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Gender-affirming Care via HRT and Difficult Anesthetization, a Critical Care Transport Consideration 重症监护转运中的性别确认护理--HRT 和困难麻醉

Q3 Nursing

Air Medical Journal

Pub Date : 2024-06-17 DOI: 10.1016/j.amj.2024.05.025

Zane Z Grimm BSN, RN, PHRN, Chase J Canter BS, FP-C

Background

With gender-affirming care seeing an 11-fold, five year availability increase in some states, patients being prescribed hormone replacement therapy (HRT) have increased. Research from greater than five years ago finds that puberty suppression treatment or gender-affirming hormone therapy and anesthesia medicines have no instances of drug-drug interaction. This case study examines difficult anesthetization of a transgender female prescribed hormone replacement therapy.

Objective

We aim to examine the anesthesia requirements of a transgender, post cardiac arrest patient during interfacility critical care transport who is prescribed hormone replacement and steroid therapy for gender affirming care.

Methods

Case Study describing a transgender female and her requirement for an unusual amount of sedation and analgesia.

Results

The patient is a 56-year-old transgender female with a history of coronary artery disease, coronary vasospasm, ventricular tachycardia, internal defibrillator placement, hypertension and gender dysphoria who receives Progesterone and Estradiol Valerate (E2V). The patient experienced an in-hospital VT arrest, received ACLS medications, defibrillation, and intubation. ROSC was achieved and prior to CCT arrival, the patient received a total of 525mcg of fentanyl, 10mg of vecuronium, 11mg of midazolam, 1mg of Dilaudid, and a 150mcg/hr fentanyl infusion for post-intubation sedation. Following CCT arrival, the patient is conscious, obviously uncomfortable, and follows commands while still being ventilated as well as restrained to the hospital bed. IV patency is ensured. To achieve a RASS of -3/-4 and appropriate ventilator compliance, she required a total of 10mg of midazolam, 200mcg of fentanyl, and 345mg of ketamine, in less than 20 minutes. It is noted that this patient does not have a significant history of alcoholism, drug use, or any conditions that would increase metabolic demand. She has relatively unremarkable CMP, CBC, and blood gas values. The patient was successfully transported 30 minutes by ground to a cardiac ICU, requiring redosing of analgesia and initiation of an infusion of ketamine at 4mcg/kg/min. Upon moving the patient to the hospital bed at the receiving, she required additional PRN analgesia and sedation doses post-transfer of care.

Conclusion

With limited, dated research on the effects of anesthesia requirements of patients receiving HRT for gender-affirming care, further studies should evaluate the need for increased anesthesia requirements for patients receiving progesterone and E2V. Critical care transport providers should be aware of the possibility of difficult anesthetization within this population.

背景随着性别确认护理在一些州的可用性在五年内增长了 11 倍，被开具激素替代疗法（HRT）处方的患者也有所增加。五年多前的研究发现，青春期抑制治疗或性别确认激素疗法与麻醉药物之间没有药物相互作用。本病例研究探讨了变性女性接受激素替代治疗后的麻醉难题。目的我们旨在研究一名变性人、心脏骤停后患者在医院间重症监护转运过程中的麻醉要求，该患者接受了激素替代和类固醇治疗，以获得性别肯定护理。结果该患者是一名 56 岁的变性女性，有冠状动脉疾病、冠状动脉血管痉挛、室性心动过速、体内除颤器置入、高血压和性别焦虑症病史，接受黄体酮和戊酸雌二醇（E2V）治疗。患者发生院内 VT 骤停，接受了 ACLS 药物治疗、除颤和插管。在 CCT 到达之前，患者接受了总计 525 毫微克的芬太尼、10 毫克的维库溴铵、11 毫克的咪达唑仑、1 毫克的地劳迪，以及 150 毫微克/小时的芬太尼输注，用于插管后镇静。重症监护室到达后，病人意识清醒，明显感觉不舒服，并听从命令，但仍在通气，并被限制在病床上。确保静脉通畅。为了达到-3/-4的RASS值和适当的呼吸机顺应性，她在不到20分钟的时间内总共需要10毫克咪达唑仑、200毫克芬太尼和345毫克氯胺酮。据悉，该患者没有明显的酗酒史、吸毒史或任何会增加代谢需求的病史。她的 CMP、CBC 和血气值相对来说并不突出。经过 30 分钟的地面转运，患者被成功送入心脏重症监护室，需要重新注射镇痛剂，并开始输注氯胺酮，剂量为 4 毫克/千克/分钟。结论由于对接受 HRT 治疗的患者的麻醉需求影响的研究有限且已过时，进一步的研究应评估接受黄体酮和 E2V 治疗的患者是否需要增加麻醉需求。重症监护转运服务提供者应该意识到这一人群可能会出现麻醉困难的情况。

