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Airway compromise is a leading cause of death in unconscious trauma patients. Although endotracheal intubation is regarded as the gold standard treatment, most prehospital providers are not trained to perform ETI in such patients. Therefore, various lateral positions are advocated for unconscious patients, but their use remains controversial in tra...
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Background
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Objective:
To evaluate the performance of a type III home sleep testing (HST) monitor including its autoscoring algorithm, in a population of obese pregnant women.
Methods:
This was an ancillary study of an ongoing prospective study of obese (BMI of ≥30) pregnant women. For the primary study, women undergo serial in-lab polysomnograms (PSG) duri...
Citations
... Intubation in the lateral position has been especially well studied [21][22][23][24]. A systematic review of different intubation positions in trauma patients suggests reduced airway patency in the supine position compared to the lateral position [25]. In a supine position, the mechanisms of upper airway obstruction include reduction of pharyngeal dilator muscle activity and gravitational effects on anterior upper airway structures [26]. ...
Background:
Tracheal intubation is a life-saving intervention, and optimizing the patient’s head and neck position for the best glottic view is a crucial step that accelerates the procedure. The left head rotation maneuver has been recently described as an innovative alternative to the traditional sniffing position used for tracheal intubation with marked improvement in glottic visualization.
Objective:
This study compared the glottic view and intubating conditions in the sniffing position versus left head rotation during direct laryngoscopy.
Methods:
This randomized, open-label clinical trial enrolled 52 adult patients admitted to Baguio General Hospital and Medical Center from September 2020 to January 2021 for an elective surgical procedure requiring tracheal intubation under general anesthesia. Intubation was done using a 45° left head rotation in the experimental group (n=26), while the control group (n=26) was intubated using the conventional sniffing position. Glottic visualization and intubation difficulty with the two procedures were assessed using the Cormack-Lehane grade and Intubation Difficulty Scale, respectively. Successful intubation is measured by observing a capnographic waveform in the end-tidal CO2 monitor after placement of the endotracheal tube.
Results:
There was no statistically significant difference in the Cormack-Lehane grade, with 85% (n=44) of patients classified under grades 1 (n=11 and n=15) and 2 (n=11 and n=7) in the left head rotation and sniffing position groups, respectively. In addition, there were no statistically significant differences in the Intubation Difficulty Scale scores of patients intubated with left head rotation or sniffing position; 30.7% (n=8) of patients in both groups were easily intubated, while 53.8% (n=14) in left head rotation and 57.6% (n=15) in sniffing position groups were intubated with slight difficulty. Similarly, there were no significant differences between the 2 techniques in any of the 7 parameters of the Intubation Difficulty Scale, although numerically fewer patients required the application of additional lifting force (n=7, 26.9% vs n=11, 42.3%) or laryngeal pressure (n=3, 11.5% vs n=7, 26.9%) when intubated with left head rotation. The intubation success rate with left head rotation was 92.3% versus 100% in the sniffing position, but this difference was not statistically significant.
Conclusions:
Left head rotation produces comparable laryngeal exposure and intubation ease to the conventional sniffing position. Therefore, left head rotation may be an alternative for patients who cannot be intubated in the sniffing position, especially in hospitals where advanced techniques such as video laryngoscopes and flexible bronchoscopes are unavailable, as is the case in this study. However, since our sample size was small, studies with a larger study population are warranted to establish the generalizability of our findings. In addition, we observed inadequate familiarity among anesthesiologists with the left head rotation technique, and the intubation success rate may improve as practitioners attain greater technical familiarization.
Trial Registration:
International Standard Randomised Controlled Trial Number (ISRCTN) ISRCTN23442026; https://www.isrctn.com/ISRCTN23442026
Interact J Med Res 2023;12:e42500
doi:10.2196/42500
... According to a systematic review of 24 randomized and non-randomized studies, the evidence supporting repositioning of the unconscious patient in the lateral decubitus position rather than in other decubitus positions is not of adequate quality to draw firm conclusions [38]. However, according to a meta-analysis of 16 studies, the supine decubitus position results in reduced respiratory capacity in unconscious patients, whereas the lateral decubitus position would be characterized by greater safety [39]. ...
