Extubating trauma patients in the emergency department

BACKGROUND

Trauma patients often require endotracheal intubation for urgent or emergent airway protection or to allow expeditious imaging when they cannot cooperate with the needed evaluation. These patients may occasionally be extubated in the emergency department (ED) when the trauma workup is negative for consequential injuries and eventually discharged from the ED. The timing and safety of discharging these patients is unclear.

OBJECTIVE

The objective of this study was to identify the adverse outcomes and evaluate the safety of extubating trauma patients who are clinically well following evaluation in the ED.

METHODS

Records of trauma patients who were intubated and then extubated in the ED at a single level 1 trauma referral center during the 4-year study period (Jan 2014 - Dec 2017) were retrospectively abstracted. The primary outcome was the incidence of a post-extubation complication, including desaturation, emesis, aspiration, need for sedative administration, or unplanned reintubation. Additional outcome measures included final disposition, duration of observation following extubation, ED length of stay and return to the hospital within 72 h.

RESULTS

There were 59 eligible patients identified over the study period, of whom 95% presented following blunt trauma. One patient (1.7%; 95% confidence interval 0-9) required unplanned reintubation and developed aspiration pneumonia following re-extubation. Forty-two (71%) of the patients were discharged from the ED following extubation and a period of post-extubation observation with a mean of 5.8 h (0.6-16.7 h). None of the patients who were discharged returned to the ED within 72 h with complications related to extubation (0%; 95% confidence interval 0-6%).

CONCLUSIONS

Patients presenting to the ED with possible acute traumatic injuries who are intubated and then extubated after trauma evaluation and resolution of the indication for intubation appear to have a low incidence of complication or return visit when discharged from the ED after a brief period of observation. Specific extubation and discharge criteria should be developed to ensure the safety of this practice. Further validation is required in the form of larger and prospective studies.

The effects of airway pressure release ventilation on respiratory mechanics in extrapulmonary lung injury

BACKGROUND

Lung injury is often studied without consideration for pathologic changes in the chest wall. In order to reduce the incidence of lung injury using preemptive mechanical ventilation, it is important to recognize the influence of altered chest wall mechanics on disease pathogenesis. In this study, we hypothesize that airway pressure release ventilation (APRV) may be able to reduce the chest wall elastance associated with an extrapulmonary lung injury model as compared with low tidal volume (LVt) ventilation.

METHODS

Female Yorkshire pigs were anesthetized and instrumented. Fecal peritonitis was established, and the superior mesenteric artery was clamped for 30 min to induce an ischemia/reperfusion injury. Immediately following injury, pigs were randomized into (1) LVt (n = 3), positive end-expiratory pressure (PEEP) 5 cmH2O, V t 6 cc kg(-1), FiO2 21 %, and guided by the ARDSnet protocol or (2) APRV (n = 3), P High 16-22 cmH2O, P Low 0 cmH2O, T High 4.5 s, T Low set to terminate the peak expiratory flow at 75 %, and FiO2 21 %. Pigs were monitored continuously for 48 h. Lung samples and bronchoalveolar lavage fluid were collected at necropsy.

RESULTS

LVt resulted in mild acute respiratory distress syndrome (ARDS) (PaO2/FiO2 = 226.2 ± 17.1 mmHg) whereas APRV prevented ARDS (PaO2/FiO2 = 465.7 ± 66.5 mmHg; p < 0.05). LVt had a reduced surfactant protein A concentration and increased histologic injury as compared with APRV. The plateau pressure in APRV (34.3 ± 0.9 cmH2O) was significantly greater than LVt (22.2 ± 2.0 cmH2O; p < 0.05) yet transpulmonary pressure between groups was similar (p > 0.05). This was because the pleural pressure was significantly lower in LVt (7.6 ± 0.5 cmH2O) as compared with APRV (17.4 ± 3.5 cmH2O; p < 0.05). Finally, the elastance of the lung, chest wall, and respiratory system were all significantly greater in LVt as compared with APRV (all p < 0.05).

CONCLUSIONS

APRV preserved surfactant and lung architecture and maintenance of oxygenation. Despite the greater plateau pressure and tidal volumes in the APRV group, the transpulmonary pressure was similar to that of LVt. Thus, the majority of the plateau pressure in the APRV group was distributed as pleural pressure in this extrapulmonary lung injury model. APRV maintained a normal lung elastance and an open, homogeneously ventilated lung without increasing lung stress.