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引用次数: 0

Evaluation of a Performance Improvement Bundle to Achieve DASHH-1A Success 评估旨在实现 DASHH-1A 成功的绩效改进捆绑计划

Q3 Nursing

Air Medical Journal

Pub Date : 2024-06-17 DOI: 10.1016/j.amj.2024.05.017

Diana Deimling BSN, RN, CCRN, CEN, CFRN, NRP, Jacob A. Miller DNP, MBA, ACNP, ENP-C, CNS, NRP, FAEN, Anthony Braun MHA, BSN, RN, CFRN, CEN, NRP, Sally Mills DNP, RN, ACNP-BC, CPNP-AC, CCRN, Katherine Connelly MD, NRP, FP-C, Joshua Lambert PhD, MS, William R. Hinckley MD, FAAEM, CMTE, MTSP-C

Background

DASHH-1A is a quality metric used across HEMS and CCT programs to evaluate the safety and effectiveness of their airway management performance. The ability to achieve DASHH-1A success is multifactorial. This quality improvement project aimed to improve our program's DASHH-1A success rate.

Local problem

With excellent airway practitioners on our staff, we were perplexed as to why we did not meet the GAMUT achievable benchmark of care in DASHH-1A airway management. Our objective was to determine what may be impacting our success rates, both negatively and positively, to ultimately improve our DASHH-1A success rates.

Methods

Four investigators each reviewed a different patient population (interfacility trauma, interfacility medical, scene trauma, scene medical) to evaluate trends in their respective cohorts which may impact our DASHH-1A success. A brief literature review of current RSI practices was also conducted. Following these studies, we implemented a performance improvement plan and compared our adult DASHH-1A success rates for the 16 month periods pre- and post-intervention. All pediatric and crash airways were excluded.

Interventions

We revised our RSI protocol to include a bundle of care for all RSI airway attempts, which was then reviewed monthly at department CQI meetings. In addition to prior RSI mandates, we specified parameters to initiate additional airway, ventilation, and/or hemodynamic resuscitative efforts; mandated bag-mask ventilation during the period between paralytic administration and initiation of laryngoscopy; mandated use of a real-time, call-and-response RSI checklist; and implemented a standardized documentation template to capture those interventions performed.

Results

Pre-intervention DASHH-1A success rate was 63% (38/60 advanced airways). This improved to 72% (39/54 advanced airways) in the post-intervention period. This resulted in an improvement of our DASHH-1A success, with an absolute difference of 8.9% and a relative increase of 14%. A notable finding revealed that we had a 92% compliance rate with the utilization of our full DASHH-1A bundle.

Conclusions

The implementation of a DASHH-1A bundle of care had a high degree of compliance and was shown to improve our program's overall adult DASHH-1A success rate. A limitation of our study was our small sample size, n = 114 total patients. Recommendations for further studies would include a multi-center pre/post study to review similar programs’ DASHH-1A airway success.

背景DASHH-1A 是一项质量指标，适用于所有 HEMS 和 CCT 项目，用于评估其气道管理绩效的安全性和有效性。能否取得 DASHH-1A 成功取决于多个因素。本质量改进项目旨在提高我们项目的 DASHH-1A 成功率。当地问题我们拥有优秀的气道从业人员，但我们不明白为什么我们在 DASHH-1A 气道管理方面没有达到 GAMUT 可实现的护理基准。我们的目标是确定影响我们成功率的消极和积极因素，以最终提高我们的 DASHH-1A 成功率。方法四名调查人员分别审查了不同的患者群体（机构间创伤、机构间医疗、现场创伤、现场医疗），以评估各自群体中可能影响我们 DASHH-1A 成功率的趋势。我们还对当前的 RSI 实践进行了简要的文献回顾。根据这些研究，我们实施了绩效改进计划，并比较了干预前后 16 个月内成人 DASHH-1A 的成功率。我们修订了 RSI 协议，将所有 RSI 气道尝试的护理包纳入其中，然后每月在科室 CQI 会议上对其进行审查。除了之前的 RSI 规定外，我们还规定了启动额外气道、通气和/或血流动力学复苏工作的参数；规定在使用麻痹剂和开始喉镜检查之间的这段时间内使用袋罩通气；规定使用实时、呼叫和响应 RSI 核对表；并实施了标准化文档模板，以记录已执行的干预措施。干预后的成功率提高到 72%（39/54 个高级气道）。这使得我们的 DASHH-1A 成功率有所提高，绝对差异为 8.9%，相对差异为 14%。结论 DASH-1A 护理包的实施具有很高的依从性，并能提高我们项目的整体成人 DASH-1A 成功率。我们研究的局限性在于样本量较少（n = 114 名患者）。对进一步研究的建议包括开展多中心前后研究，回顾类似项目的 DASHH-1A 气道成功率。