Background
The aim of this document is to support clinical decision-making concerning positioning and mobilization of the critically ill patient in the early identification and resolution of risk factors (primary prevention) and in the early recognition of those most at risk (secondary prevention). The addresses of this document are physicians, nurses, physiotherapists, and other professionals involved in patient positioning in the intensive care unit (ICU).
Methods
A consensus pathway was followed using the Nominal Focus Group and the Delphi Technique, integrating a phase of focused group discussion online and with a pre-coded guide to an individual phase. A multidisciplinary advisory board composed by nine experts on the topic contributed to both the phases of the process, to reach a consensus on four clinical questions positioning and mobilization of the critically ill patient.
Results
The topics addressed by the clinical questions were the risks associated with obligatory positioning and therapeutic positions, the effective interventions in preventing pressure injuries, the appropriate instruments for screening for pressure injuries in the ICU, and the cost-effectiveness of preventive interventions relating to ICU positioning. A total of 27 statements addressing these clinical questions were produced by the panel. Among the statements, nine provided guidance on how to manage safely some specific patients’ positions, including the prone position; five suggested specific screening tools and patients’ factors to consider when assessing the individual risk of developing pressure injuries; five gave indications on mobilization and repositioning; and eight focused on the use of devices, such as positioners and preventive dressings.
Conclusions
The statements may represent a practical guidance for a broad public of healthcare professionals involved in the management of critically ill patients.
... Intubation in the lateral position has been especially well studied [21][22][23][24]. A systematic review of different intubation positions in trauma patients suggests reduced airway patency in the supine position compared to the lateral position [25]. In a supine position, the mechanisms of upper airway obstruction include reduction of pharyngeal dilator muscle activity and gravitational effects on anterior upper airway structures [26]. ...
Background:
Tracheal intubation is a life-saving intervention not only for physicians but also for allied health workers. Optimizing the patient's head and neck position for the best glottic view is a crucial step that accelerates tracheal intubation. The left head rotation maneuver has been recently described as an innovative approach to tracheal intubation with marked improvement in glottic visualization and can be an alternative before proceeding to a surgical airway.
Objective:
This study compared the glottic view and intubating conditions in the sniffing position versus left head rotation during direct laryngoscopy.
Methods:
This randomized, open-label clinical trial enrolled fifty-two adult patients admitted to the Baguio General Hospital & Medical Center from September 2020 to January 2021 for an elective surgical procedure requiring tracheal intubation under general anesthesia. Intubation was done using a 45-degree left head rotation in the experimental group (n=26), while the control group (n=26) was intubated using the conventional sniffing position. Glottic visualization and intubation difficulty with left head rotation and sniffing position were assessed using Cormack-Lehane Grade and Intubation Difficulty Scale, respectively. Successful intubation is measured by observing a capnographic waveform in the end-tidal CO2 monitor after placement of the endotracheal tube.
Results:
There was no significant statistical difference in the clinicodemographic characteristics between the left head rotation and sniffing position groups. There was no statistically significant difference in the Cormack-Lehane Grade, with 85% of patients classified under Grades 1 and 2 in both groups. Also, there were no statistically significant differences in the Intubation Difficulty Scale scores of patients intubated with left head rotation or sniffing position; 30.7% of patients in both groups were easily intubated, while 53.8% in left head rotation and 57.6% in sniffing position groups were intubated with slight difficulty. Similarly, there were no significant differences between the two techniques in any of the seven parameters of the Intubation Difficulty Scale, although numerically fewer patients required the application of additional lifting force [7 (26.9%) vs. 11 (42.3%)] or laryngeal pressure [3 (11.5%) vs. 7 (26.9%)] when intubated with left head rotation. The intubation success rate with left head rotation was 92.3% vs. 100% in the sniffing position, but this difference was not statistically significant.
Conclusions:
Left head rotation produces comparable laryngeal exposure and intubation ease to the conventional sniffing position. Therefore, left head rotation may be an alternative for patients who cannot be intubated in the sniffing position, especially in hospitals where advanced techniques such as video laryngoscopes and flexible bronchoscopes are unavailable, as is the case in this study. However, since our sample size was small, studies with a larger study population are warranted to establish the generalizability of our findings. In addition, we observed inadequate familiarity among anesthesiologists with the left head rotation technique, and the intubation success rate may improve as practitioners attain greater technical familiarization.
