喉罩在院前急救中的应用

目的 探讨喉罩(LMA)在院前急救中应用的简易性和有效性.方法 对院前发生心跳呼吸骤停的患者84例,根据CPR时对患者建立人工气道的不同措施,将其分为2组进行回顾性对比.A组47例,常规CPR时即盲插喉罩通气;B组37例,常规CPR时即行气管内插管.结果 一次插管成功率:A组盲探下插入喉罩全部一次成功,成功率100%;B组插管,一次成功26例,两次成功8例,三次以上成功4例,一次插管成功率70%.两组相比有显著性差异(P＜0.01).插管时间:A组(10.4±7.5)s,B组(96±25.7)s,两组相比有显著性差异(P＜0.01).有效通气效果评定:两组比较无显著性差异(P＞0.05).结论 在院前心肺复苏时,早期盲插喉罩通气具有操作快捷、可盲探插管且成功率高、能够保证有效通气和提高抢救成功率的优点,值得在院前急救中推广使用.     

喉罩在院前急救中的应用

目的探讨喉罩（LMA）在院前急救中应用的简易性和有效性。方法对院前发生心跳呼吸骤停的患者84例,根据CPR时对患者建立人工气道的不同措施,将其分为2组进行回顾性对比。A组47例,常规CPR时即盲插喉罩通气;B组37例,常规CPR时即行气管内插管。结果一次插管成功率：A组盲探下插入喉罩全部一次成功,成功率100％;B组插管,一次成功26例,两次成功8例,三次以上成功4例,一次插管成功率70％。两组相比有显著性差异（P〈0．01）。插管时间：A组（10．4±7．5）s,B组（96±25．7）s,两组相比有显著性差异（P〈0．01）。有效通气效果评定：两组比较元显著性差异（P〉0．05）。结论在院前心肺复苏时,早期盲插喉罩通气具有操作快捷、可盲探插管且成功率高、能够保证有效通气和提高抢救成功率的优点,值得在院前急救中推广使用。     

喉罩替代气管插管在心肺复苏中的临床应用

目的探讨心肺复苏(CPR)时盲插喉罩通气对复苏成功率的影响。方法将我科2003-06~2007-05所接诊的心跳骤停患者51例作为观察组,应用盲插喉罩通气;另选同期所接诊的心跳骤停患者46例作为对照组,应用气管内插管通气。结果插管所需时间:观察组(28.1±12.6)s;对照组(130±56)s,两组比较差异有统计学意义(P<0.001)。一次插管成功率:观察组盲探下插入喉罩一次成功47例(成功率92%);对照组气管内插管一次成功19例(成功率41.3%),两组比较差异有统计学意义(P<0.01)。复苏成功率:观察组复苏成功25例(成功率49%);对照组复苏成功12例(成功率26%),两组比较差异有统计学意义(P<0.01)。结论在CPR时,盲插喉罩通气具有操作简便、迅速、复苏成功率高的优点,可以代替气管内插管。     

紧急气管插管在特殊情况心肺复苏中的临床应用

目的:探讨紧急气管插管在重型颅脑外伤、中毒、淹溺、自缢、异物窒息等特殊情况下院前心肺复苏(CPR)中临床应用的必要性、可行性,以提高急救水平.方法:对院前因重型颅脑外伤、中毒、淹溺、自缢、异物窒息等特殊情况导致心跳呼吸骤停患者48例根据CPR时先行建立人工气道的不同措施将其分为两组,院前CPR时先行紧急气管插管(A组,n=40);院前CPR时先行肓探置人喉罩(B组,n=8).结果:A组现场发现不同程度气道阻塞31例,全部插管成功,插管时间均少于2 min,通气良好,复苏成功28例;B组现场先行盲探置入喉罩,但通气不良,均改行紧急气管插管,发现8例均有不同程度气道阻塞,全部插管成功,插管时间均少于2 min,通气良好,复苏成功2例;A组复苏成功率明显高于B组(P<0.05).结论:在重型颅脑外伤、中毒、淹溺、自缢、异物窒息等特殊情况下院前心肺复苏抢救中,紧急气管插管仍是无可替代的建立人工气道首选方法.     