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引用次数: 0

GAMUT Metric Implementation Improves Ventilator Documentation and Management Practices GAMUT 指标的实施改进了呼吸机文档和管理实践

Q3 Nursing

Air Medical Journal

Pub Date : 2024-06-17 DOI: 10.1016/j.amj.2024.05.019

Kellan Doberstein, Dr. Andrew Cathers, Dr. Craig Tschautscher, Dr. Ryan Newberry, Dr. Brittney Bernardoni

Background

It is well established that lung-protective ventilation strategies are imperative for reducing patient morbidity and mortality. Recognizing the importance of early lung-protective ventilation in the pre-hospital setting, the Ground and Air Medical qUality Transport (GAMUT) Quality Improvement Collaborative recently established a metric that aims to keep plateau pressure < 30 mmHg. GAMUT develops and tracks transport-specific quality metrics used by both domestic and international critical care transport (CCT) programs. The impact of GAMUT metric implementation on documentation practices and patient care in a CCT program remains unanswered.

Objectives

To determine if incorporation of the GAMUT metric, plateau pressure < 30 mmHg, changed the incidence of plateau pressure documentation or lung-protective ventilation.

Methods

This was a single center, retrospective cohort study of endotracheally intubated and mechanically ventilated adult patients transported by a university affiliated, physician/nurse-staffed CCT program between August 2021 and October 2022. Patients mechanically ventilated via an extraglottic airway and those under the age of 18 were excluded. Pre-GAMUT data was collected from August 2021 to January 2022 and post-GAMUT implementation data from May 2022 to October 2022. February 2022 to April 2022 was excluded from analysis as this was the initial education and implementation period. Data was extracted from the transport service chart by a trained data abstractor and recorded in an external database (REDCap). Statistical analysis was performed using a Pearson chi square for categorical variables and a two-sample t-test for continuous variables.

Results

Before implementation of the GAMUT metric, plateau pressure was documented in 11.8% of charts (n=22/187) compared to 69.4% (n=109/157) in post GAMUT charts (p < 0.0125). There was a statistically significant increase in the proportion of patients ventilated with both plateau pressure < 30 mmHg and driving pressure < 15 mmHg post GAMUT metric implementation (p < 0.0125 for both).

Conclusions

Our findings indicate that GAMUT metric implementation not only improved documentation of plateau pressure by nearly 6-fold, but also significantly increased the proportion of patients transported with lung-protective ventilation as evidenced by both lower plateau and driving pressures. Implementation of a GAMUT metric appears to improve both documentation practices and quality of patient care.

背景众所周知，肺保护性通气策略对于降低患者发病率和死亡率至关重要。认识到院前早期肺保护性通气的重要性，地面和空中医疗质量转运（GAMUT）质量改进合作组织最近制定了一项指标，旨在将高原压保持在 30 mmHg。GAMUT 制定并跟踪国内和国际重症监护转运 (CCT) 计划使用的特定转运质量指标。目标确定 GAMUT 指标（高原压 < 30 mmHg）的纳入是否改变了高原压记录或肺保护性通气的发生率。方法这是一项单中心、回顾性队列研究，研究对象为 2021 年 8 月至 2022 年 10 月间由大学附属、医生/护士参与的 CCT 项目转运的气管插管和机械通气成人患者。不包括通过声门外气道进行机械通气的患者和未满 18 岁的患者。2021 年 8 月至 2022 年 1 月收集了 GAMUT 实施前的数据，2022 年 5 月至 2022 年 10 月收集了 GAMUT 实施后的数据。由于 2022 年 2 月至 2022 年 4 月是教育和实施的初始阶段，因此不在分析之列。数据由经过培训的数据抽取员从运输服务图表中提取，并记录在外部数据库（REDCap）中。结果在实施 GAMUT 指标前，11.8% 的病历（n=22/187）记录有高原压，而在实施 GAMUT 后，69.4% 的病历（n=109/157）记录有高原压（p <0.0125）。结论我们的研究结果表明，GAMUT 标准的实施不仅将高原压的记录提高了近 6 倍，而且还显著提高了肺保护性通气患者的转运比例，这体现在较低的高原压和驱动压上。GAMUT 指标的实施似乎同时改善了记录方法和患者护理质量。