Targets and elective colorectal cancer: outcome and symptom delay at surgical resection

OBJECTIVE

To determine, for elective patients with colorectal cancer, if associations exist between the length of symptom history at surgical resection and Dukes stage, completeness of the surgical procedure and patient survival.

PATIENTS AND METHODS

A prospective cohort study was undertaken. Five hundred and eighty-two patients with colorectal cancer, admitted for surgical resection after outpatient consultation, divided into four equal quartiles according to length of symptom history (short: n = 131, 0-103 days; medium: n = 136, 104-177 days; long: n = 136, 178-318 days; very long: n = 137, 319-1997 days). The main outcome measures used were the Extent of tumour (Dukes stage) at resection, completeness of resectional surgery (curative vs palliative), patient survival after resection.

RESULTS

For patients undergoing elective surgical resection of colorectal cancer we did not find an association between Dukes stage and duration of patient history (Dukes stage C tumours were seen in 37% (CI: 26.2%-48.0%) of patients with a short symptomatic history as opposed to 34% (CI: 32%-62%) with a very long symptomatic history). Elective curative resection was not associated with a significantly different symptom duration than elective palliative resection (Palliative resections were performed in 24% (CI: 11.7%-36.4%) of patients with a short symptomatic history as opposed to 16% (CI: 2.4%-29.9%) with a very long symptomatic history). The median survival time for the four elective colorectal patient groups defined by length of symptomatic history was not significantly different - (short: n = 131, 4.3 years; medium: n = 136, 5.9 years; long: n = 136, 7.1 years; very long: n = 137, 5.0 years).

CONCLUSION

Tumour extent, completeness of resection and patient outcome after elective colorectal cancer resection was not found to have an association with length of patient history at the time of surgery.

Realities of developing community health orientation programs

The realities of developing an orientation program include recognizing the critical influence of organizational culture and management priorities on the final form of plans and projects. The step from theory to practice is illustrated in the experience of three of the authors as they began to implement competency-based orientation programs. The common experiences of these three very different agencies were that programs are affected by organizational readiness, evolution to meet organizational needs, and the administrative context.

A model skills list for orienting nurses to community health agencies

Nurse managers in community health can streamline the orientation of new employees by building planning and evaluation on a list of nursing skills that meet requirements for beginning practice. A model list of skills required in public health nursing and home health care can guide individual agencies in tailoring orientation programs to their respective needs, streamlining the process, reducing overall costs, and producing long-term benefits for nurse managers and nursing staff.

Making the fit: orienting new employees to community health nursing agencies

Community health nurse managers require tested orientation methods to fit new employees into the rapidly changing conditions of professional practice, increase nursing productivity, and reduce turnover. The clinical competencies for community health nursing provide a workable framework for applying orientation principles to the special demands of community health nursing.

Clinical competencies for community health nursing

Cost-containment strategies initiated in the early 1980s caused a major shift in site of care delivery for persons needing nursing care. Where once the majority of clients were cared for in the acute-care setting until they were self-sufficient, now most are discharged to the home environment still requiring acute-care nursing interventions as well as community health nursing skills. This rapid shift in practice sites has placed severe strain on community health nursing agencies. Not only are more nurses required to fill the increased demand for services, but the demand comes at a time when we are experiencing a severe nursing shortage. This has forced many agencies to hire acute care nurses who have little or no community health nursing experience. These nurses come to community health nursing expecting to use the same set of skills and knowledge base used in their acute-care practice; however, the skill levels and concepts required for community health nursing are quite different from the acute care setting. Educational preparation has not kept pace with this shift in practice. Consequently, many nurses are not adequately prepared to enter community health nursing. Preparation must include theoretical and experiential components that focus on assessment skills (of the community and individual), decision making, case management, health systems management, teaching, and leadership. Collaborative efforts between community health organizations and educational institutions would seem to be one solution that would ensure adequately prepared nurses for community health nursing. The establishment and maintenance of strong staff-development programs within community health nursing agencies are also required.

Home health services in a climate of cost containment

A survey of medicare certified agencies in the Northwest Region conducted to identify clinical problems of patients and families resulting from early discharge from hospitals revealed many concerns related to health care delivery. Major areas of concern were: Home Care and Community Services; Reimbursement and Funding; Rules and Regulations; Continuity of Care; Quality of Care; and Legal and Ethical Issues. Specific problems in each of the categories are discussed and strategies that home health agencies may utilize in addressing these areas are presented.