Clinicaltrial:
This trial was registered in the International Traditional Medicine Clinical Trial Registry (ISRCTN23442026).
... We found studies on PHC of patients with suspected TSCI consisting of SI, transport and movement, extrication, spinal clearance, airway protection and the role of prehospital providers. There were 42 studies selected for review based on the inclusion criteria: 18 articles regarding immobilization [6,[11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27], 12 articles regarding movement, positioning and transport [28][29][30][31][32][33][34][35][36][37][38][39], 4 articles regarding spinal clearance [40][41][42][43], 3 articles regarding airway protection [44][45][46] and 2 articles regarding the role of TSCI PHC providers [47,48]. Some articles covered two topics: one article regarding movement, positioning and transport and airway protection [49], and two other articles regarding spinal clearance and the role of TSCI PHC providers [7,50]. ...
... These patients are also at risk of airway obstruction [44]. Hyldmoetal's study demonstrated that the supine position worsens the airway condition in unconscious patients, and LTP improves airway expansion compared to the supine position [45]. ...
... It has therefore been recommended that the unconscious trauma patient be placed in a lateral position. LTP is a novel technique that minimizes the risk of airway obstruction and has been recommended for use in unconscious, non-intubated trauma patients [45,49]. Narrative review To present safe, rapid, and careful transport of the spinal injured patient to a medical facility Transport - ...
Purpose
To gain insight into current research regarding prehospital care (PHC) in patients with potential traumatic spinal cord injury (TSCI) and to disseminate the findings to the research community.
Methods
In March 2019, we performed a literature search of publications from January 1990 to March 2019 indexed in PubMed, gray literature including professional websites; and reference sections of selected articles for other relevant literature. This review was performed according to Arksey and O’Malley’s framework.
Results
There were 42 studies selected based on the inclusion criteria for review; 18 articles regarding immobilization; 12 articles regarding movement, positioning and transport; four for spinal clearance; three for airway protection; and two for the role of PHC providers. There were some articles that covered two topics: one article was regarding movement, positioning and transport and airway protection, and two were regarding spinal clearance and the role of PHC providers.
Conclusion
There was no uniform opinion about spinal immobilization of patients with suspected TSCI. The novel lateral trauma position and one of two High Arm IN Endangered Spine (HAINES) methods are preferred methods for unconscious patients. Controlled self-extrication for patients with stable hemodynamic status is recommended. Early and proper identifying of potential TSCI by PHC providers can significantly improve patients’ outcomes and can result in avoiding unwanted spinal immobilization. Future prospective studies with a large sample size in real-life settings are needed to provide clear and evidence-based data in PHC of patients with suspected TSCI.
... Previous studies reported on the usefulness of life-saving interventions in MCIs, such as control of exsanguinating hemorrhage, the recovery position [35,36] and the use of antidote-type medication with self-injector [20]. There is controversy over the recovery position for unconscious people; guidelines describe this intervention as useful in all unconscious injured people with spontaneous breathing [37,38], but recommend caution in injured people when spinal trauma is suspected. A study that compared the recovery position with the HAINES (High Arm IN Endangered Spine) technique [39] on cadavers did not reach evidence on which is the best version of the recovery position in injured people with cervical injuries [40]. ...
The use of drones for triage in mass-casualty incidents has recently emerged as a promising technology. However, there is no triage system specifically adapted to a remote usage. Our study aimed to develop a remote triage procedure using drones. The research was performed in three stages: literature review, the development of a remote triage algorithm using drones and evaluation of the algorithm by experts. Qualitative synthesis and the calculation of content validity ratios were done to achieve the Aerial Remote Triage System. This algorithm assesses (in this order): major bleeding, walking, consciousness and signs of life; and then classify the injured people into several priority categories: priority 1 (red), priority 2 (yellow), priority 3 (green) and priority * (violet). It includes the possibility to indicate save-living interventions to injured people and bystanders, like the compression of bleeding injuries or the adoption of the recovery position. The Aerial Remote Triage System may be a useful way to perform triage by drone in complex emergencies when it is difficult to access to the scene due to physical, chemical or biological risks.
