Umfrage zu Behandlungspfaden bei Bauchschmerzen in der ZNA

Die Arbeitsgruppe Wissenschaft führt eine Umfrage zum Thema Behandlungspfade für Patienten mit Bauchschmerzen durch und freut sich über die kurze Beantwortung von wenigen Fragen zu diesem Thema. Angesprochen sind vor allem OÄ und Ärztliche sowie Pflegerische Leitungen von Notaufnahmen.

Bitte nehmen Sie sich ein paar Minuten Zeit für dieses interessante wissenschaftliche Projekt oder leiten Sie den Link an entsprechende Personen weiter.

JC: Getting the Balance Right: The PROPPR Trial

St Emlyns - Meducation in Virchester #FOAMed

  Last week saw the publication of the results of the Pragmatic Randomised Optimal Platelet and Plasma Ratios (PROPPR) Trial by Holcomb et al. (et al. includes almost all of the big names in massive transfusion in trauma!). It would be remiss of me not to mention the much-cited fact that 40% of traumatic deaths […]

The post JC: Getting the Balance Right: The PROPPR Trial appeared first on St Emlyns.

Doctor Cents–There is NO price too LOW for BAD advice!

In the last post we talked about the importance of making a financial plan. This concept rightfully scared some of you. Hopefully this post will help ease some anxiety regarding your personal financial plan by helping you determine how you are going to make your personal financial plan. As a PEM fellow or PEM attending you will be approached by many different individuals who want to “help” you do financial planning (if you haven’t been approached already).   Financial advisors usually come in one of four flavors: commission based employee of a brokerage firm or insurance company fee only advisor your (insert family/friend relationship here) who has a great investment opportunity you   Many doctors feel that they would be best served with having a professional manage their finances. They make this decision based on the assumption that they don’t have enough time to properly manage their financial assests, fear of the “complexity” of personal finance, or just because their physician friends use a professional financial advisor.   Other physicians choose to be their own financial advisor. They make this choice for varied reasons as well. Some enjoy the control over their financial life that going it alone provides, some relish the opportunity to learn about personal finance as a way to challenge their minds or diversify their educational experiences and some just don’t want to pay someone else to handle finances realizing that every dollar they pay for this service is a dollar they don’t have in their accounts! It is also eye opening to realize that some financial advisors who are “working” for you, really aren’t working for you at all—they are getting paid to sell you stuff!!!   Let’s talk about the 4 options listed above: The commission based financial advisor You know you have a commission based financial advisor if your financial advisor works for an insurance company. The other way to know if the potential financial advisor you are considering is a commission based advisor is to ask them how they are paid. This may seem like a rude question to ask a professional but it is a completely relevant and proper question to ask. The reason you need to know if your financial advisor is commission based is because it might effect the advice you get. A commission based financial advisor is paid by the company they represent to sell you something—thus their duty is to the company who is paying them, not necessarily to you! One can quickly see how this arrangement may not be in YOUR best interest. I want the person handling my money to hold my best interests paramount and not to be clouded by his/her compensation being tied to what product they sell me! The fee based financial advisor The fee based financial advisor comes in several different flavors. Some are paid as a percentage of the assests they manage for you (usually 1% of your portfolio but can range from 0.5% to 3%). Some are paid a flat fee for services provided (the more services they provide you, the higher their fees). These fees can be hourly, monthly, quarterly or yearly. Services rendered fees range widely and can be $3-400 per hour or $4000 a year up to $10000 per year depending on the amount of your account and services they provide.   In this type of relationship, the advisor does not make money by selling you certain products (insurance, mutual funds, annuities, etc…) and thus their compensation is directly tied to you and your happiness with their results and service. Someone you know has a great investment opportunity […]

Orale Antikoagulation – To bridge or not to bridge

Wie gehe ich mit Patienten um, welche eine orale Antikoagulation erhalten und eine kardiale oder nicht-kardiale Prozedur/Intervention nötig haben. Diese wichtige Frage …
wird in einer retrospektiven Analyse in Circulation näher analysiert.
Komplikationen treten in dieser Phase der Intervention relativ selten auf. Die wichtigsten weiteren Ergebnisse dieser großen Kohortenstudie von Patienten mit OAK bei Vorhofflimmern sind:
1) Unterbrechungen der oralen Antikoagulation wegen Prozeduren sind häufig, auch bei Prozeduren mit geringem Risiko einer Blutung.
2) Eine Antikoagulation zur Überbrückung wird in etwa einem Viertel betroffener Patienten durchgeführt. Dies hängt von verschiedenen Faktoren betroffener Patienten ab.
3) Die überbrückende Antikoagulation ist mit einer höheren Komplikationsrate (wie z.B. Blutung etc.) assoziiert.

Die Autoren ergänzen, dass insbesondere der Umgang mit DOACs offensichtlich noch sehr ungewohnt ist und hier wenig fundierte Handlungsweisen praktisch durchgeführt werden.

Zusammenfassend zeigt diese Studie auf, dass der Umgang mit Patienten unter OAC für viele sehr ungewohnt ist. Es gibt auch hier keine klaren Handlungsanweisungen, da die entsprechenden Leitlinien meist aus Expertenmeinungen bestehen. Wichtig für den Alltag ist, dass bei vielen Interventionen die Antikoagulation nicht unterbrochen werden muss. Ansonsten gilt es, das Blutungsrisiko bei Interventionen bzw. das Risiko durch Absetzen der Antikoagulation abzuschätzen und entsprechende Entscheidungen zu treffen. Bridging Konzepte bedürfen der interdisziplinären Absprache. Einige Krankenhäuser haben dies umgesetzt.

