Background Pneumonia leading to acute respiratory distress syndrome (ARDS) is one of the devastating consequences of coronavirus disease 2019 (COVID-19). Airway pressure release ventilation (APRV) has been described as beneficial in acute lung injury and ARDS. We hypothesized that utilizing APRV would be advantageous in the COVID-19 ARDS population. Methods Prospective, observational, single-center study. Data were extracted on demographics, vasopressors, sedatives, analgesics, and oxygenation (PaO2/FiO2). A generalized linear mixed models analysis was performed to compare low tidal volume ventilation (LTV) with APRV for patients who required intubation due to ARDS from COVID-19 and who were managed with at least 48 consecutive hours of APRV in our surgical intensive care unit (SICU). Results Twelve patients met criteria; two were on APRV mode from admission to the SICU and were not included in the study. Ten patients were analyzed and were primarily male (70%), average age of 64.5 ± 12.9 years, and 70% were obese (average body mass index of 30.6 ± 8.0 kg/m2). There were no smokers in the sample, but two patients presented with underlying lung pathology. APRV was shown to significantly increase the PaO2/FiO2 ratio by 30% (5% to 61%) (p = 0.05) and was associated with up to a 12% (−26% to 5%) reduction in the level of FiO2 and reduction in the use of vasopressor support (−59% [−83% to −2%]), sedatives (−15% [−29% to 2%]), and analgesics (−16% [−38% to 12%]). Conclusions This pilot study showed that APRV was associated with decreases in FiO2, vasopressors, sedatives, and analgesic requirements with an increase in PaO2/FiO2 ratio. In the current pandemic, where providers are grappling with ways to manage COVID-19 ARDS, APRV may be the optimal ventilator mode. Prospective randomized studies are required to validate whether use of APRV in the COVID-19 population leads to improved oxygenation and a subsequent decrease of ventilator days and length of stay.
Sinking skin flap syndrome is a rare syndrome leading to increased intracranial pressure, known to neurosurgeons, yet uncommon and hardly ever reported in trauma patients. In a hospitalized trauma patient with declining neurological status, rarely do we encounter further deterioration by elevating the patients’ head, diuresis and hyperventilation. However, after craniectomy for trauma, a partially boneless cranium may be compressed by the higher atmospheric pressure, that intracranial pressure rises to dangerous levels. For such cases, paradoxical supportive management with intravenous fluid infusion, and reverse Trendelenburg positioning, is used to counteract the higher atmospheric pressure, as a bridge to definitive treatment with cranioplasty. These steps constitute an urgent and easily applied intervention to reduce further neurological deterioration, of which every trauma healthcare provider should be aware.
Highlights Hemodynamically stable gunshot wound patients may be managed without retrieval of the bullet. Nearly 90% of patients with cardiac bullet emboli on initial presentation are hemodynamically stable. Non-operative management of stable patients includes intensive observation and additional imaging to localize the bullet.
BACKGROUND: Suspension trauma syndrome is a life-threatening event that occurs when a person is "trapped" in a prolonged passive suspension. It is most commonly seen in people who engage in occupational or sport activities that require harness suspension. The aim of this study is to identify the predisposing factors, pathophysiology, and management of suspension trauma. METHODS:A review and analysis of the literature published in English and Spanish from 1972 to 2020 on suspension trauma were performed. Search sources were PubMed, Medline, Cochrane Library, MeSH, UpToDate, and Google Scholar. Articles referring to suspension trauma associated with other injury mechanisms (traumatic impact injuries, drowning, asphyxiation, or bleeding), case reports, and pediatric population were excluded.RESULTS: Forty-one articles were identified. Of these, 29 articles related to mechanism, pathophysiology, and management of individuals who suffered prolonged suspension trauma without associated traumatic injuries were included in the study. We encountered several controversies describing the putative pathophysiology, ranging from blood sequestration in the lower extremities versus accumulation of metabolic waste and hyperkalemia to dorsal hook-type harness as a trigger cause of positional asphyxia; to vascular compression of femoral vessels exerted by the harness causing decreased venous return. Pstients suspended in a full-body harness with dorsal hook showed more hemodynamic alterations in response to the compressive effect on the rib cage, causing a reduction in perfusion by presenting a decrease in pulse pressure. Management strategies varied across studies.CONCLUSIONS: Progress has been made in individualizing the population at risk and in the management of suspension trauma. We recommend the formation of consensus defi nitions, larger cohort or registry studies to be conducted, and experimental animal models to better understand the mechanisms in order to develop management and life support guidelines from a trauma and emergency medicine perspective.
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