... More research is needed to evaluate the effect of a side-lying recovery in a dental setting as it improves airway patency and the passive drainage of fluids. 16,57,58 Risk assessment by means of medical history taking (MRRH) was proven to be an ineffective prevention protocol in this review. 41 Nonetheless, recording medical history remains important as it points out risk factors for dental treatment. ...
Introduction
: This systematic review aimed to give an overview of the current evidence surrounding the aetiology and management in terms of treatment and prevention of syncope in dental practices. Alongside the occurrence, the practitioner's competence, and the association between syncope and local anaesthetics were discussed.
Methods
: An electronic search in EMBASE, Web of Science, PubMed, Cochrane databases and a hand search were performed by 2 independent reviewers to identify studies up to November 2019. Eligibility criteria were applied and relevant data was extracted. Inclusion criteria covered all types of dental treatment under local anaesthesia or conscious sedation performed by a wide range of oral health care workers in their practices. Risk of bias of the included studies was assessed using the methodological tools recommend by Zeng et al. ¹ No restrictions were made to exclude papers from qualitive analysis based on risk of bias assessment.
Results
: The search yielded a total of 18 studies for qualitative analysis. With the exception of one prospective cohort study, all articles were considered having a high risk of bias. Meta-analysis showed that dentists encountered on average 1.2 cases of syncope per year. The male gender (RR = 2.69 [1.03, 7.02]), dental fear (RR = 3.55 [2.22, 5.70]), refusal of local anaesthesia in non-acute situations (OR = 12.9) and the use of premedication (RR = 4.70, [1.30, 16.90]) increased the risk for syncope. Treatment and prevention were underreported as both were solely discussed in one study. The supine recovery position with raised legs and oxygen administration (15l/min) was presented as an effective treatment. The Medical Risk-Related History (MRRH) system was proposed as prevention protocol, yet this protocol was ineffective in reducing incidence rates (p = 0.27). The majority of dentists (79.2%) were able to diagnose syncope, yet most (86%) lacked the skills for appropriate treatment. Only 57,6% of dental practices were equipped with an oxygen cylinder.
Conclusions
: Syncope is the most common emergency in dental practices. Nonetheless, the vast majority of dentists do not seem competent nor prepared to manage this emergency. Psychogenic factors seem to play an important role in provoking syncope. Placing the patient in a supine reclined position with raised legs in combination with the administration of oxygen seems effective for regaining consciousness. Although valuable in many aspects, risk assessment by medical history taking is not proven to result in fewer episodes. The strength of these conclusions is low based on GRADE guidelines.
... Secondary insults result from movement, hypoxia, hypotension, and haematoma compressing the spinal cord. There are questions about the efficacy and safety of traditional spinal immobilisation for all trauma patients [149][150][151][152]. A more selective approach may be better [149,153,154]. ...
Background
Multiple trauma in mountain environments may be associated with increased morbidity and mortality compared to urban environments.
Objective
To provide evidence based guidance to assist rescuers in multiple trauma management in mountain environments.
Eligibility criteria
All articles published on or before September 30th 2019, in all languages, were included. Articles were searched with predefined search terms.
Sources of evidence
PubMed, Cochrane Database of Systematic Reviews and hand searching of relevant studies from the reference list of included articles.
Charting methods
Evidence was searched according to clinically relevant topics and PICO questions.
Results
Two-hundred forty-seven articles met the inclusion criteria. Recommendations were developed and graded according to the evidence-grading system of the American College of Chest Physicians. The manuscript was initially written and discussed by the coauthors. Then it was presented to ICAR MedCom in draft and again in final form for discussion and internal peer review. Finally, in a face-to-face discussion within ICAR MedCom consensus was reached on October 11th 2019, at the ICAR fall meeting in Zakopane, Poland.
Conclusions
Multiple trauma management in mountain environments can be demanding. Safety of the rescuers and the victim has priority. A crABCDE approach, with haemorrhage control first, is central, followed by basic first aid, splinting, immobilisation, analgesia, and insulation. Time for on-site medical treatment must be balanced against the need for rapid transfer to a trauma centre and should be as short as possible. Reduced on-scene times may be achieved with helicopter rescue. Advanced diagnostics (e.g. ultrasound) may be used and treatment continued during transport.