插管型喉罩与常规复苏面罩在院前急救中应用的效果比较

目的探讨2种不同气道建立方式对院前心搏骤停患者通气效果的影响。方法将60例院前急救心搏骤停患者按使用喉罩通气、面罩通气分为两组。A组30例在心脏按压的同时予喉罩置入辅助通气,B组30例给予心脏按压的同时予常规复苏面罩辅助通气。比较两组患者气道装置放置成功时间、呼末二氧化碳值、自主循环恢复率等指标。结果面罩通气建立气道用时短,喉罩通气建立气道用时较长;心脏按压2min、5min呼末二氧化碳值A组高于B组;自主循环恢复率A组高于B组。结论在院前心肺复苏时,早期盲插喉罩通气有利于提高气道通气质量。     

喉罩通气道与气管内插管在急救复苏中重建有效通气道的对比研究

目的检测喉罩通气道用于急救复苏中重建有效通气道的优越性.方法L组20例系各种因素导致呼吸衰竭或呼吸停止的患者,选择合适3～4型号的喉罩盲探插入正确位置,进行控制呼吸.E组20例手术麻醉患者,在静脉快诱导明视下行气管内插管机械通气,观察2组插管困难程度、插管成功次数、插管时间、插管后PetCO2波形、气道顺应性、SPO2、胸廓起伏状况、双肺呼吸音.结果L组盲探下插管全部1次成功,E组诱导明视下插管1次成功16例,3次以上4例.插管时间L组全部在30s内完成,E组在30s内完成16例,其余长达1min30s～3min20s(P＜0.05),相比差异有显著性.插管后两组气道顺应性,PetCO2、SPO2、双肺呼吸音判断导管位置均正确无误.结论应用喉罩通气道于急救复苏,与使用喉镜明视下快诱导行气管内插管相比,具有体位要求不高,操作简单,可盲探插管,为抢救此类患者赢得宝贵的抢救时间.     

喉罩通气在急诊心肺复苏中的应用

目的：探讨喉罩在急诊心肺复苏中的优越性及安全性。方法：将心搏、呼吸骤停患者70例按随机原则选取复苏程序,分为对照组和观察组。对照组采用传统的面罩加压给氧,待麻醉师到场后改用气管内插管,而观察组选用第三代便捷盲插喉罩（LMA-ProSeal喉罩）建立人工气道。结果：SpO2上升时间观察组为（128.8±36.7）s,对照组为（260.1±41.6）s,观察组明显短于对照组（P〈0.05）;喉罩一次置入成功率观察组为98.9%,对照组为71.4%,观察组高于对照组的气管内插管,且置入所花费时间明显较对照组短（P〈0.05）;观察组的复苏成功率与对照组相似（P〉0.05）。结论：喉罩通气在重建人工气道时,具有置入快捷方便、连接准确可靠的优势,值得在急诊急救中推广使用。     

不同方式气管插管的疗效比较

[目的]为临床急救工作探索便捷、实用的人工通气方法,以提高急救抢救成功率.[方法]对呼吸科58例急救气管插管者, 随机分为3组:A 组21例,B组18例,C组19例,分别采用经喉罩气管插管、经喉镜气管插管、经纤维支气管镜气管插管术.[结果]在1次插管成功例数上,A组1次成功20例(95.24%),B组14例(77.77%),C组18例(94.73%),A组、C组分别与B组比较,差异均有统计学意义(P<0.05).在1次成功平均时间上A组与B组、B组与C组、A组与C组比较,差异均有统计学意义(P<0.01).[结论]经喉罩气管插管简易、可靠,值得临床推广.     