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引用次数: 0

High Fidelity Simulation as a Learning Tool: The Staff's Perspective 高仿真模拟作为一种学习工具：员工的视角

Q3 Nursing

Air Medical Journal

Pub Date : 2024-06-17 DOI: 10.1016/j.amj.2024.05.023

Leslie Rostedt MSN, BA, AAS, CCRN, CEN, Paramedic, Julius McAdams BME, PF-C, CCP-C, NRP, William F. Powers IV MD, FACS

Objective

To obtain the staff perspective regarding utilization of simulation principles incorporating prebriefing, video recorded simulation, and debriefing with guided reflection and self-evaluation.

Methods

A Likert survey was conducted pre- and post-simulation to obtain impressions before and evaluations after a simulation experience. Fifty-two critical care providers participated with the surveys during seventeen sessions in 2023. Responses were voluntary, results were anonymous. Prebriefing consisted of introduction to the simulator, video recording equipment, the recording process, monitoring equipment, and medical equipment. Objectives were reviewed prior to the simulation. The simulation targeted participant understanding and treatment traumatic brain injury. The debriefing process included video review with the participants utilizing protocols for self-evaluation of success with guided reflection. Compilation of data occurred after all sessions. The data specifically looked at comfort level with video recording, the ability to ask questions and receive constructive feedback, and the ability to analyze learner behaviors during the experience. In addition, learners were asked if they felt the experience was specific to their level and if they deemed it a tool that promoted learning.

Results

The results of the survey showed that the mean scores increased between pre-simulation and post-simulation at all data points. Video recording results demonstrated the most change. The mean score increased from 3.0 to 4.2, with decreased variability in responses after the experience. The mean increased in the ability to ask questions from 3.6 to 4.7, and the report on the constructive feedback mean changed similarly from 3.6 to 4.8. Variability for both was minimal in responses before and after the experience, focused on just two responses. Learners reported a mean score of 3.4 for the ability to analyze their behavior before, and 4.8 after the experience, with limited variability that centered on only two answers. The mean for specificity to the level of practice was reported to be 2.6 before the experience and 4.8 afterward, with responses centered around two responses. The mean for learning promotion increased from 3.5 to 4.8 from the pre-experience to post-experience with initial variability of three responses and post-experience of two responses.

Conclusions

Impressions to pre-Likert surveys were moderate. Concerns were specific to video recordings, especially whom had access. Only the specific participants would have access to the recording; only used for educational purposes, without impact on annual performance appraisal. Participants response to all questions noted overall increase in confidence in the post-simulation Likert. Anecdotal reports included appreciating review of the simulator capabilities and equipment before beginning the simulation and iso

