Emergency medicine clinics of North America
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Capnography provides continuous, dynamic assessment of the ventilatory status of patients. Carbon dioxide physiology and the technology utilized in end-tidal carbon dioxide monitor devices are reviewed. ⋯ Current guidelines for use of capnography within emergency medicine are included. Potential future applications are also presented.
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Emerg. Med. Clin. North Am. · Nov 2008
ReviewChallenges and advances in intubation: rapid sequence intubation.
Rapid sequence intubation is the process involving administration of a sedative (eg, induction agent) followed almost immediately by a neuromuscular blocking agent to facilitate endotracheal intubation The purpose of emergency RSI is to make emergent intubation easier and safer, thereby increasing the success rate of intubation while decreasing the complications. Possible disadvantages are complications from the additional drugs, prolonged intubation with hypoxia, and precipitating an emergent or crash airway. Controversy has arisen regarding various steps in RSI; however, RSI remains the standard of care in emergency medicine airway management.
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Mechanical ventilation using high tidal volume (VT) and transpulmonary pressure can damage the lung, causing ventilator-induced lung injury. Permissive hypercapnia, a ventilatory strategy for acute respiratory failure in which the lungs are ventilated with a low inspiratory volume and pressure, has been accepted progressively in critical care for adult, pediatric, and neonatal patients requiring mechanical ventilation and is one of the central components of current protective ventilatory strategies.
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ECMO is an important tool to provide oxygen delivery and carbon dioxide removal in addition to cardiac support for patients with intractable reversible respiratory or cardiovascular collapse unresponsive to conventional treatment. Even though ECMO can be a life-saving modality, it is expensive and labor-intensive and carries a significant complication risk. Early recognition and prompt referral of patients who may benefit from ECMO in addition to careful patient selection, continuous communication between ECMO centers and their referral base, and meticulous care can improve the outcome of these critically ill patients who previously had no chance of survival.
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Needle cricothyrotomy with percutaneous translaryngeal ventilation (PTLV) can be a life-saving procedure when an emergency airway is needed. Needle cricothyrotomy is preferred over surgical cricothyrotomy in infants and young children. ⋯ Preliminary reports suggest that PTLV may be also useful in the endotracheal intubation of patients who have a difficult or failed airway and may help prevent aspiration, although further studies are needed. The emergency physician should be familiar with the indications, contraindications, complications, and procedure of this type of rescue airway, which is also used to ventilate patients during elective laryngeal surgery.