Extracorporeal Membrane Oxygenation in Traumatic Injury: An Overview of Utility and Indications
Severe respiratory failure may develop in the trauma patient as a consequence of direct lung injury, in response to trauma‐associated systemic inflammatory response syndrome (SIRS), as a result of infection, or at times as an unintended consequence of the life‐saving management of the acute traumatic injury. Approximately 0.5% of all adult trauma patients develop some form of pulmonary dysfunction along the acute lung injury (ALI) – acute respiratory distress (ARDS) spectrum, with the incidence of severe respiratory failure reaching 10–20% in multisystem trauma victims. Of concern, mortality in patients with acute respiratory failure who go on to develop severe pulmonary dysfunction can be as high as 37–50% with the use of conventional therapeutic modalities. Extracorporeal membrane oxygenation (ECMO) has been proposed as a rescue strategy when less invasive primary or adjunctive attempts fail. Numerous case reports and single‐center studies demonstrate potential benefits of early implementation of veno‐venous (VV)‐ECMO for the treatment of severe respiratory failure associated with trauma or sequelae of trauma. In this clinical context, VV‐ECMO can be employed to correct for both ventilatory and oxygenation failure while allowing the treating physician to provide much needed rest to the patient's lungs and permit healing to take place. The use of ECMO (mainly veno‐venous, with limited use of veno‐arterial circuits for cardiac indications) has been described in patients with severe chest injuries, traumatic pneumonectomy, bronchopleural fistulas, and various forms of respiratory failure refractory to conventional therapies.
Part of the book: Extracorporeal Membrane Oxygenation
Patient Frailty: Key Considerations, Definitions and Practical Implications
By 2020, the elderly (≥65-year-old) world population is projected to exceed one billion individuals. This demographic megatrend has brought topics such as physiological age and frailty to the forefront of medical research efforts around the globe. The concept of frailty has evolved significantly since the mid-twentieth century. The outdated stereotype of a “thin, stooped, slow octogenarian” has transitioned to a more scientific and objective understanding of the problem. Still, a comprehensive and concise definition of “frailty” remains elusive. Until such a definition is firmly established and universally agreed upon, clinicians continue to rely on the somewhat subjective conceptual framework of today. In this chapter, the authors review key issues pertaining to clinical management of frail patients, including diagnosis/identification, preventive strategies, therapeutic approaches, and common pitfalls. The relationship between frailty, various domains of life, and functional status is also discussed. Finally, we will touch upon the concepts of end-of-life and goals of care, focusing on their relationship to frailty.
Part of the book: Challenges in Elder Care
Septic Embolism: A Potentially Devastating Complication of Infective Endocarditis
Infective endocarditis is associated with significant cardiac and noncardiac morbidity. Among many complications, septic embolism has the potential of causing devastating sequelae and even life-threatening clinical situations. This dreaded clinico-pathologic entity is characterized by its heterogeneous presentation and the ability to affect various body systems and organs. Septic emboli to the brain, kidneys, spleen, and the pulmonary system constitute the vast majority of metastatic infections. However, other organ systems can also be affected. This chapter provides an overview of septic embolism associated with infective endocarditis, focusing on key diagnostic and therapeutic considerations in the most commonly seen and clinically relevant scenarios.
Part of the book: Contemporary Challenges in Endocarditis
Foreign Intravascular Object Embolization and Migration: Bullets, Catheters, Wires, Stents, Filters, and More
Foreign intravascular object embolization (FIOE) is an important, yet underreported occurrence that has been described in a variety of settings, from penetrating trauma to intravascular procedures. In this chapter, the authors will review the most common types of FIOEs, including bullet or “projectile” embolism (BPE), followed by intravascular catheter or wire embolization (ICWE), and conclude with intravascular noncatheter object (e.g., coil, gelatin, stent, and venous filter) migration (INCOM). In addition to detailed topic-based summaries, tables highlighting selected references and case scenarios are also presented to provide the reader with a resource for future research in this clinical area.
Part of the book: Embolic Diseases
Patient Self-Harm in the Emergency Department: An Evidence- Based Approach
Violence, deliberate self harm, and suicide in emergency departments and hospitals is likely to remain a significant problem for health care systems well into the future. Understanding how to confront, intervene, and manage episodes of patient deliberate self harm is extremely important, and can be life-saving. Here, through a clinical vignette, and a discussion of deliberate self harm we will highlight the importance of the direct observation of such patients, containment procedures (seclusion and physical restraints), and the use of pharmacological adjuncts. We hope that this concise, practically-oriented review will provide our readers with foundational understanding of the topic, including the most important theoretical and clinical considerations.
Part of the book: Vignettes in Patient Safety
Interhospital Transfers: Managing Competing Priorities while Ensuring Patient Safety
Interhospital patient transfers (IPTs) are highly complex logistical undertakings, involving a multitude of interdependent procedures, critical steps and a degree of unpredictability. Beginning with interfacility communication and patient acceptance agreement, a cascade of numerous handoffs takes place, ultimately culminating in safe arrival of the patient at the receiving facility. Due to the complexity of the IPT process, significant potential for critical errors and adverse patient safety (PS) outcomes exists. To minimize any associated risks, key PS considerations include checklists, handoffs, vehicle/aircraft safety, distance of travel, crew training, team factors, and many other critical components. Detailed knowledge of factors that may influence the risk of errors or adverse events is critical to optimizing both PS and clinical outcomes.
Part of the book: Vignettes in Patient Safety
The Process of Organ Donation from Non-Living Donors: A Case-Based Journey from Potential Donor Identification to Organ ProcurementView all chapters
Each year, thousands of people worldwide succumb to end-organ failure while awaiting life-saving transplantation procedures. The shortage of organs continues with no signs of easing in the foreseeable future. The availability of organs from living donors continues to be constrained. At the same time, the cumulative knowledge of organ preservation is advancing steadily resulting in an enhanced ability to utilize a growing number of previously unsuitable tissue and organ gifts. Our ability to procure and preserve more organs is accompanied by the increasing use of so-called “expanded criteria” donors, or those whose organs may not have been suitable without modern advances in organ preservation science. Within the overall context of organ donation from non-living donors, the importance of physiologic and end-organ optimization cannot be understated. This chapter discusses our current state of understanding of optimized organ procurement approaches derived from practical experiences and “lessons learned” at a high-performing, community-based tertiary referral hospital.
Part of the book: Organ Donation and Transplantation