... ; https://doi.org/10.1101/2020.11.13.20230979 doi: medRxiv preprint position in patients with cervical injuries [35]. The systematic review conducted by Hyldmo et al. [36], provides evidence that unconscious victims with trauma should be placed in the recovery position. Mesar et al. [37] proposed to send tourniquets, dressings or painkillers. ...
The use of drones for the triage of victims in mass-casualty incidents has recently emerged as a promising technology. However, there is not a triage system really adapted to a remote usage. The objective of our study was to develop a remote triage procedure using drones. The research was performed in three stages: literature review, development of a remote triage algorithm using drones and evaluation of the algorithm by experts. A qualitative synthesis and the calculation of content validity ratios were done to achieve the Aerial Remote Triage System. The system assesses first major bleeding, second walking, third conscious (awake) and fourth sign of life; and classify the victims inside priority categories: priority 1 (red), priority 2 (yellow), priority 3 (green) and priority * (violet). It includes the possibility to indicate save-living interventions to victims and bystanders, like the compression of bleeding injuries or the recovery position. The Aerial Remote Triage System is valid in complex health emergencies when it is difficult or impossible an immediate access to the scene due to physical, chemical or biological risks. It can be useful to know vital information about the emergencies.
... With respect to the transportation of unconscious, non-intubated trauma patients, our group supports the use of the novel lateral trauma position (LTP) or other positioning maneuvers like the HAINES-maneuver (high-arm-IN-endangeredspine) for time-critical spinal stabilisation. This is in line with previous studies, which suggest that these maneuvers do not produce more movement in the unstable spine than the traditional log-rolling maneuver [67][68][69][70]. ...
Abstract Traumatic spinal cord injury is a relatively rare injury in Denmark but may result in serious neurological consequences. For decades, prehospital spinal stabilisation with a rigid cervical collar and a hard backboard has been considered to be the most appropriate procedure to prevent secondary spinal cord injuries during patient transportation. However, the procedure has been questioned in recent years, due to the lack of high-quality studies supporting its efficacy. A national interdisciplinary task force was therefore established to provide updated clinical guidelines on prehospital procedures for spinal stabilisation of adult trauma patients in Denmark. The guidelines are based on a systematic review of the literature and grading of the evidence, in addition to a standardised consensus process. This process yielded five main recommendations: A strong recommendation against spinal stabilisation of patients with isolated penetrating trauma; a weak recommendation against the prehospital use of a rigid cervical collar and a hard backboard for ABCDE-stable patients; and a weak recommendation for the use of a vacuum mattress for patient transportation. Finally, our group recommends the use of our clinical algorithm to ensure good clinical practice.
... Those principles were introduced with the Prehospital Trauma Life Support (PHTLS) guidelines [5] and have dominated the field of prehospital trauma care for decades. Nevertheless, focus has shifted towards possible negative effects caused by immobilizing patients, particularly a possible increase in intracranial pressure by applying a rigid neck collar to patients with a traumatic brain injury [6][7][8] and reduced airway patency caused by being strapped on a rigid spine board in the supine position [9]. These potential negative consequences resulted in divergent procedures for prehospital management of this patient group in Norway. ...
Background:
A debate regarding the potential harmful effects of rigid neck collar and backboard usage among prehospital and hospital care providers in Norway provoked the development of an evidence-based guideline. "The Norwegian guideline for the prehospital management of adult trauma patients with potential spinal injury" was developed with rigorous scientific methods and published in 2016. An e-learning course was developed in parallel. The aim of this study is to explore whether emergency medical services personnel in Norway have implemented the guideline, and to what extent the e-learning course was applied during the implementation process.
Method:
An electronic survey was distributed individually to registered prehospital personnel in Norway 18 months after publication of the guideline.
Results:
In all, 938 of 5500 (17%) EMS personnel responded to the survey. More than one-half confirmed knowledge of the guideline; among these, 56% claimed that the guideline was implemented in the service they work. Not having responded to trauma cases in real life was the main reason for not having executed the guideline. The e-learning course had been completed by 18% of respondents.
Conclusion:
Although the guideline has not been authorized or made compulsory by national authorities, one-half of respondents with knowledge of the guideline reported it as implemented. E-learning did not seem to have affected the implementation. The guideline was developed based on perceived needs among care providers, and this probably facilitated implementation of the guideline.