方法在模拟前和模拟后进行李克特调查，以获得模拟体验前的印象和模拟体验后的评价。在 2023 年的 17 次培训中，52 名重症护理人员参与了调查。回答是自愿的，结果是匿名的。事前简报包括对模拟器、视频记录设备、记录过程、监控设备和医疗设备的介绍。模拟前对目标进行了回顾。模拟的目标是让参与者了解和治疗创伤性脑损伤。汇报过程包括与参与者一起回顾视频，利用协议对成功进行自我评估，并引导参与者进行反思。所有课程结束后都进行了数据汇总。这些数据具体考察了学员对视频录制的舒适度、提出问题和接受建设性反馈的能力，以及分析学员在体验过程中的行为的能力。此外，学习者还被问及他们是否觉得这种体验符合他们的水平，以及他们是否认为这种体验是一种促进学习的工具。结果调查结果显示，在所有数据点上，模拟前和模拟后的平均得分都有所提高。视频录制结果显示了最大的变化。平均分从 3.0 上升到 4.2，体验后的回答差异减少。提问能力的平均分从 3.6 提高到 4.7，建设性反馈报告的平均分同样从 3.6 提高到 4.8。在体验前后，这两个方面的差异都很小，仅集中在两个方面。学员在体验前对自己行为的分析能力平均得分为 3.4 分，体验后为 4.8 分，变化有限，仅集中在两个答案上。对于实践水平的具体性，体验前的平均值为 2.6 分，体验后为 4.8 分，答案集中在两个答案上。从体验前到体验后，学习促进的平均值从 3.5 增加到 4.8，最初有三个答案，体验后有两个答案。对录像的关注是特定的，尤其是谁可以接触到录像。只有特定的参与者才能接触到录像；录像仅用于教育目的，对年度绩效评估没有影响。参与者在回答所有问题时都指出，模拟后的 Likert 信心总体上有所增强。轶事报告包括在开始模拟前对模拟器功能和设备的审查以及视频隔离的赞赏。许多参与者注意到了超出目标预期的行为，包括泵的挑战和呼吸机屏幕的变化。这些调查的结果表明，参与者认为 "汇报前-模拟-汇报 "的过程非常有价值，而且适用于他们的学习和实践。这意味着模拟不仅是一种评估工具，也是一种学习过程，在知识、信心和能力之间架起了更多的桥梁。在为运输专业人员应用视频录像模拟方面，还需要进行更多的研究。未来的步骤包括将模拟项目扩展到多个服务项目。

{"title":"High Fidelity Simulation as a Learning Tool: The Staff's Perspective","authors":"Leslie Rostedt MSN, BA, AAS, CCRN, CEN, Paramedic, Julius McAdams BME, PF-C, CCP-C, NRP, William F. Powers IV MD, FACS","doi":"10.1016/j.amj.2024.05.023","DOIUrl":"https://doi.org/10.1016/j.amj.2024.05.023","url":null,"abstract":"<div><h3>Objective</h3><p>To obtain the staff perspective regarding utilization of simulation principles incorporating prebriefing, video recorded simulation, and debriefing with guided reflection and self-evaluation.</p></div><div><h3>Methods</h3><p>A Likert survey was conducted pre- and post-simulation to obtain impressions before and evaluations after a simulation experience. Fifty-two critical care providers participated with the surveys during seventeen sessions in 2023. Responses were voluntary, results were anonymous. Prebriefing consisted of introduction to the simulator, video recording equipment, the recording process, monitoring equipment, and medical equipment. Objectives were reviewed prior to the simulation. The simulation targeted participant understanding and treatment traumatic brain injury. The debriefing process included video review with the participants utilizing protocols for self-evaluation of success with guided reflection. Compilation of data occurred after all sessions. The data specifically looked at comfort level with video recording, the ability to ask questions and receive constructive feedback, and the ability to analyze learner behaviors during the experience. In addition, learners were asked if they felt the experience was specific to their level and if they deemed it a tool that promoted learning.</p></div><div><h3>Results</h3><p>The results of the survey showed that the mean scores increased between pre-simulation and post-simulation at all data points. Video recording results demonstrated the most change. The mean score increased from 3.0 to 4.2, with decreased variability in responses after the experience. The mean increased in the ability to ask questions from 3.6 to 4.7, and the report on the constructive feedback mean changed similarly from 3.6 to 4.8. Variability for both was minimal in responses before and after the experience, focused on just two responses. Learners reported a mean score of 3.4 for the ability to analyze their behavior before, and 4.8 after the experience, with limited variability that centered on only two answers. The mean for specificity to the level of practice was reported to be 2.6 before the experience and 4.8 afterward, with responses centered around two responses. The mean for learning promotion increased from 3.5 to 4.8 from the pre-experience to post-experience with initial variability of three responses and post-experience of two responses.</p></div><div><h3>Conclusions</h3><p>Impressions to pre-Likert surveys were moderate. Concerns were specific to video recordings, especially whom had access. Only the specific participants would have access to the recording; only used for educational purposes, without impact on annual performance appraisal. Participants response to all questions noted overall increase in confidence in the post-simulation Likert. Anecdotal reports included appreciating review of the simulator capabilities and equipment before beginning the simulation and iso","PeriodicalId":35737,"journal":{"name":"Air Medical Journal","volume":"43 4","pages":"Pages 367-368"},"PeriodicalIF":0.0,"publicationDate":"2024-06-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141424577","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 0