Health care at the end of life: Trending Topic, by Iñaki Saralegui

Articles of opinion, research studies or reports of Scientific Societies in relation to care for the patients at the end of life have been numerous in recent months.

It is an issue which is of concern to citizens and health proffesionals. Health institutions and services have not succeeded in producing processes that, based on scientific knowledge and respecting the preferences of patients, improve coordination of treatments, care and spiritual care requiring patients and their families.

Thus, the journal New England Jornal of Medicine in its issue of February 12, 2015 published several articles about.

In End-of-Life Advance Directives we are invited to reflect and send feedback on a practical case in which arises what specialist could arrange the best way of decision-making with the patient and care planning. How, when and where. At first glance we could suggest a coordinated care, but it is interesting to read the arguments of each proffesional.

Another interesting item is the revision of laws and American programs related to end of life care in the last 40 years. Both in this text (Forty Years of Work in End-of-Life Care – From Patient´s Rights to Systemic Reform) as in other of the same number (Should we practice what we profess? Care near the End-of-Life) it is cited the report Dying in America del Institute of Medicine (IOM), whose basic recommendations are:

1. Providing comprehensive and coordinated palliative care.

2. Improving communication with the patient and care planning.

3. Training on aspects related to the end of life.

4. Institutional programmes focusing on the patient care.

5. Information for citizens to achieve their involvement.

Reading these articles should invite us to reflect in a first step and then act.

Clinical Bioethics could be interesting and entertaining. This is one of the aspects to improve: Bioethics as pure entertainment, when in essence should be action.

To act essentially we need to read, listen, reflect, discuss, propose and finally implement programs and processes that improve health care.

With the ill person as objective.

Dr. Iñaki Saralegui (@InakiSaralegui)
Intensive Care Unit. 
Hospital Universitario de Alava.
Chairman of the Medical Ethics Committee
Bioethics Working Group - SEMICYUC

Perc Trach Step-by-Step Tutorial

Resus Review

For patients requiring prolonged mechanical ventilation a cuffed tracheostomy tube is required in place of the endotracheal tube. Traditionally this has been done with an open surgical procedure. However, a bedside procedure has been developed that allows the tracheostomy to be placed using the Seldinger technique with dilation of the dilation rather than dissection. It is formally known as a Percutaneous Dilational Tracheostomy (PDT) and can be done either with or with bronchoscopic guidance.

This is considered a minimally invasive bedside procedure that may be easily performed in the intensive care unit or at the patient’s bedside – with continuous monitoring of the patient’s vital signs.

Evaluation for Perc Trach

Two critically important preoperative criteria for PDT are:

  • The ability to hyperextend the neck
  • Presence of at least 1 cm distance between cricoid cartilage and suprasternal notch ensuring that the patient will be able to be reintubated in case of accidental extubation

Patients should not be considered for this procedure if they are:

  • Children (younger than 12 years of age)
  • Patients with severe coagulopathies
  • Patients with unidentifiable landmarks

Perc Trach Techniques

There are several different systems and approaches for PDT, but the one in most widespread use is the Ciaglia. With this technique, there is no sharp dissection involved beyond the skin incision. The patient is positioned and prepped in the same way as for the standard operative tracheostomy. General anesthesia is administered and all steps are done under bronchoscopic vision.

Advantages of Perc Trach

The procedure itself is fairly easy to learn, especially in proctored settings. Time required for performing bedside PDT is considerably shorter than that for an open tracheostomy. Elimination of scheduling difficulty associated with operating room and anesthesiology teams for critical care patients. PDT expedites the performance of the procedure because critically ill patients who would require intensive monitoring to and from the operating room need not be transported. Cost of performing PDT is roughly half that of performing open surgical tracheostomy due to the savings in operating room charges and anesthesia fees.

Procedure Steps

Step 1

The neck should be carefully palpated and all of the anatomy carefully identified (thyroid cartilage, cricoid cartilage, and 2-3 tracheal rings). The ideal location of the tracheostomy would be between the 1st and 3rd tracheal ring. Once you have identified your location, a horizontal skin incision made about 2-3 cm in length.


Step 2

The pretracheal tissue is cleared by blunt dissection, until the trachea is clearly palpable. It need not be fully visualized.


Step 3

The bronchoscope is feed through the endotracheal tube but kept with the tube itself. The endotracheal tube is withdrawn until the Kelly clamp can be seen bouncing between the tracheal rings. The cuff should not be higher than the level of the glottis. A laser can be used through the surgical would to also help guide the withdrawal of the endotracheal tube.

The introducer needle is then used to puncture the anterior wall of the trachea under direct bronchoscopic visualization.


Step 4

The needle is withdrawn leaving the catheter.


Step 5

A guidewire is fed through the catheter. On the bronchoscope, it should be seen going distally down the trachea towards the carina.


Step 6

The catheter is removed, and the first small dilator is used to dilate the track.


Step 7

The large progressive dilator is then used to further dilate the track over the extended catheter.


Step 8

A tracheostomy tube with inner trocar is cannulated into the trachea over the extended catheter.


The tracheostomy tube trocar, wire, and extended catheter can then be removed. The tracheostomy tube should be inflated and the inner cannula insert. You should inspect the site for any cuff leak. The bronchoscope should be removed from the endotracheal tube, and placed down the tracheostomy tube to visualize the carina. Only then should the endotracheal tube be removed.

The tracheostomy tube is secured to the skin with sutures and the tracheostomy tape.

Dont forget to document your perc trach procedure well.

Perc Trach Step-by-Step Tutorial