翻转法置入PLMA在小儿心肺复苏中的应用

目的:翻转法置入小儿ProSeal喉罩在心肺复苏中的应用效果。方法:80例CPR过程中需插入食管引流型喉罩(PLMA)的小儿随机分为翻转组(R组)和标准组(S组)两组,对成功置入喉罩时间、置入次数、变换置入方法次数及喉罩漏气,喉罩反折,罩体带血,操作者手指痛感等不良反应和CPR成功率进行比较。结果:R组喉罩置入时间明显短于S组(P<0.05),置入一次成功率明显高于S组(P<0.05),R组操作者手指痛感明显少于S组(P<0.05),CPR成功率R组心肺复苏成功23例(57.5%)明显高于S组15例(37.5%)(P<0.05)。结论:小儿ProSeal喉罩翻转置入法操作快速安全有效,提高抢救成功率。     

不同方式气管插管的疗效比较

[目的]为临床急救工作探索便捷、实用的人工通气方法,以提高急救抢救成功率。[方法]对呼吸科58例急救气管插管者,随机分为3组：A组21例,B组18例,C组19例,分别采用经喉罩气管插管、经喉镜气管插管、经纤维支气管镜气管插管术。[结果]在1次插管成功例数上,A组1次成功20例（95.24%）,B组14例（77.77%）,C组18例（94.73%）,A组、C组分别与B组比较,差异均有统计学意义（P〈0.05）。在1次成功平均时间上A组与B组、B组与C组、A组与C组比较,差异均有统计学意义（P〈0.01）。[结论]经喉罩气管插管简易、可靠,值得临床推广。     

Guns and Knives in New Mexico: Patterns of Penetrating Trauma, 1978–1993

Objective: To identify patterns of nonfatal and fatal penetrating trauma among children and adults in New Mexico using ED and medical examiner data.
Methods: The authors retrospectively sampled in 5-year intervals all victims of penetrating trauma who presented to either the state Level-1 trauma center or the state medical examiner from a 16-year period (1978–1993). Rates of nonfatal and fatal firearm and stabbing injury were compared for children and adults.
Results: Rates of nonfatal injury were similar (firearm, 34.3 per 100,000 person-years; stabbing, 35.1). However, rates of fatal injury were significantly different (firearm, 21.9; stabbing, 2.7; relative risk: 8.2; 95% confidence interval: 5.4, 12.5). From 1978 to 1993, nonfatal injury rates increased for children (p = 0.0043) and adults (p < 0.0001), while fatal penetrating injury remained constant. The increase in nonfatal injury in children resulted from increased firearm injury rates. In adults, both stabbing and firearm nonfatal injury rates increased.
Conclusions: Nonfatal injury data suggest that nonfatal violence has increased; fatal injury data suggest that violent death rates have remained constant. Injury patterns vary by age, mechanism of trauma, and data source. These results suggest that ED and medical examiner data differ and that both are needed to guide injury prevention programs.     

Interprofessional approaches to creating safe,high quality health care

Three supplementary perspectives are presented arguing that interprofessional collaboration is both necessary and desirable. Nonetheless, there are often too many serious intra-professional barriers and obstacles to interprofessional collaboration to make it successful. Some of these barriers, it is argued and illustrated, are found in the multiple ways in which professional identity is tacitly acquired and embodied in the practitioners' habitual, everyday practice. The paper then explores ways in which reflection, especially Second order reflection, can help to elucidate and overcome these obstacles, as well as increasing professional adaptability and competence.     

Systematic Reviews Published in the January 2011 Issue of The Cochrane Library

ABSTRACT

The Cochrane Library of Systematic Reviews is published quarterly as a DVD and monthly online. The January 2011 issue (first quarterly DVD for 2011) contains 4515 complete reviews, 1985 protocols for reviews in production, and 13,521 one-page summaries of systematic reviews published in the general medical literature. In addition, there are citations of 641,000 randomized controlled trials, and 14,018 cited papers in the Cochrane methodology register. The health technology assessment database contains over 9300 citations. One hundred and seven new reviews have been published in the last 3 months, of which five have potential relevance for practitioners in pain and palliative medicine.     