Air Transport Medicine: From the Field 航空运输医学研究评论

Q3 Nursing

Air Medical Journal

Pub Date : 2024-06-08 DOI: 10.1016/j.amj.2024.05.004

Ryan Newberry DO, MPH, Craig Tschautscher MD, Brittney Bernardoni MD, Andrew Cathers MD, James Price MBBS, Ed B.G. Barnard PhD

引用次数: 0

Electrolyte Disorders: Causes, Diagnosis, and Initial Care—Part 3 电解质紊乱：原因、诊断和初始护理--第 3 部分

Q3 Nursing

Air Medical Journal

Pub Date : 2024-06-08 DOI: 10.1016/j.amj.2024.05.007

Nicholas J. Larson BA, NREMT, Frederick B. Rogers MD, MS, MA, FACS, Jennifer L. Feeken MLIS, Benoit Blondeau MD, MBA, FACS, David J. Dries MD, MSE, FACS, MCCM

引用次数: 0

July/August 2024 Forum 2024 年 7 月/8 月论坛

Q3 Nursing

Air Medical Journal

Pub Date : 2024-06-04 DOI: 10.1016/j.amj.2024.05.009

引用次数: 0

REVA Air Ambulance and Seaplane Medevac Operations REVA 空中救护和水上飞机救护行动

Q3 Nursing

Air Medical Journal

Pub Date : 2024-05-09 DOI: 10.1016/j.amj.2024.03.017

Sean Bryan RN, BSN, MBA-HM

REVA, INC (Air Ambulance) is an Air Ambulance company headquartered in Fort Lauderdale, Florida. The company was formed in 2012 after the merger of two air ambulance companies, Aero Jet International and Air Ambulance Professionals. REVA completes around 1,300 medical transports a year, primarily international. It has always been a goal to provide more support to the Bahamas and hard to reach islands, which led to REVA launching its Seaplane Medevac Operation in December of 2022. The development of this program allows them to have a medical equipped seaplane available 365 days a year to service the Bahamas and hard to reach areas.

REVA公司（空中救护公司）是一家空中救护公司，总部位于佛罗里达州劳德代尔堡。公司成立于 2012 年，由两家空中救护公司 Aero Jet International 和 Air Ambulance Professionals 合并而成。REVA 每年完成约 1,300 次医疗转运，主要是国际转运。为巴哈马和难以到达的岛屿提供更多支持一直是 REVA 的目标，这促使其在 2022 年 12 月启动了水上飞机医疗后送行动。该计划的制定使他们能够拥有一架配备医疗设备的水上飞机，一年 365 天为巴哈马和难以到达的地区提供服务。

引用次数: 0

Management Considerations for Air Medical Transport Programs Transfusing RhD-Positive Red Blood Cell–Containing Products to Females of Childbearing Potential 为具有生育能力的女性输注 RhD 阳性含红细胞产品的空中医疗运送计划的管理注意事项

Q3 Nursing

Air Medical Journal

Pub Date : 2024-05-05 DOI: 10.1016/j.amj.2024.03.012

Michael P. McCartin MD , Geoffrey D. Wool MD, PhD , Sarah A. Thomas , Meaghan Panfil MSN, RN , David Schoenfeld MD , Ira J. Blumen MD , Katie L. Tataris MD, MPH , Stephen H. Thomas MD, MPH

Recent years have seen increased discussion surrounding the benefits of damage control resuscitation, prehospital transfusion (PHT) of blood products, and the use of whole blood over component therapy. Concurrent shortages of blood products with the desire to provide PHT during air medical transport have prompted reconsideration of the traditional approach of administering RhD-negative red cell–containing blood products first-line to females of childbearing potential (FCPs). Given that only 7% of the US population has blood type O negative and 38% has O positive, some programs may be limited to offering RhD-positive blood products to FCPs. Adopting the practice of giving RhD-positive blood products first-line to FCPs extends the benefits of PHT to such patients, but this practice does incur the risk of future hemolytic disease of the fetus and newborn (HDFN). Although the risk of future fetal mortality after an RhD-incompatible transfusion is estimated to be low in the setting of acute hemorrhage, the number of FCPs who are affected by this disease will increase as more air medical transport programs adopt this practice. The process of monitoring and managing HDFN can also be time intensive and costly regardless of the rates of fetal mortality. Air medical transport programs planning on performing PHT of RhD-positive red cell–containing products to FCPs should have a basic understanding of the pathophysiology, prevention, and management of hemolytic disease of the newborn before introducing this practice. Programs should additionally ensure there is a reliable process to notify receiving centers of potentially RhD-incompatible PHT because alloimmunization prophylaxis is time sensitive. Facilities receiving patients who have had PHT must be prepared to identify, counsel, and offer alloimmunization prophylaxis to these patients.

