Emergency medicine clinics of North America
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Emerg. Med. Clin. North Am. · Aug 2022
ReviewAirway Pressure Release Ventilation: A Field Guide for the Emergency Physician.
Airway pressure release ventilation (APRV) is a mode of ventilation that uses high airway pressures to recruit and maintain patients' lung volumes. The goal of this mode of ventilation is 2-fold: first, to maintain patients as close to their functional residual capacity as possible and second, to promote safe spontaneous breathing. ⋯ Eventually, patients are able to fully support their ventilatory needs and no longer require any release breaths to maintain normal CO2 levels. Now, patients can be "stretched" to CPAP.
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Emergency clinicians are tasked with managing a variety of patients with acute deformities. One of the most acute situations management of the patient who presents with an airway emergency. ⋯ In some cases, challenging anatomic issues can be predicted before beginning laryngoscopy, but in many situations, prediction models fall short. It is critically important for emergency clinicians to anticipate anatomic issues in all airways and to have premeditated strategies for managing them.
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Right ventricular dysfunction is an important component of the pathophysiology of several disorders commonly encountered in the emergency department (ED). Interventions often performed routinely early in the ED course such as fluid administration and endotracheal intubation have the potential to cause precipitous clinical deterioration in patients with right ventricular failure and pulmonary hypertension. It is important for emergency physicians to understand the pathophysiology of acute decompensated right ventricular failure in order to avoid common pitfalls in diagnosis and management that can result in significant morbidity and mortality.
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This article explains the physiologic basis and fundamentals behind the technology of continuous positive airway pressure, bilevel positive airway pressure, and high flow nasal canula. Additionally, it explores some of the core literature behind their clinical applications. It will also compare HFNC with other noninvasive modalities for respiratory failure alongside clinical titration and weaning algorithms in the emergency department setting.
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Emergency physicians intubate critically ill patients almost daily. Intubation of the critically ill emergency department (ED) patient is a high-risk, high-stress situation, as many have physiologic derangements such as hypotension, hypoxemia, acidosis, and right ventricular dysfunction that markedly increase the risk of peri-intubation cardiovascular collapse and cardiac arrest. This chapter discusses critical pearls and pitfalls to intubate the critically ill ED patient with physiologic derangements. These pearls and pitfalls include appropriate preoxygenation; circulatory resuscitation; proper patient position and room setup; selection of medications for rapid sequence intubation; and intubation of patients with severe acidosis, traumatic brain injury, and pulmonary hypertension.