Determination of creatine kinase isoenzyme MB activity in serum using immunological inhibition of creatine kinase M subunit activity. Activity kinetics and diagnostic significance in myocardial infarction.

This is a new method for the determination of creatine kinase isoenzyme MB activity in serum. The method uses direct activity measurement of creatine kinase B subunit activity after blocking of CK-M subunit activity by inhibiting antibodies. The test takes no longer than 15 min. The method yields an intra-serial C.V. of 2.0-12.9%, and a C.V. from day to day of 5.5%. The detection limit is 3.4 U/l creatine kinase MB. In the 95 cases with proven myocardial infarction several types of creatine kinase MB activity kinetics could be determined. The percentage of creatine kinase MB of peak CK-total is 6-25%, with a mean of 11.1%. The amount of creatine kinase MB with respect to total CK activity after reinfarction is higher than the amount after initial infarction.     

俯卧位通气对高海拔地区肺复张治疗无效急性呼吸窘迫综合征患者氧合的影响

目的 探讨俯卧位通气对高海拔地区肺复张术(RM)治疗无效急性呼吸窘迫综合征(ARDS)患者的治疗作用.方法 从海拔2260m的地区医院筛选RM治疗无效的41例ARDS患者[平均氧合指数( PaO2/FiO2)较RM前升高＜20％视为RM无效],依不同病因分为肺内源性ARDS组(ARDSp组)和肺外源性ARDS组(ARDSexp组),每组再按信封法随机分为俯卧位组和仰卧位组,即ARDSp俯卧位组(11例)、ARDSp仰卧位组(9例)、ARDSexp俯卧位组(10例)、ARDSexp仰卧位组(11例).在通气前及通气1、2、3、4h监测动脉血氧分压( PaO2)、PaO2/FiO2、静态顺应性(Cst)、气道阻力(Raw)的变化.结果 通气lh时,ARDSexp俯卧位组PaO2/FiO2( mm Hg,l mm Hg=0.133 kPa)即较通气前显著升高(157.4±40.6比129.3±48.7,P＜0.05),并随通气时间延长呈持续增高趋势,4h达峰值(219.1 ±41.1);且ARDSexp俯卧位组通气3h内PaO2/FiO2较其他3组显著增高,另3组间则差异无统计学意义.ARDSp俯卧位组、ARDSexp俯卧位组通气4h时PaO2/FiO2均较相应仰卧位组显著增高(208.8±39.7比127.4±47.1,219.1±41.1比124.9±50.8,均P＜0.05).4组通气前后Cst无显著改变,各组间差异也无统计学意义.ARDSp俯卧位组通气4h时Raw(cmH2O·L-1·s-1)较通气前显著降低(6.8±1.7比10.7±1.8,P＜0.05),且明显低于其他3组;其他3组各时间点Raw组内及组间比较差异均无统计学意义.结论 俯卧位通气作为ARDS机械通气重要策略之一,可以改善RM无效高原ARDS患者的氧合,为抢救患者赢得宝贵的时间.     

Digital imaging among medical facilities

The Department of Veterans Affairs (VA) in the USA operates a network of 172 medical centres which all utilize a hospital information system (HIS) which has been developed and is currently maintained by the VA. During the past several years, an image management and communication module has been developed, installed and clinically utilized at the Washington DC and Maryland VA Medical Centres. This image management and communication system, referred to as the decentralized hospital computer program (DHCP) imaging system, is fully integrated with a commercial picture archiving and communication system (PACS). The system is utilized to capture, archive, and display all images generated within the hospital including radiology, nuclear medicine, pathology, endoscopy, bronchoscopy, and dermatology, intraoperative photographs, ECG data, and a limited number of paper documents. The ultimate goal of the project is to have all patient text and image data available at any clinical workstation to any authorized user anywhere within the network of medical centres. Clinical requirements for an imaging workstation include ease of use, rapid and reliable access to the complete set of patient information, and images which are of acceptable quality to meet the requirements of the user and the subspecialty. Patient confidentiality and data security must be safeguarded at all times. Integration of the images with the remainder of the patient's database was found to be critical to the success of the project. The experience at the Washington and Maryland facilities suggests that an imaging system that is successfully integrated with a hospital information system can provide substantial clinical and economic benefits both within and among medical centres. Clinical acceptance and utilization of the system has been excellent, particularly in diagnostic radiology where DHCP Imaging has been interfaced to a commercial PAC system. Based upon this initial experience, the VA has begun to deploy the system throughout its large network of medical centres.     