This review aims to provide air medical transport professionals with an understanding of the pathophysiology and management of HDFN and provide a template for the early management of FCPs who have received an RhD-positive red cell–containing PHT. This review also covers the initial workup and long-term anticipatory guidance that receiving trauma centers must provide to FCPs who have received RhD-positive red cell–containing PHT.

近年来，围绕损伤控制复苏的益处、院前输血（PHT）以及使用全血而非成分血治疗的讨论越来越多。由于血液制品的短缺以及在空中医疗运送过程中提供 PHT 的愿望，促使人们重新考虑为有生育能力的女性（FCPs）一线输注 RhD 阴性红细胞血液制品的传统方法。鉴于美国人口中只有 7% 的人血型为 O 阴性，38% 的人血型为 O 阳性，一些项目可能仅限于向 FCP 提供 RhD 阳性血液制品。向 FCPs 一线提供 RhD 阳性血液制品的做法可将 PHT 的益处扩大到此类患者，但这种做法会带来未来胎儿和新生儿溶血病（HDFN）的风险。虽然在急性大出血的情况下，RhD 不相容输血后胎儿未来死亡的风险估计很低，但随着越来越多的空中医疗运送项目采用这种做法，受这种疾病影响的 FCP 人数将会增加。无论胎儿死亡率如何，监测和管理 HDFN 的过程也会耗费大量时间和金钱。计划将 RhD 阳性的含红细胞产品 PHT 转运至 FCP 的空中医疗转运项目，应在引入此操作前对新生儿溶血病的病理生理学、预防和管理有基本的了解。此外，由于异体免疫预防具有时间敏感性，项目应确保有可靠的流程通知接收中心可能存在的 RhD 不兼容 PHT。本综述旨在让空中医疗运送专业人员了解 HDFN 的病理生理学和处理方法，并为接受过含 RhD 阳性红细胞 PHT 的 FCP 早期处理提供模板。本综述还包括接诊创伤中心必须为接受过含 RhD 阳性红细胞 PHT 的 FCP 提供的初步检查和长期预期指导。

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引用次数: 0

A Novel Technique for Temporally Securing a Chest Tube in a Resource-Limited Environment 在资源有限的环境中暂时固定胸管的新技术

Q3 Nursing

Air Medical Journal

Pub Date : 2024-05-04 DOI: 10.1016/j.amj.2024.03.010

Harmony Osborn MD , Aileen Newmyer MD , William Krebs DO, RDMS, EMT-P

In the prehospital, transport, and resource-limited setting, patients with traumatic hemothorax, pneumothorax, or cardiac arrest require emergency tube thoracostomy for stabilization and transport. With the possibility of multiple patients, limited providers, and inability to commit a 1:1 provider-to-patient ratio for safe tubeless thoracostomies, a chest tube is often the safest option. Mercy Health Life Flight Air Medical program has developed practice over decades using towel clamps and tape to achieve securement rapidly and reliably. We report on this subject as an option for temporarily securing a chest tube in the disaster, resource-poor, prehospital, or critical care transport setting.

在院前、转运和资源有限的环境中，创伤性血胸、气胸或心脏骤停患者需要进行紧急插管胸腔造口术以稳定病情和转运。由于可能有多名患者，医疗服务提供者有限，而且无法承诺医疗服务提供者与患者的比例为 1:1，以进行安全的无管胸腔造口术，因此胸腔插管通常是最安全的选择。数十年来，Mercy Health Life Flight 空中医疗项目使用毛巾夹和胶带快速、可靠地固定胸管，积累了丰富的实践经验。我们报告的主题是在灾难、资源匮乏、院前或重症监护转运环境中临时固定胸管的一种选择。

引用次数: 0

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