelines based on a study showing the inability to maintain occlusion for over two minutes.

MAIN SYMPTOM

This report details a gunshot wound to the left axillary area with complete transection of the axillary artery, leading to profuse junctional hemorrhage and profound hemorrhagic shock.

THERAPEUTIC INTERVENTION

Proximal pressure of the subclavian artery was applied against the first rib (the pressure points technique) and maintained for 28 minutes.

OUTCOMES

Cessation of apparent bleeding and excellent, enduring physiologic response to blood transfusion were observed.

CONCLUSION

The pressure points technique can be life-saving in junctional arterial hemorrhage and should be reconsidered in prehospital guidelines.

A randomized trial to investigate needle redirections/re-insertions using a handheld ultrasound device versus traditional palpation for spinal anesthesia in obese women undergoing cesarean delivery

BACKGROUND

Ultrasound may be useful to identify the spinal anesthesia insertion point, particularly when landmarks are not palpable. We tested the hypothesis that the number of needle redirections/re-insertions is lower when using a handheld ultrasound device compared with palpation in obese women undergoing spinal anesthesia for cesarean delivery.

METHODS

Study recruits were obese (body mass index (BMI) >30 kg/m²) women with impalpable bony landmarks who were undergoing spinal anesthesia for elective cesarean delivery. Women were randomized to ultrasound or palpation. The primary study outcome was a composite between-group comparison of total number of needle redirections (any withdrawal and re-advancement of the needle and/or introducer within the intervertebral space) or re-insertions (any new skin puncture in the same or different intervertebral space) per patient. Secondary outcomes included insertion site identification time and patient verbal numerical pain score (0-10) for comfort during surgical skin incision.

RESULTS

Forty women completed the study. The mean BMI (standard deviation) for the ultrasound group was 39.8 (5.5) kg/m² and for the palpation group 37.3 (5.2) kg/m². There was no difference in the composite primary outcome (median (interquartile range) [range]) between the ultrasound group (4 (2-13) [2-22]) and the (6 (4-10) [1-17]) palpation group (P=0.22), with the 95% confidence interval of the difference 2 (-1.7 to 5.7). There were no differences in the secondary outcomes.

CONCLUSIONS

Handheld ultrasound did not demonstrate any advantages over traditional palpation techniques for spinal anesthesia in an obese population undergoing cesarean delivery, although the study was underpowered to show a difference.

Peripartum anesthetic management of women with SARS-CoV-2 infection in eight medical centers across three European countries: prospective cohort observation study

OBJECTIVE

Several reports of obstetric anesthesia management have been published since the onset of the COVID-19 pandemic. We aimed to collect high-quality broad and detailed data from different university medical centers in several European Society of Anesthesiologist countries.

METHODS

This prospective observational survey was performed in eight medical centers in Spain, Israel and Portugal from 1^st April to 31^st July 2020. Institutional review board approval was received at each participating center. Inclusion criteria: all women with a positive test for COVID-19. Retrieved data included maternal, delivery, anesthetic, postpartum details, and neonatal outcomes. Descriptive data are presented, and outcomes were compared for women with versus without respiratory signs and symptoms.

RESULTS

Women with respiratory symptoms (20/12.1%) had significantly higher mean (standard deviation) temperature (37.2 °C (0.8) versus 36.8 °C (0.6)), were older (34.1 (6.7) years versus 30.5 (6.6)) and had higher body mass index kg m^-2 - (29.5 (7.5) versus 28.2 (5.1)). Women with respiratory symptoms delivered at a significantly earlier gestational age (50% < 37 weeks) with a 65% cesarean delivery rate (versus 22.1% in the group without respiratory symptoms) and 5-fold increased rate of emergency cesarean delivery, 30% performed under general anesthesia. A higher rate of intrauterine fetal death (3%) was observed than expected from the literature (0.2-0.3%) in developed countries. There was no evidence of viral vertical transmission.

CONCLUSION

Well-functioning neuraxial analgesia should be available to manage laboring women with respiratory symptoms, as there is a higher frequency of emergency cesarean delivery. We report a higher rate of undiagnosed parturient and intrauterine fetal death.

High level of satisfaction among women who underwent oocyte retrieval without anesthesia

OBJECTIVE

To assess the level of satisfaction of women undergoing transvaginal oocyte retrieval (TOR) without anesthesia as well as the comfort of the gynecologists.

DESIGN

Single-center, prospective cohort study of women undergoing TOR from July 2017 to January 2018.

SETTING

This study was conducted in an academic public hospital.

PATIENT(S)

Women with ≤15 follicles for retrieval were eligible. Women with body mass index > 35, difficult vaginal approach, endometrioma > 5 cm, or pelvic inflammatory disease were excluded.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Our primary endpoint was patient satisfaction. Secondary endpoints were women's willingness to recommend or undergo the procedure again without anesthesia, anxiety levels before the procedure, expected level of pain, actual pain levels during the procedure, and gynecologist's level of difficulty or technical compromise.

RESULT(S)

During the study period, 500 TORs were performed, of which 402 (80%) were screened for study eligibility. Overall, data were analyzed for 50 eligible women who had their first in vitro fertilization cycle (participating in the study) without anesthesia. High rates of satisfaction were reported, and 90% would recommend the procedure without anesthesia to their friends. Physicians graded the difficulty of the procedure as very easy in 35 procedures; in only two procedures was difficulty reported.

CONCLUSION(S)

TOR without anesthesia is feasible, with a relatively high satisfaction rate from both patients and gynecologists, suggesting that it should be considered in selected women.

Correlates of burnout among professionals working with people with intellectual and developmental disabilities

BACKGROUND

Although burnout has been recognised as an important stress-related problem among staff working with people with intellectual and developmental disabilities (IDD), literature on the subject is limited yet emerging. The aim of this study is twofold: (1) to evaluate the level of burnout within different professions working with IDD; (2) to examine the association between socio-demographic, professional and organisational characteristics and burnout.

METHOD

One hundred ninety-nine professionals working with people with IDD were enrolled in the study (66% response rate). Participants were recruited from several facilities that provide care for people with IDD of all ages, in the Jerusalem area and in other cities in central Israel. The anonymous questionnaires included valid and reliable measures of burnout, socio-demographic variables, professional variables and organisational variables.

RESULTS

Participants' mean age was 38.3 years, and most were women. There were no significant differences in burnout levels among the different professionals. Role ambiguity, perceived overload, care-recipient group and job involvement were significant predictors of burnout. The model explained a high percentage (46.8%) of the observed variance.

CONCLUSIONS

Most of these predictors are organisational measures. These findings demonstrate that organisational variables are more significantly associated with burnout of staff working with people with IDD than the socio-demographic factors or professional characteristics. Identifying and better understanding the specific factors associated with burnout among professionals working with IDD could facilitate unique intervention programs to reduce burnout levels in staff.