Myocardial elastography at both high temporal and spatial resolution for the detection of infarcts

Myocardial elastography is a novel method for noninvasively assessing regional myocardial function, with the advantages of high spatial and temporal resolution and high signal-to-noise ratio (SNR). In this paper, in-vivo experiments were performed in anesthetized normal and infarcted mice (one day after left anterior descending coronary artery [LAD] ligation) using a high-resolution (30 MHz) ultrasound system (Vevo 770, VisualSonics Inc., Toronto, ON, Canada). Radiofrequency (RF) signals of the left ventricle (LV) in longitudinal (long-axis) view and the associated electrocardiogram (ECG) were simultaneously acquired. Using a retrospective ECG gating technique, 2-D full field-of-view RF frames were acquired at an extremely high frame rate (8 kHz) that resulted in high-quality incremental displacement and strain estimation of the myocardium. The incremental results were further accumulated to obtain the cumulative displacements and strains. Two-dimensional and M-mode displacement images and strain images (elastograms), as well as displacement and strain profiles as a function of time, were compared between normal and infarcted mice. Incremental results clearly depicted cardiac events including LV contraction, LV relaxation and isovolumetric phases in both normal and infarcted mice, and also evidently indicated reduced motion and deformation in the infarcted myocardium. The elastograms indicated that the infarcted regions underwent thinning during systole rather than thickening, as in the normal case. The cumulative elastograms were found to have higher elastographic SNR (SNR(e)) than the incremental elastograms (e.g., 10.6 vs. 4.7 in a normal myocardium, and 6.0 vs. 2.4 in an infarcted myocardium). Finally, preliminary statistical results from nine normal (m = 9) and seven infarcted (n = 7) mice indicated the capability of the cumulative strain in differentiating infracted from normal myocardia. In conclusion, myocardial elastography could provide regional strain information at simultaneously high temporal (>/=0.125 ms) and spatial ( approximately 55 microm) resolution as well as high precision ( approximately 0.05 microm displacement). This technique was thus capable of accurately characterizing normal myocardial function throughout an entire cardiac cycle, at the same high resolution, and detecting and localizing myocardial infarction in vivo.     

Prise en charge des entorses externes de cheville : étude clinique préliminaire sur l’efficacité du dispositif Myolux™

Ankle sprains are the most common injury of the musculoskeletal system and are associated with significant societal and economic impacts. It has been proven that classical therapeutic strategies may not be effective in preventing recurrent injuries: the recurrence rates reported in the literature can reach 73%. In order to provide an effective rehabilitation solution, a destabilizing orthosis was developed. This device is equipped with a mechanical articulator reproducing the subtalar mechanics and placed under the heel. In this paper, we present the main results of a preliminary clinical study conducted between 2004 and 2007. All subjects included in this study were treated with the abovementioned orthosis during 10 rehabilitation sessions of 30 minutes each. Data show a relatively low recurrence rate of 12% for the overall population. Moreover, it's of primary importance to note that this satisfactory ratio is largely reduced (3% of recurrence rate) for the 29 patients who performed one training session per month after the 10th initial rehabilitation sessions. Hence, the destabilizing orthosis appears to be an effective solution to prevent recurrent ankle sprains. However, joint protection requires long-term and regular training sessions. This result has motivated the development of a similar device allowing patients to perform training sessions at home. Finally, data obtained in this study are promising awaiting the final results of the comparative, multicentric and independent clinical trials currently managed by the Hospices Civils de Lyon.